Pratyusha Tummala Narra

The long-term implications for sexual assault, such as risk of anxiety, depression, suicidal ideation, eating disorders, substance abuse, and sexual dysfunction, have been documented by researchers and clinicians working with survivors.1,2,3 The internal life of survivors is often marked with feelings of shame, self-blame, and powerlessness, all of which contribute to challenges in self-care and establishing safe and fulfilling relationships.2 Sexual violence further involves stress that is rooted in social injustice and requires attention on individual, community, and societal levels. Despite these challenges, survivors find ways to cope with the extraordinary demands of the aftermath of sexual violence.

As traumatic experiences such as childhood sexual abuse, incest, and adulthood rape have highly complex and individualized effects on survivors' lives, various approaches to recovery need to be considered in attending to the unique needs of survivors. This chapter will address a psychodynamic approach to recovery from sexual violence that is based on contemporary theory and practice integrating individual, relational, and sociocultural contexts of survivors. Psychodynamic theory with its close relationship with psychoanalysis expands on particular aspects of traumatic experience, such as the relationship between external traumatic events and internal processes related to these experiences. The ways in which sexual violence overwhelms the sense of self and the relationship between the individual and his/her environment (family, community) will be explored through a psychodynamic lens, informed by trauma theory and research. A clinical case example will be discussed to illustrate the contributions of psychodynamic theory to an understanding of traumatic experience, resilience, and recovery. First, I will provide a brief overview of psychodynamic psychotherapy followed by a discussion of specific aspects of psychodynamic psychotherapy related to recovery from sexual trauma, including attachment and relationships, affect and memory, real and symbolic features of trauma, and the social context of trauma.

OVERVIEW OF PSYCHODYNAMIC PSYCHOTHERAPY

Psychodynamic psychotherapy includes treatments based on psychoanalytic concepts. In a recent review of the efficacy of psychodynamic psychotherapy, Shedler4 highlighted empirical evidence supporting psycho-dynamic psychotherapy for clients coping with a range of psychological concerns. While psychodynamic therapies vary to some degree with respect to specific foci, some common features of these approaches include an attention to affect and expression of emotion, exploration of attempts to avoid distressing thoughts and feelings, identification of recurring themes and patterns, discussion of past experience as it may influence present challenges, focus on interpersonal relations, focus on the therapy relationship, and exploration of fantasy or symbolic life.4 Psychodynamic psychotherapy emphasizes moving beyond relieving immediate crisis or symptoms and helping the client additionally through self-reflection or introspection within a safe therapeutic relationship. As such, the process of psychody-namic psychotherapy may be either short-term, lasting several weeks, or long-term, lasting several months or years.

With respect to trauma, various short-term and long-term models of psychodynamic treatment for post-traumatic stress disorder have been developed.5,6 For example, Krupnick6 developed a twelve-session treatment approach for a single event of trauma that focuses on the traumatic experience and related intrapersonal (e.g., self-concept) and interpersonal (e.g., typical ways of relating with others). Long-term models of psychodynamic psychotherapy usually address complex post-traumatic stress disorder or complex PTSD,2 which is experienced in cases of chronic, repeated trauma. These models emphasize the relationship between the therapist and client to help the client better understand his/her interpersonal patterns and their connection to childhood relationships with significant people, such as caregivers.7 The role of developmental stress, such as life transitions, losses, and separations, as it intersects with traumatic experience is a focus of psy-chodynamic approaches to trauma.

Much of traumatic and nontraumatic stress, in a psychodynamic perspective, is conceptualized as located in the individual's unconscious, and the concept of bringing unconscious material to conscious awareness in a safe therapeutic space is thought to be central to effectively and accurately discovering connections between past events (traumatic and nontraumatic)

and present day-to-day struggles. Psychodynamic psychotherapy is further concerned with defenses or ways of dealing with painful and/or conflictual needs, feelings, wishes, or impulses that often become compromised under traumatic conditions. This approach focuses on helping a survivor develop the meaning of the trauma itself and how it may fit with his/her sense of self. Finally, psychodynamic psychotherapy is concerned with the ways in which traumatic events interact with an individual's broader personality and development.7

Trauma theory, such as that developed by Judith Herman,2 involves psychodynamic ideas such as the use of defense mechanisms, such as repression and dissociation, in coping with traumatic experience. However, Herman2 emphasizes the feminist concepts of empowerment and reconnection as central parts of the recovery process, which is conceptualized as involving three stages, including the establishment of safety, remembering and mourning traumatic events, and reconnection or the establishment of intimacy in safe relationships. The idea that the survivor be the "author" of his/her own recovery is central to the recovery process.2 In the sections that follow, I will describe in more detail some central aspects of recovery from sexual trauma from a trauma-informed, psychodynamic perspective.

