Ritual Abuse and Developmental Trauma
Ritual Abuse and Developmental Trauma: Application of the Triphasic Model of Trauma Treatment in the Case of “Sarah”
The University of New Mexico, Rio Rancho, NM
Clients who have experienced ritual abuse (RA) in childhood present to therapy with a variety of complex symptoms. The case of “Sarah” provides clinicians with an example of the presenting problems experienced by adult survivors of childhood cultic abuse. This case conceptualization utilizes developmental trauma disorder (DTD; van der Kolk, 2009) as an organizing framework for understanding the client’s symptoms and psychological distress. Sarah’s treatment and related counseling interventions follow Herman’s (2015/1992) triphasic model of trauma recovery, while referencing the fragmentation of trauma memory (van der Kolk, 1996) as a foundation for trauma processing. I also discuss the role of alternative internal identities, or “alters,” in the recovery process.
Keywords: Ritual abuse, developmental trauma disorder, triphasic model of trauma recovery, trauma treatment
Theoretical and Research Basis for Treatment
In this article, I review the background and foundations for counseling treatment of client “Sarah” while she was receiving mental health services at a college resource center. Sarah’s experience with adverse childhood events, specifically cult-perpetrated ritual abuse of a sadistic nature, explains the origins of her symptoms and psychological distress. I use developmental trauma disorder (DTD) as a framework for understanding the complex nature of her symptoms and fragmented identity.
Adverse Childhood Events and Ritual Abuse
Exposure to traumatic events and adverse experiences in childhood increases the likelihood that individuals will experience additional exposure or victimization in adolescence, and adulthood (Herman, 2015/1992). Children who experience traumatic events are more likely to experience adverse physical and mental health symptoms across their lifespan. Upon entering adulthood, these children are at greater risk of developing liver disease, chronic obstructive pulmonary disease, autoimmune disease, somatization (negative somatic symptoms with no biomedical cause), depression, suicide attempts, and efforts to self-medicate through the use of substances (Felitti & Anda, 2010). Ritual abuse is a distinct form of child abuse that not only predisposes individuals to an increased likelihood of developing the aforementioned difficulties; but it is also correlated with an increased risk of dissociative symptoms and disorders (Noblitt & Perskin, 2000). This form of abuse is frequently associated with destructive cults of various ideological backgrounds, organized crime groups, or both (Noblitt & Noblitt, 2008).
The ritual abuse of a child is a unique form of trauma that aims to break down the child’s integrity of self and create dissociative states, with the ultimate aim of contributing to the individual’s (or when the abuse occurs within a group, the group’s) perceived sense of power (Noblitt & Perskin, 2000). Ritual abuse consists of maltreatment that is perpetrated “in a ceremonial or circumscribed manner and where the abuse causes traumagenic dissociation and/or establishes or reinforces control over dissociated states” (Noblitt & Noblitt, 2008, p. 25). This form of abuse often includes the use of programming, a method that includes extreme physical, emotional and/or psychological pain to induce dissociative states and create new internal, or “alter,” identities (Miller, 2012).
Abuse of children within cultic settings may also follow a nonritualized course, with children subjected to sexual, physical, and/or psychological abuse that is not directly related to ritualized programming. Although nonritualized abuse may be perpetrated as a means of asserting control through violence, such abuse is not associated with prescribed rituals or ceremonies. In my clinical experience, not all cults practice ritual abuse, nor due all groups who may be classified as cults necessarily engage in ritual abuse of its members. For those groups who engage in abuse of their members (and/or members’ children), the level of sadism exercised in ritual versus nonritualized abuse is individualized and inconsistent; thus, the “level of sadism” of ritual abuse cannot be generally stated. The case of “Sarah,” described in the following text, illustrates that severely sadistic abuse can occur as an isolated event or isolated events with individual cult members or persons not explicitly affiliated with the cult.
The instances of abuse I discuss in this manuscript include both ritualized and nonritualized sadistic abuse, and also incest. Sadistic abuse is defined as “extreme adverse experiences” wherein the perpetrator derives pleasure from the suffering of the victim(s), and it includes “acts of torture, overcontrol, and terrorization, . . . ritual involvements, and malevolent emotional abuse” (Goodwin, 1993, p. 181). The sadistic nature of the traumatic content I describe in this manuscript may be disturbing for some readers, particularly those individuals who have survived abuse or violence. I encourage readers to use discretion should the material shared here elicit a strong negative response.