SEXUAL ASSAULT AND RELATIONAL LIFE

Sexual violence in childhood and adulthood contributes to significant challenges in survivors' ability to establish safe, trusting relationships. Childhood sexual abuse, including incest, is especially fraught with betrayal and boundary violations that have lasting impact on the child's attachment with significant people in his/her life such that the child comes to expect into adulthood that relationships will be abusive. Psychodynamic theorists, such as Davies and Frawley,8 similar to feminist trauma theorists, value the importance of validating the survivor's traumatic experience. It is often the case that the therapist is either the only person or among the few people with whom the survivor has discussed his/her sexual trauma. A trauma-informed, psychodynamic approach entails bearing witness to the survivor's narrative of traumatic experience.

A focus on developmental issues related to traumatic experience is especially helpful in clarifying how early attachments and traumatic experience shape one's identity. The adverse effects of traumatic experience on attachment are well documented. Studies in developmental psychopathology have found not only that insecure attachment resulting from trauma and severe neglect is connected with difficulties in regulating emotions, attention, and self-control, but also that insecure attachment is a relatively stable problem for individuals, particularly in the face of ongoing negative life events.9,10,11

Fonagy and Bateman9 suggest that trauma in early or late childhood causes disruption in one's capacity to understand and differentiate one's own experiences as well as those of others. They point out that a child who is sexually violated may identify with the aggressor or perpetrator in order to gain or maintain a sense of control over the abuser and abusive conditions. In this case, the child internalizes the "intent of the aggressor in an alien (dissociated) part of the self," (p. 5), and while this internalization is an adaptation to the trauma, it can contribute to feelings of self-hatred and self-blame. Psychodynamic theorists, focusing primarily on childhood sexual abuse, further conceptualize dissociation in traumatic experience to be unavoidable as a survivor attempts to integrate contradictory images of the self and abusive adult. Dissociation in this sense can be a positive adaptation when an individual is experiencing trauma as he/she copes with overwhelming feelings of terror and helplessness, and may later continue to persist as an individual copes with new traumatic and nontraumatic stress. New experiences, both positive and negative, intersect with old images of self and other, consciously and unconsciously, to form self-concept in the present day.12,13 Internalizing aspects of the abuser and the abuse are thought to be rooted in the experience of powerlessness and loss of hope, both of which are central parts of traumatic experience.14 In other words, internalization is a way to maintain connection in the face of loss of personal control and safety. Even in situations when a maltreated child defies the abuser, he/she may internalize negative attitudes of the abuser, such as feeling like he/she is a bad person, characterizing a traumatic bond that may be resistant to change.2,14 Marjorie, a thirty-five-year old survivor of childhood sexual abuse by an uncle, stated in a psychotherapy session, "I just avoid him (uncle) most of the time, but when I saw him at my sister's wedding, it felt like his opinion matters to me. I used to look up to him. I hate him, and I want him to leave me alone." Deidre, a twenty-seven-year-old survivor of rape in adulthood, stated, "I still think that sometimes that I let this guy do this (rape) to me, like he saw something about me that was vulnerable. I'm not a strong person, and maybe he could see that about me." These struggles with emotionally separating oneself from the abuser and the abuse characteristic of traumatic bond are especially difficult in the case of sexual abuse in childhood, which involves distortion and overstimulation of bodily sensations without boundaries between the abusive adult or older child, and the child who is violated; the confusion of loving and hostile feelings; the betrayal of trust; and the secrecy imposed by the abuser.13,15

In addition to internalization of negative attitudes, sexual violation contributes to confusion about sexuality. Trauma research has indicated an association between trauma and sexual risk behaviors.1,16 For example, women of diverse ethnic backgrounds (White, African American, Hispanic) who experienced sexual trauma were at greater risk to use substances at the time of sexual intercourse with partners, and to have two or more sexual partners at the same time.17,18 Additionally, sexual violation can contribute to confusion concerning sexual orientation and identity, even though the experience of sexual violation does not determine sexual orientation. While both men and women who have been sexually abused may experience post-traumatic symptoms, such as flashbacks, loss of trust, depression, feelings of shame, dissociation, addictive behaviors, and boundary violations, sexual abuse may have different meanings for boys and girls.19 For example, men tend to underreport experiences of sexual violation and may experience sexual trauma as undermining or challenging a sense of gender identity and sexual orientation. James, a twenty-five-year-old gay survivor of childhood sexual abuse by a male "friend" of the family, stated in a psychotherapy session, "I don't think that I'm gay because of what happened to me, but I think that he (abuser) might have figured out that I'm gay. Maybe this is why he kept pursuing me and just spending so much time with me. I've realized that I'm like him in that I try too hard to pursue other men now." My client's experience of being chosen for this abuse is common to both female and male survivors. James's struggle with being "too pushy" at times in finding a sexual partner in his adult life reflects his struggles with his early experience with his abuser. For male survivors, the difficulty with negotiating differences between sex, love, affection, and abuse may be pronounced as they cope with traditional expectations of masculinity.19

One of the most salient consequences of sexual violation on relationships involves the degree to which external validation and supports are available to a survivor. Smith14 has described the intense emotional aloneness that characterizes traumatic experience, which can exacerbate difficulty in revisiting or talking about the trauma. Psychodynamic therapy approaches the experience of emotional isolation through the survivor's connection with the empathic presence of the therapist.15 Just as the survivor's interactions with the abuser hold significant meanings for the survivor's relational life, the experience of neglect or parental absence in the case of childhood sexual trauma can be equally important. For example, when a survivor of childhood sexual abuse is not protected by the other parent or caregivers or when an adult survivor of sexual assault is told by a family member or a friend that the assault was provoked by the survivor, the capacity to establish trust and self-esteem is compromised. A nonprotecting bystander who does not bear witness to the survivor's experience or trauma contributes to ongoing emotional costs to the survivor.20 A survivor may feel distrustful and become hypervigilant to his/her surroundings or maintaining safety in relationships. This may be true in the case of psychotherapy, as well. The lack of safety in relating to others can be reexperienced in psychotherapy, as the therapist may be experienced unconsciously by a survivor as an abuser, victim, rescuer, or nonprotective bystander at varying times in the course of psychotherapeutic work. This type of traumatic transference is worked through and discussed with the survivor, as healing from trauma requires that sexual violence be revisited through talking.2,21 The role of the therapist as bearing witness to the trauma story and holding hope for the survivor is a central part of the healing from the relational challenges implicated in sexual trauma.

SEXUAL ASSAULT, AFFECT, AND MEMORY

Sexual assault occurring in childhood and adulthood contributes to important changes in one's emotional functioning. Children need emotional signals to be accurately mirrored by their caregivers to develop a positive, coherent sense of self. Recent research in neuroscience indicates that the experience of early childhood abuse and neglect has adverse effects on the nonverbal right hemisphere of the brain, which is involved with regulation of emotions and dissociation.22 When traumatic experience is invalidated by parents in the case of sexual abuse in childhood, or by significant others in the case of sexual violence in adulthood, the survivor's self-perceptions and his/her ability to identify and label emotions are compromised.9 When a safe emotional environment is unavailable, an individual's sense of self or ego is overwhelmed with the cruelty of abuse, and self states or fragmented aspects of the self can form as a way of coping with unbearable emotional pain.8,23,24 These self states are thought to function independently and can remain disconnected from each other even when the abuser is no longer a threat to the survivor. The survivor then faces difficulty with feeling his/her experience as "multidimensional, layered, conflictual, and contextual,"23 and may find that he/she cannot access internalized anger, sadness, or shame.

In the case of childhood sexual abuse by a caregiver, the need to stay connected with the abusive parent perpetuates these dissociative processes, in which affect or emotional experience is disconnected from conscious-level experience. Trauma experts2,15 have pointed out how child survivors of sexual abuse experience internal splitting as they face separate realities, including the reality of abuse and the minimization or denial of the child's experience by the abuser and/or family environment. In such cases, affect, memory, meaning, and fantasy remain dissociated from conscious awareness and remembered only as isolated parts of the trauma. Dissociation is experienced by children and adults who suffer sexual trauma and tends to persist in cases of chronic or repeated abuse, particularly when the experience is not discussed or validated.2,15,25 One of the most pronounced ways in which dissociation is evidenced in survivors is the disconnection between cognition and affect, where a survivor becomes numb or talks about the abuse in a way that is only factual.