The organized and systemic nature of ritualized trauma includes multiple experiences of torture, threats of death to self and loved ones, and exposure to gruesome scenes. Children subjected to ritual abuse are often brought into the abuse by a trusted loved one or caregiver and are subjected to repeated exposure throughout childhood. This repeated victimization affects development of emotional regulation and interpersonal skills (Cloitre et al., 2009), and it impairs the individual’s ability to master developmental milestones. Dr. Bessel van der Kolk (2005) labeled the disruption of victims’ lifespan development and resulting symptomology as developmental trauma disorder.
Developmental Trauma Disorder: Framework for Presenting Problem
DTD accounts for the complex nature of traumatic stress when the client has experienced ongoing trauma at the hands of caregivers that extends over multiple developmental periods (Bremness & Polzin, 2014). Van der Kolk and colleagues (2009) proposed the addition of DTD to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), but they were unsuccessful. The DSM-5 maintains posttraumatic stress disorder (PTSD) as the only diagnosis that explains the symptomology attributed to traumatic experience. Although DTD is not officially acknowledged as a diagnosis by the American Psychiatric Association (APA), the symptoms outlined in DTD consist of consensus criteria developed by the National Child Traumatic Stress Network (NCTSN). These criteria were derived from numerous longitudinal studies that utilized diagnostic interviews to explore the experience of children who have been exposed to complex trauma to include ritual and cult abuse (Bremness & Polzin, 2014).
DTD provides practitioners with a comprehensive outline for understanding the spectrum of symptoms and altered perception experienced by survivors of ritual abuse. Individuals with DTD experienced multiple traumatic exposures that incited “intense affects such as rage, betrayal, fear resignation, defeat and shame,” and caused the child/adult survivor to engage in “efforts to ward off the recurrence of those emotions”; these efforts included avoiding experiences that preceded the trauma or “engaging in behaviors that convey a subjective sense of control in the face of potential threats” (van der Kolk et al., 2009, p. 10). Survivors with DTD experience somatic problems, from headaches and stomach aches to specific sensations associated with body memories.
Miller (2012) has described body memories as bodily sensations experienced in the present that have no current biomedical cause, and that are directly related to some aspect of trauma. Persons with developmental trauma are also more likely to experience an overall lack of connection with their bodies and affective states (Levine, 1997). They may struggle to read their environment and interpret external cues that indicate other’s intentions. The inability to adequately interpret the intentions of others, combined with stressful stimuli that remind individuals of the trauma, cause those with DTD to feel “constantly on guard, frightened and over-reactive” (van der Kolk et al., 2009, p. 11).
DTD attends to the many unique concerns and symptoms presented by persons who have experienced ritual abuse. The case study that follows uses DTD as an organizing framework within which to understand how the client’s presenting complaints harkened back to her traumatic experiences. Following the case study, an impact statement gives voice to the influence “Sarah” has had on my professional practice as a therapist, and on my personal experience.
The Triphasic Model of Recovery: Organizing Framework for Treatment in Counseling
As context for the case study, I organized the client’s treatment using Herman’s (2015/1992) triphasic model of trauma recovery. Per phase 1 of the model, initial counseling sessions focused on gathering information and helping the client build resources and internal resiliency. During phase 2, the focus shifted toward the processing of traumatic memory, with the client and me working collaboratively to identify fragments of memory and create a cohesive narrative of the experience. The second portion of phase 2 consisted of exploring together the ways that the client had derived meaning from her traumatic experience, and the related aftereffects.
I further enhanced Herman’s (2015/1992) organizing framework through the use of additional counseling interventions. These other interventions included psychoeducation regarding the fragmentation of traumatic memory (van der Kolk, 1996) and identification of body memories using somatic experiencing (Levine, 1997). Using cognitive behavioral therapy strategies (Beck, 1995), I identified and challenged the client’s core beliefs and thought processes that had been altered by the traumatic experiences.
The triphasic model provided a recursive means for organizing therapy. When the client experienced increased distress or overwhelming feelings during trauma processing (phase 2), I would realign interventions to focus solely on building resources (phase 1). Returning to phase 1, sessions would focus on increasing client access to both physical resources (i.e., food, shelter, safety) and internal resources (i.e., ability to self-regulate strong affective states and navigate interpersonal relationships). Once the client reported a return to baseline homeostasis and seemed to adequately regulate emotions and symptoms, treatment would again focus on the processing of memories and the dentification and reframing of irrational beliefs.
Case Introduction and Presenting Complaints: The Case of “Sarah”
The following case study describes the treatment of “Sarah,” a 27-year-old Hispanic female with a history of childhood incest perpetrated by her mother, and ritual abuse perpetrated by members of the cults in which her mother participated. Sarah presented to counseling with recurring panic attacks, and the inability to fall asleep and stay asleep. Sarah also reported somatic distress for which no biomedical cause could be determined. She reported being diagnosed with autism spectrum disorder (ASD) around age 7 and stated that she hoped counseling could help her “learn to function.”
Sarah grew up in the Southwest United States, within walking distance of the Mexican-American border. She described her hometown as riddled with violence, organized crime, and corruption that spilled over from a neighboring city in Mexico. At home, she lived with her father, a civilian contractor for the military, and her mother, who stayed at home to care for Sarah. Sarah was an only child until the age of 13, when her younger brother was born.
Sarah’s earliest memories centered on her mother’s involvement in cult activities in the small town where she grew up. She described her mother maintaining a variety of cover-up activities to conceal her cult involvement. These activities ranged from taking Sarah to visit family in Mexico for periods of time, to stints of homeschooling, intense involvement in agricultural clubs, and organized beauty pageants that required travel. Sarah stated that her father was unaware of her mother’s connection with local cults because he worked anywhere from 60 hours to 80 hours a week. Sarah believed her father did not notice her odd behavior following episodes of abuse because he was “autistic and couldn’t read me.”
Sarah described the cults in which her mother was involved as consistently organized and centered on gaining spiritual power or money through the sadistic abuse of children and animals. She identified the cults through pieces of information and details she recalled during the processing of traumatic memories. Sarah described the cults as follows:
• an ideologically based cult founded in an extreme subsect of the Christian faith, wherein ceremonies mimicked Catholic ceremonies but included ritualized sexual abuse of children and infanticide;
• a coven cult whose primary goal was connection with the power of demonic forces through the use of hedonistic practices with children and animals, and of animal sacrifices (specifically the use of dogs and goats);
• cult activities disguised as meetings for a children’s agricultural club;
• sex trafficking of young children under the guise of organized beauty pageants that served pedophiles seeking sex with children; and
• organized crime that involved the transportation of illicit substances and undocumented persons by Sarah’s mother, coordinated by what Sarah described as “the Mexican cartel. “Sarah described the aforementioned cults as the most prominent and identifiable in her memory, but stated that the nature of her memories prevented her from recalling specific names or locations.
Sarah stated that she remembered fragments of childhood trauma that occurred between the ages of 3 and 16. She described extended periods of her childhood during which she was unable to recall any memories. Sarah described her mother being involved in a number of cults because her mother seemed to consistently “mess things up” and be “forced out,” to which her mother would respond by seeking out a “new group of fanatics.”
Sarah recalled instances during childhood and early adolescence during which she would “just start screaming . . . because I would remember some part of the abuse.” She said that her mother explained these instances to witnesses and to Sarah’s father by saying that she was “retarded.” It was after one of these episodes that Sarah’s mother took her to the doctor, who diagnosed Sarah with autism.
At age 16, Sarah was sexually assaulted by her mother. She described this experience as one that she now recalled vividly, but that she had “blocked the memory” immediately following the assault. Sarah stated that it was shortly after being assaulted by her mother that she met her boyfriend, now husband. Upon graduating from high school, Sarah said that she and her boyfriend married and moved in together. Sarah described feeling uncomfortable, and at times terrified when around her mother, but that she was unable to recall the ritual abuse or incest until the birth of her first child, a daughter, when she was 23.
Immediately after giving birth, Sarah began experiencing floods of overwhelming emotion accompanied by snippets of memory. She described experiencing auditory hallucinations at night that began during this timeframe and consisted of the auditory portions of fragmented memories.