Psychoanalytic scholars have written about the concept of "unformulated experience,"26 or the way in which dissociated, traumatic material remains closed to elaboration and symbolization, such that this aspect of the experience is not connected with verbal language.27 As separate self states are formed in the case of sexual violence, memories of abuse may resurface unconsciously as nightmares or flashbacks, somatic or physical distress, and through reenactments or repetitions of abusive or destructive relational patterns.2,8 Traumatic experience expressed and remembered through physical distress may be particularly salient in the experience of survivors whose cultural backgrounds may emphasize the expression of psychological distress through physical symptoms, such as headaches and gastrointestinal problems, rather than verbal expression of distress.28

An example of the way that trauma is remembered behaviorally is evident in the case of a survivor who engages in risky sexual behavior, perhaps as a way to regain control and mastery over past abusive experience, only to experience fear, sadness, and aloneness. The recovery from sexual trauma necessitates that a survivor discloses his/her story gradually in psychotherapy, and while revisiting the traumatic past, address feelings of shame, guilt, loss of control, and conflicts related to one's own aggressive thoughts and impulses. Psychodynamic approaches to recovery emphasize the unique meanings of the trauma to the survivor, and related affective and memory processes that are shaped through past and ongoing interpersonal contexts. As such, the survivor faces his/her ambivalence, confusion, and doubt about the traumatic memories and works toward a more coherent, meaningful narrative of his/her traumatic experience and its place in present-day life.

THE REAL AND SYMBOLIC ASPECTS OF TRAUMA

Psychodynamic approaches to recovery from sexual assault address the ways in which external realities of sexual violence are experienced by an individual in the context of his/her unique developmental and interpersonal contexts. This intersection of external events and internal life, as evidenced in psychodynamic concepts such as internalization of traumatic experience, is the basis for attending to the real and symbolic features of trauma. Maureen, a forty-six-year-old survivor of sexual violence by her former husband, expressed in a psychotherapy session, "I hated it when he would drink. This pretty much meant that he was going to rape me. I was scared that he would kill me. He just saw me as a thing to control, like a nobody. I think I felt like this even before I got married to him, but he just made it worse. I guess I didn't accomplish what he did professionally. I thought I was nobody for a long time." Maureen's statement concerning the meaning of her husband's aggression against her speaks to not only the actual sexual violence, threat to her life, and related dissociation from the rape, but also the symbolic meaning of her traumatic experience, which involved feelings of worthless-ness or like a "nobody," a feeling she described as a familiar one that dates back to her life prior to marriage. The ways in which this external traumatic event is processed in the context of her life preceding her marriage (childhood, adolescence, early adulthood) and following her divorce is a focus of psychodynamic psychotherapy.

Maureen's internalization of feeling like a "nobody" is an aspect of her trauma that has implications for her personality. Mathews and Chu15 highlighted the way in which actual trauma and the memory of trauma are composed of external and internal elements. One example of this intersection of the external and internal aspects of trauma occurs when an adult survivor of childhood sexual abuse remembers being threatened by an abusive parent, and at the same time remembers his/her own imagined or fantasied feelings of terror, guilt, or rage. A fantasy of feeling guilty or responsible for the abuse is then met with the terrible reality of abuse. These interactions between the abuse and beliefs about the self in relation to the abuser become components of personality functioning, as evidenced in vulnerability to fragmentation, dissociation, feelings of self-blame, helplessness, problems in forming and maintaining supportive relationships, limited range of defenses and positive ways of coping with stress, and difficulty with authenticity and positive life change in adulthood.15

Psychodynamic approaches conceptualize psychological distress, including that resulting from trauma, as involving a narrative of the self and the external world as evolving.2,29 How trauma is experienced for a survivor changes with time, as new experiences influence self-image and interactions with others. Additionally, the therapeutic relationship contributes to these evolving narratives, as trauma may be understood and experienced differently by a survivor as he/she works through enactments within the therapy that reflect aspects of the traumatic experience. For example, Malcolm, a thirty-eight-year-old survivor of rape in his early twenties, stated, "I want to start trusting you (the therapist), but it still feels like if I start talking about more details, then you might see me as weak or something." At this point in his treatment, Malcolm acknowledged the importance of trusting me, which he was unable to do early in our work, as he worried that trusting me would signify weakness or vulnerability.

Over the course of several months, he was able to share with me his concerns about trust more explicitly and how this difficulty fits with the actual rape. In the second year of psychotherapy, he expressed in one session, "I've told you what happened to me (the rape). You seem like you can handle it. I've always been a strong person, independent. This feels different in here to talk about this stuff. Maybe this is being strong . . . I don't know." Malcolm's statement indicates a movement toward a possibly different narrative of his internal experience of the actual traumatic experience and specifically his self-image as someone who is still strong and independent even when he feels vulnerable. Psychoanalysts such as Davies and Frawley8 have also suggested that different self states or ego states experienced by the survivor should be explored in psychotherapy as a way of ongoing elaboration of narrative of trauma and of the self. In other words, psychodynamic therapy involves the therapist and client to explore fully the various aspects of the self that have been shaped by the traumatic experience, how constructions of the self may change with context and time, and eventually how an individual makes meaning of his/her trauma and develops new safe and fulfilling relationships.

ATTENDING TO SOCIOCULTURAL CONTEXT

In recent years, psychodynamic approaches have increasingly considered the role of sociocultural context to be a critical element of understanding the effects of traumatic experience on survivors of trauma. Traumatic experience and expression of distress are influenced by cultural beliefs, sociocultural histories, and community of reference. A survivor of sexual assault who has been raised with a cultural value on modesty of clothing style may experience a sense of guilt and wonder whether or not she had somehow provoked the assault. In another instance, a survivor of sexual abuse who strongly identifies with a religious belief that denounces premarital sex may feel that she is damaged or dirty. In a different example, a survivor for whom it is more culturally compatible or congruent to express psychological distress through physical symptoms may find it challenging to talk about the sexual trauma in psychotherapy. Sociocultural context further involves the issue of language. For bilingual or multilingual survivors, memories may be processed in the first or native language, contributing to varying experiences of sexual trauma in each language. Some of my clients who are bilingual have expressed that it is easier to talk about their childhood sexual abuse in English rather than a native language, as the abuser was someone who spoke the native language and the abuse "occurred" in the native language. For other clients, the reverse is more compatible with their experience, when it is important to talk about the traumatic experience in the native language. In some cases, speaking in one's own native language can facilitate a more immediate connection to and accessibility to a wider range of feelings associated with the traumatic experience. These variations in sociocultural context hold important meanings for the ways in which social roles and identifications shape aspects of self-experience in the case of sexual trauma.30,31

Social structures such as racial hierarchies evident in many societies, including the United States, further engender experiences of good and bad self states, involving feelings of devaluation and shame imposed by dominant society to members of racial and ethnic minority groups.30,32 Racial identity and ethnic identity have important implications for survivors' constructions of sexual violence, and their identifications with and relationships with their communities of reference. Daniel33 has written about the negative impact of racial and sexual trauma directed against African American women. She highlighted the problem of negotiating identity in the context of historical and ongoing racial injustice and sexualization of African American women by dominant society. In such instances, survivors of sexual violence cope with multiple burdens imposed by social context, contributing to silence and invisibility of traumatic stress.31,34 The invisibility of traumatic stress experienced by many ethnic minorities contributes to the perpetuation of stereotypes and racially driven trauma perpetrated by abusers from both within and outside the survivor's racial and/or ethnic group.

The experience of homophobia in conjunction with sexual trauma is further reflective of how social context can influence traumatic experience. Gay, lesbian, and bisexual (GLB) survivors of sexual violence remain largely neglected in the research literature. Russell, Jones, Barclay, and Anderson35 pointed out that GLB survivors are often blamed for their abuse by others, contributing to feelings of powerlessness, shame, and fear. The lack of acceptance and homophobic reactions of significant people in a survivor's life can engender confusion about sexual, gender, and social identity and complicate the coming-out process.35 Different forms of oppression such as racism, homophobia, sexism, and poverty compound the effects of sexual violence and are sometimes used to shift blame to the survivor.36 Psychody-namic approaches to sexual assault consider the ways in which a survivor makes meaning of his/her social context as it shapes and informs his/her experience of trauma, and how social difference between therapist and client may influence the therapeutic relationship.31,37