Sarah reported continuing to have a relationship with her mother, albeit distant, until her daughter was 9 months old. At that time, Sarah and her husband left the child with Sarah’s mother “for a couple of hours . . . so we could have a date night.” Sarah said that when she went to pick up her daughter from her mother’s house, she walked in on her mother molesting her daughter. She described feeling a rush of physical and emotional numbness and derealization as she grabbed her daughter and quickly left the house. Sarah said that she reported the abuse to child protective services and began meeting with a counselor. Sarah and her husband then relocated to another state and ceased all contact with Sarah’s mother.
Since this experience 4 years ago, Sarah has relocated multiple times and discontinued all contact with her mother, father, brother, and all other family members. She described herself and her present family as “on the run” from cult members and from her mother, who “want me dead because I talked.” Sarah said that she had been in counseling on and off since her mother molested her daughter, and that new memories seemed to be consistently surfacing. Sarah and her husband had another child when their first daughter was 2 years old.
After her family relocated so that Sarah could attend the state university, she was referred to a resource center on campus for counseling services. Sarah began meeting with me over the summer as she was settling her family into campus housing and preparing for the fall semester. She asked that counseling be used as her “trauma therapy space,” because she felt that “no one else will believe me . . . just you and my husband.”
My initial assessment of Sarah consisted of a biopsychosocial intake assessment. The assessment included questions inquiring about Sarah’s presenting problem and her history of suicidal ideation, homicidal ideation, self-injurious behavior, substance use and abuse, prescription medication, previous diagnoses, medical history, family of origin and their medical and trauma histories, and her traumatic experiences. Sarah indicated that her primary presenting problem was panic attacks and insomnia, which she attributed to extensive childhood trauma. Sarah’s trauma history thus became a point of consistent reassessment and exploration in session.
Case Conceptualization: Course of Treatment and Assessment of Progress
Sarah’s treatment in counseling initially focused on achieving psychological stability and improved access to resources. This included Sarah accessing resources through the university where she was a student, and also applying for healthcare benefits and nutritional assistance. Additionally, Sarah and I cultivated psychological resources such as coping strategies and improved distress tolerance. The final portion of treatment focused on Sarah processing traumatic memories and grieving the loss of “alters” or fragmented portions of her identity.
Phase 1: Pragmatic Interventions
During her intake assessment, Sarah reported a previous diagnosis of autism spectrum disorder (ASD) in childhood. She attributed a range of current experiences to ASD, including her struggle to read other’s social cues and her need for a consistent schedule, and overwhelming anxiety when she was faced with changes. She described experiencing a sense of overwhelm and panic when confronted with too many auditory stimuli, and so she used headphones and loud music “to cope.”
Sarah stated that she believed that the ASD symptoms she had experienced since childhood complicated the distressing symptoms she experienced following episodes of ritual abuse. Examples of the complicated interplay of symptoms include Sarah’s tendency to experience panic attacks on campus when any of the following occurred: an unexpected change in class schedule, group activities that required conversing with classmates, and interacting with anyone during days associated with the anniversary of a trauma. Sarah and I worked together to identify practical ways of insuring her success as a student, while we also developed ways for her to regulate overwhelming affect and surf the somatic sensations associated with anxiety attacks.
During the first phase of treatment, Sarah’s stability and access to resources was the priority. Initially, attending to her basic needs was not only the most pragmatic approach, but also one that aligned with Herman’s (2015/1992) triphasic model of trauma recovery. Following the intake assessment, our first goal was to obtain academic accommodations through the university. Sarah met with a rehabilitation-counseling case worker who assessed her symptoms and provided her with a letter for her course instructors that indicated Sarah was to receive excused absences and extended time to complete assignments and tests.
Once Sarah had obtained academic accommodations, she met with a student advocate who helped her to understand the financial costs that were applied to her university bursar’s account and the status of her financial aid. The advocate set up a meeting between Sarah and a financial-aid advisor, who then helped her to obtain multiple scholarships and a loan to cover the costs of attending classes. After multiple meetings with advocates and advisors, Sarah obtained enough financial aid to be able to register for courses.