RECOVERY AS COMPLEX AND MULTIDIMENSIONAL

Recovery from sexual trauma, from a psychodynamic perspective, is conceptualized as complex, involving multiple dimensions of exploration. A trauma-informed psychodynamic perspective focuses on the ways in which sexual trauma interfaces with internalized aspects of the trauma to give meaning to one's experience of the self, and therefore addresses conscious and unconscious dimensions of trauma. Similar to trauma theory, psycho-dynamic theory conceptualizes recovery from trauma as involving validation of the survivor's experience, integration of self-identity, improvement in affect tolerance, impulse control, organization of defenses and coping, and supportive interpersonal relationships.2,38,39 Additionally, the role of bearing witness and sharing power in the therapy relationship is a central goal of trauma-informed psychodynamic psychotherapy.40

The recovery process from a psychodynamic perspective is thought to be "structured and paced"15 such that traumatic experience is discussed in the context of a safe therapeutic space. The initial stages of therapy involve the development of safety and trust, and the pace of therapy is largely directed by the client. Many survivors who enter psychotherapy are coping with significant difficulties with trust, and through developing a safe and consistent relationship with a therapist, develop an increasing capacity to trust others and recognize and tolerate their own feelings of anger toward others and themselves. During the early phase, the therapist validates the survivor's intense emotional suffering connected with the traumatic event and facilitates the survivor's attempts to tolerate and accept these painful feelings. A major goal of this initial stage of recovery involves improving one's self-care and safety in areas such as substance abuse, self-injury, and high-risk or dangerous situations where a survivor could be victimized. Safety and self-care are achieved through a growing awareness of the impact of trauma on one's life, mobilizing resources to increase day-to-day functioning, developing strategies to express one's feelings more effectively, and encouraging one's connections to others who are supportive.2,15

As a survivor develops adequate safety in his/her life, therapeutic work increasingly involves a more in-depth discussion of traumatic history, at a pace that is tolerable and therapeutic. As this exploration can be experienced as retraumatizing, it is critical that safety and supports are well enough established for this work to proceed in an effective way. An important aspect of this phase of treatment is the exploration of the details of the trauma and what may be fantasy connected with and produced in the context of trauma. Mathews and Chu15 suggest that the middle stage of psychodynamic psychotherapy entails a period of mourning of both the sexual trauma as well as what was lost as a result of the sexual trauma, such as the wish for a loving parent or a trusted significant other. Additionally, this phase of recovery involves remembering and reconstructing traumatic experiences into a more coherent narrative than what previously was remembered by the survivor. Traumatic memories that were previously dissociated may emerge in the context of the interaction between the therapist and the client, in which the therapist may be experienced unconsciously by the survivor as a loving parent or friend and at other times as an aggressor or perpetrator. The therapist may also develop a wide range of feelings, such as anger, helplessness, and sadness, as the survivor discusses traumatic experiences. It is by working through the transference and countertrans-ference that traumatic memories and reconstruction of these memories gradually inform the survivor's present experience and understanding of the traumatic event(s). This process of remembering and reconstruction typically involves grief and mourning in which a survivor may experience intense feelings of loss connected to the trauma, as he/she begins to make sense of what has happened in his/her life.2,8,15

The final stages of trauma recovery involve the consolidation of new insights, practicing new skills, developing new relationships, and transforming identity.2,15 In this phase, a survivor actively seeks to confront and engage with his/her fears and seeks positive, mutual relationships with others. For example, a survivor of rape may work more actively to experience sexual pleasure with a partner, something that he/she felt was impossible or difficult to attain following the rape. In other cases, survivors are engaged with social action as a form of empowerment and healing. One recent example of this type of engagement involves the survivors of sexual abuse by priests who have spoken out about their experiences of sexual trauma and its impact on their lives. A survivor's public expression of these experiences can help to transform the stifling and sometimes debilitating silence of sexual trauma for the survivor and other survivors and raise societal awareness of sexual violence directed against children and adolescents. While recovery from trauma has been described in the language of stages or phases, it is clear that recovery does not follow a linear path and that each phase may be revisited throughout one's life, particularly during important life transitions.