Sarah stated that both she and her husband were struggling to find work. Sarah met with an advocate through campus career services who helped her to create a resume and apply for multiple student jobs and work-study positions on campus. Sarah also utilized this resource to role play and further develop her interview skills. To ensure that Sarah and her family’s basic needs were met, I assisted Sarah in completing the applications for Medicaid, the Supplemental Nutrition Assistance Program (SNAP), and Women, Infants, and Children (WIC) benefits.
Phase 1: Psychological Resources
After the first four sessions, Sarah stated that she felt she had the resources she needed to be successful as a student, and that she wished to begin addressing the panic attacks, nightmares, and distress she experienced as a result of her traumatic memories. At that point, her primary focus in treatment shifted from building access to resources needed for daily living to developing both tolerance to distress and coping skills.
I obtained Sarah’s permission to introduce her to some of the models for understanding posttrauma reactions. Sarah and I reviewed Porges’s (2004) polyvagal theory, exploring how Sarah was presently experiencing fight, flight, and immobilization in response to trauma reminders. Sarah and I discussed how her body seemed to unconsciously detect whether an individual or situation was safe or unsafe, with the body perceiving the majority of stimuli as threatening. We explored early signs that her autonomic nervous system was beginning to react, and also identified the related trauma triggers (Levine, 1997). Identifying triggers enabled me to begin inducing these reactions in session, and for Sara to practice coping strategies (e.g., mindful breathing coupled with grounding exercises, leaning in to the somatic and emotional experience).
Phase 2: Trauma Processing
Each of Sarah’s counseling sessions included a review of the status of resources and current needs before we engaged in any traumatic material. Phase 2 consisted of processing traumatic material while creating a “trauma narrative” (Herman, 2015/1992) that brought together multiple fragments to create a cohesive chronology of events. During each session, I asked Sarah whether she had had a distressing memory surface over the previous week. She usually reported three to five fragmented memories that had caused particular distress, either through adrenaline-inducing nightmares or from newly identified trauma reminders.
Van der Kolk’s (1996) model of the fragmentation of trauma memory provided Sarah and me with a means for understanding how her memories were stored and recalled. Each time Sarah reexperienced a traumatic memory, she would recall only a couple of pieces perceived through touch, taste, smell, feel, or hearing. Van der Kolk (1996) explained this phenomenon to be the result of the fragmented nature of trauma memories. During a traumatic experience, the individual’s threshold for affect and distress are surpassed, and the mind fragments the memories and fails to process them into declarative memory. The failure to maintain the integrity of the memory leads to the reexperiencing of fragments whenever one encounters trauma reminders.
When she was reexperiencing a trauma memory, Sarah would experience each fragment as though it were occurring in real time. She most frequently provided a sound that she recalled during the early morning hours, or that awakened her in the middle of the night. She described these instances as moments when she heard a voice or a scream in real time. Sarah said that she was aware that these experiences were not occurring in real time only because she had become accustomed to pausing and grounding herself in the room, recognizing that the experience was not actively occurring but was in fact a piece of the past.
When Sarah was processing these auditory memories, I asked her to recall whether any other fragments were attached to this portion of the memory. I asked that she sit with the sound for a moment and recall whether there was a smell, sight, tactile sensation, or taste associated with it. Sarah often recalled additional somatic experience associated with the traumatic experience, and we used these pieces of information to construct a narrative of the event. I would then record in writing the details Sarah provided regarding the event, Sarah’s approximate age at the time the event occurred, and any contextual variables such as location and persons involved. Recording remembered events helped Sarah to create a larger timeline of events, thus contributing to the trauma narrative of her childhood and adolescence.
Phase 2: Honoring, Deriving Meaning From, and Grieving the Voices of “Alters”
Herman’s (2015/1992) phase 2 of the triphasic model aims to help the client grieve the losses associated with the trauma and derive a sense of meaning from their suffering. After the initial five to six sessions focused on developing resources, Sarah’s trauma processing began. It was at this time that she informed me she had “alters,” or alternate personalities. She concurrently identified and acknowledged the alters during the processing of her memories. She described these alters as ranging from “violently angry” to “incredibly sad,” and that they each carried specific memories from difficult traumatic experiences. Each alter was a version of Sarah at a specific age, which was created during a traumatic experience facilitated by the programmers, whom Sarah identified as members of her mother’s cults tasked with using torture to create dissociative states in children to ensure that they would not remember the abuse.
Sarah’s description of dissociative states seemed to follow the course of psychological decompensation associated with dissociative identity disorder (DID) because her outward expression of multiple identities seems to have been triggered by her removal from the traumatic situation. Sarah described a dramatic increase in the experience of derealization and depersonalization following her move from the community and state in which her mother lived to a new community in a new state, with all connections to former family and friends severed. Although Sarah had never been formally diagnosed with DID, she had described symptoms that meet the diagnostic criteria.
Sarah reported more than two distinct personality states that she called “alters.” When switching between personalities, Sarah described having varying levels of awareness of the transition from one personality to the next. She said that when she switched to those alters with whom her primary personality “is more merged” (the primary or host personality being Sarah), her host personality remained cognizant of the alters’ actions. She described one current alter, however, who had conversations with her husband at night that were completely out of her awareness. Following an evening episode with this alter, whom Sarah called “Roe,” she brought her husband to session to discuss his experiences with Roe. It was during this session that Sarah shared about gaps in memory, specifically in the evenings, and she shared her distress and fear about “not having control . . . I don’t know what I’m doing then.” Sarah’s symptoms did not appear to be associated with any substance use, medical condition, or religious or cultural practice; thus, the aforementioned symptoms meet the diagnostic criteria for DID (APA, 2013). We discussed the symptoms and diagnosis of DID during multiple sessions, but Sarah determined that the diagnosis would not be helpful for her because she attributed her symptoms to the programming she experienced in the cult. She stated that she wished to work toward merging her alters with her primary personality.
Sarah’s most prominent alter was Fred, a young man about age 10 who “lives in a library in my head.” She described Fred as coming into existence during a sexual assault during which the perpetrator repeatedly stated that “girls can’t do anything . . . they’re only good for sex.” Fred then took over the counseling session, stating that he had switched with Sarah, the “shell personality” that “holds us.” He then described the sexual assault in greater detail, and how he came into existence during that violent sexual assault to protect Sarah from the experience.
Fred also allowed Sarah to deny the many negative statements made by cult members about her worth as a female. When cult members or “customers” would degrade Sarah, she said Fred would assume the primary personality and tell everyone that she was not a girl, so those things “did not apply to me.” Sara identified customers as the individuals whom “my mom trafficked me to.” These individuals provided Sarah’s mother “with drugs” in exchange for sex with her daughter, sex that Sarah described as violent and “sick.”
Throughout treatment, Sarah identified alters who “held specific memories.” Whenever a new memory surfaced, her recall of fragments of the memory brought the alter into an awareness of who held the memory. Sarah said that she had given most of the alters names, but that some of them had informed her of their name. One alter named Mangle held immense pain, especially in her feet and left side of her face. Mangle stated that she was 6 years old. During session, Sarah asked to bring Mangle into the room. Upon switching with the primary personality, Mangle began rocking back and forth as if to self-soothe.
While rocking, Mangle began shaking her head left to right as though her head were on a swivel. She made no eye contact with me, and she recalled torture that included “being drugged,” then laid down on a table and having needles placed underneath her toenails. She said that the left side of her face hurt terribly, that the light in the room hurt her eyes, and there was “just so much pain.” Mangle sat with me for about ten minutes, then asked in a fearful voice to leave because she couldn’t “take any more pain.” Mangle then switched back to Sarah, who reported being an observer to Mangle’s pain and behavior in the session. Sarah stated again that, other than her experiences with alter Roe, her primary personality “rarely fully goes away” when she switches to another alter.
Switching in session became a routine experience because Sarah said that allowing her alters to speak encouraged them to “merge with me.” She stated that previous alters, including the most violent and angry alter, had merged with her primary self. She identified the merging process as one that enabled alters to process the memories and pain they carried, which then allowed them to become one with Sarah. When their voices were heard, Sarah no longer needed them to protect her by holding the suffering in a separate space outside of her awareness.
Phase 3: New Awareness
Sarah’s acknowledgement of alternate versions of the self and embrace of the emotions and body memories they carried created new awareness. After switching and processing the alters’ material in session, Sarah’s primary personality described remembering each of the alter’s memories with vivid clarity. Sarah reported a new sense of wholeness and physical integrity after each alter had merged with her primary self.
Sarah celebrated the loss of each alter personality while grieving the loss of her childhood, and of healthy attachment to the persons tasked with caring for her child self. Remembering the role her mother played in her abuse had caused Sarah to question what it means to be a mother. She reframed experiences with her mom as “teaching me what not to do as a parent,” and she cried when discussing the loving bond between herself and her two daughters.
One of Sarah’s primary fears was that her mother or former cult members would find her and carry out the threats they made about torturing or killing her should she talk about her past. Sharing her memories and allowing alters to speak of the horrors they witnessed violated the cult’s programming. Sarah stated that the consequences for violating programming, for disclosing abuse, were death. Each session concluded with Sarah expressing extreme fear that her programmers (also referenced as “handlers”) or other cult members would find her. We used cognitive behavioral therapy exercises to explore her thoughts and feelings associated with these beliefs, and to challenge the rationale that supported them (Beck, 1995).
Each counseling session thus became a small victory, as Sarah challenged her belief that speaking about the trauma would result in her being hunted down, tortured, and killed. Sarah described deriving new meaning from her experiences as she began writing a book about those experiences in the cult and how they had impacted her present life. Her hope was that sharing her experience would help others to seek professional help, and inspire them to connect with others, rather than to remain isolated out of fear.
While she was in treatment, Sarah was incredibly skeptical of formalized interventions and assessments. She declined to complete the Dissociative Experiences Scale (Carlson & Putnam, 1993) and the Post Traumatic Stress Disorder Checklist (Weathers et al., 2013). She also refused a referral for a psychiatric evaluation, stating that she was unwilling to take medication because when “drugged as a kid” during cult-related abuse, she “seemed too sensitive to medication.” Sarah described feeling fearful and distrusting of doctors, and thus would not seek outside evaluations or intervention.
Sarah’s panic attacks seemed to worsen during specific anniversary dates related to her traumatic experiences in childhood. The worst of these anniversary dates occurred during the 2 weeks prior to Halloween. During that time of the year, Sarah experienced several worse-than-usual panic attacks. She dealt with the worsening symptoms by engaging in additional counseling sessions with me and receiving crisis counseling through the university’s student health center. Although Sarah continued to refuse a psychiatric evaluation, she met with a doctor during the month of October for a physical and to rule out any medical complications.
Access and Barriers to Care
The resource center where I counseled Sarah was located on campus and provided free counseling services to students and community members. Sarah’s status as a student placed in her in direct contact with a multitude of resource centers on campus, including our center. Only two other counseling agencies in the local area provided pro bono services, with one agency located on campus and the other located several miles away from the university.
Sarah and her spouse initially used their bicycles to travel from campus housing to the university and around town. Two weeks after we began our sessions, Sarah’s spouse had his bike stolen from the bike rack in front of university housing. Three weeks later, Sarah’s bike was stolen from a bike rack on campus. After that, she, her husband, and their children either walked or used the bus to travel. Sarah’s limited transportation made it increasingly difficult for both her and her husband to apply for employment and obtain food from local food banks.
The resource center that facilitated Sarah’s counseling partnered with other organizations on campus to bring resources such as food, hygiene products, and clothing to the center. Sarah was able to take advantage of these resources in addition to the counseling. The center also helped her to obtain a free student bus pass to improve her access to transportation. Despite the mobilization of resources to support Sarah, her access to more intensive treatment continued to be incredibly limited because of her financial and geographic barriers.
Trauma Work: A Catalyst for Personal and Professional Transformation
Over the course of our 10 months working together, Sarah and I had met for more than thirty weekly counseling sessions. During the first 2 months of treatment, the duration of sessions ranged from one to one and a half hours. After those first 3 months, when the fall semester began and Sarah had achieved a sense of stability, we transitioned to one 1-hour session each week, with the occasional emergency session when Sarah experienced a panic attack or crisis. While the goal of our weekly sessions was to help Sarah process her memories, gain important resources, and derive meaning from her experience, these sessions also acted as a catalyst for my own personal and professional transformation.
My work with Sarah caused me to critically reevaluate many of my beliefs I had previously taken for granted, particularly my sense of safety in my community. Sarah once compared her life experience to the Upside Down, a parallel universe described in a popular television show as a darker version of our current world. She said that she had lived the majority of her life in the Upside Down, a space for her that paralleled the world everyone else lived in and that for her was inhabited by monsters and steeped in the ever-present threat of death.
Confronted with the reality that my community contains real monsters—people who use their power to harm children and derive pleasure from the abuse they perpetrate—my own reality was transformed. I now view once-trusted others with skepticism. I find myself hyperaware and ever vigilant for signs of danger in the environment, and in the body language of strangers. Although I left organized religion years before I worked with Sarah, I now find myself concerned about the legitimacy of local religious organizations, particularly those that facilitate activities at my children’s school. Although my experience with Sarah may have restricted my sense of safety, I have also had the honor of bearing witness to her healing journey. Sarah’s resilience and drive are evidence that the propensity to overcome human suffering is immeasurable, and that the will to live and love trumps even the most unthinkable cruelty.
Some of my colleagues may attribute the changes in my worldview and identity to vicarious trauma (McCann & Pearlman, 1990), or as the result of countertransference because of my own unresolved issues (Saakvitne & Pearlman, 1996). Vicarious trauma and countertransference speak to the potential adverse effects of bearing witness to our client’s suffering, but they fail to capture the positive effects of expansions in worldview. While I acknowledge the ugliness of the Upside Down and am aware of my new hypersensitivity to potential sources of danger, I now see and appreciate the resilience of life and strength of survivors. I find myself drawn to spending more of my time in the present moment, appreciating the comfort and beauty in simply being.
Treatment Implications and Follow-Up
The effects of cumulative childhood trauma, perpetrated and facilitated by a trusted caregiver, impacted Sarah’s ability to attend to activities of daily living. The distress and panic Sarah experienced when confronted with specific trauma reminders helped her to recall the origins of these triggers. Sarah pieced together fragments of traumatic memories, discovering cohesive recollections of events that related to one another. The creation of a trauma narrative gave Sarah a sense of awareness of and control over her past, and an understanding of how those prior adverse experiences influence her experience in the present.
Sarah described living each day pendulating between emotional flooding and utter numbness. As noted, her symptoms seemed to align with DTD. Although not formally assessed, Sarah’s reported dissociation when confronted with specific trauma reminders and the presence of alternate identities may have warranted the diagnosis of DID (APA, 2013).
The treatment model I have described in this text utilizes basic counseling skills, coupled with a framework for understanding complex childhood trauma, to organize trauma processing. Client and counselor work together to identify and dissect moments of particular distress, then they piece together related fragments of traumatic memory. Rejoining pieces of memory and exploring context and affective states enables the client to create a cohesive narrative and derive meaning from an experience once characterized by chaos and fear.
Recommendations to Clinicians and Students
Clients who report complex childhood trauma, particularly ritual and cultic abuse, often present information in session that seems chaotic and emotionally charged. Providing clients with a rationale for both understanding their problem and the necessary treatment is essential to achieving positive outcomes. Informing Sarah of the purpose behind each intervention, each phase of treatment, and how it related to the developmental trauma she experienced seemed to help her tame the chaos that pervaded her thoughts, feelings, and behaviors.
Sarah was successful in treatment because she developed rapport with her counselor and believed that the therapeutic process could help her. Our sessions were collaborative, and she was provided the opportunity to alter each intervention to meet her needs. My experience with Sarah renewed my belief in the importance of honoring a client’s voice. As clinicians, we honor the client by believing their story, and by acknowledging that they are the expert of their lives.
Understanding how clients came to experience the distress and suffering they present in session is only half of the battle. Clients must be willing to reexperience difficult emotions and painful memories in session. As clinicians, we must provide a framework for helping these clients to practice new skills and develop new perspectives.
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About the Author
Cortny Stark, LPCC, LADAC, CRC, a 2013 graduate of New Mexico Highlands University’s Masters of Community Mental Health Counseling and Rehabilitation Counseling program, is currently a doctoral candidate, graduate assistant, and teaching assistant in the University of New Mexico Counselor Education program. Her clinical practice is grounded in a wellness-based humanistic approach, with an emphasis in trauma-informed care. As a mental health, substance abuse, and rehabilitation counselor, Cortny can provide counseling services for a variety of mental health concerns. Her clinical experiences have led her to specialize in trauma work, substance-use issues, crisis intervention, women’s issues, and medical cannabis as a mental health and medical intervention.