Psychodynamic perspectives further consider the centrality of resilience in the trauma recovery process. While this approach is deeply concerned with the losses incurred in sexual trauma, it also attends to how a survivor has coped with and adapted to unbearable circumstances and betrayal. This approach honors survivors' ability to not only survive the trauma but also to create stability in various aspects of their lives. Most of my clients who are survivors of sexual assault have mobilized their internal strengths and capacities and external resources to achieve success in important areas of their lives, such as academic achievement and raising children in a safe environment. Lily, a forty-year-old survivor of rape, stated, "I don't think anyone now could guess that I was raped. I know I come off strong because I'm a leader at work. I wonder sometimes, though, if someone can tell." Lily's comment speaks to the complex nature of trauma, resilience, and recovery, in which parts of her experience are separated from each other. Nonetheless, her ability to transform her traumatic experience is evident.

Resilience in the face of sexual trauma can be conceptualized as multidimensional, including individual, family, and community levels.39 While individualistic notions of resilience tend to focus on an individual's personality traits or achievement as characterizing resilience, collective resilience is defined through positive connections with family members and larger com-munities.31 Engaging in groups for the purpose of social action and change compose other ways of mobilizing one's supports and resilience. Herman,41 in a study of restorative justice among victims of violent crime, found that the role of community support is critical in helping a survivor who chooses to take legal action against the perpetrator, as the survivor's anger toward the perpetrator is often stigmatized in the legal system and more generally in society. The wish for communities to take a stand against the offense was clearly voiced among the participants in Herman's study.41

Psychotherapy can be one critical means through which a survivor accesses his/her resilience, as the therapeutic space is one in which the survivor feels empowered and gains a sense of agency in his/her own life. A trauma-informed psychodynamic approach to recovery considers the importance of addressing sexual violence on multiple levels, all of which may help a survivor to engage with unique and multiple layers of traumatic experience. This approach seeks to facilitate the ability of the survivor to voice his/her own narrative and aims to help the survivor to gain insights that he/she will integrate with new relationships and a transformed sense of self. Such work requires attention to both what is lost and sustained in the traumatic experience. The following case example illustrates the way that a trauma-informed, psychodynamic approach to recovery from sexual assault contributes to the changes that I have mentioned.

CASE EXAMPLE

Lorna is a thirty-two-year-old single, second-generation Chinese American woman, who sought psychotherapy to cope with increasing anxiety in her relationships with her family and her boyfriend. I worked with Lorna for three years in weekly individual psychotherapy. When I first met Lorna, she was enrolled in a graduate program in a finance-related discipline. Lorna had seen a therapist in her third year of college when she had experienced recurrent nightmares about being locked in a room by her paternal aunt. While working with a female therapist for four months in college, she disclosed to her therapist that she had been sexually abused by her paternal aunt, who was in charge of taking care of her periodically throughout her childhood (ages five through nine). Lorna had not told anyone other than her best friend in college that she had been abused in childhood. After learning that her therapist was relocating, she decided to end psychotherapy, although she reported feeling helped by her therapist. Approximately five years later, she was raped by a former boyfriend whom she had dated for a year. The rape occurred after he had followed her home after a party at a mutual friend's home. Lorna expressed that she had ended the relationship because she felt "emotionally and financially controlled" by him. After the rape, she called a friend who helped her access medical care. Lorna decided to not press charges against her former boyfriend. Other than speaking with her physician about the rape, she has not discussed it with anyone in depth.

Lorna was born and raised in a poor, urban neighborhood in the United States. Her parents immigrated to the United States prior to her birth and worked in a family business owned by her father's older brother. Lorna has a younger brother who apparently did not suffer any sexual abuse, although she recalls that both she and her brother were often left alone to care for themselves for long periods of time. Her parents worked long hours and had minimal financial resources to access child care. Lorna's paternal aunt was one of their relatives who was apparently available to take care of her and her brother while her parents were working. Her aunt sexually molested her and threatened to hurt her, her brother, and her parents if Lorna ever revealed the abuse to anyone. The abuse continued until she was nine years old, after her paternal aunt and uncle divorced and relocated to different parts of the country. Lorna remembered that she did not sleep or eat well throughout her childhood and adolescence. When she was an adolescent, her parents tried to establish a closer relationship with her and her brother as they attained financial stability. However, she remembers feeling lonely and tended to withdraw from them when they tried to become more involved in her life.

Lorna enjoyed attending school, as she felt that this gave her a "break" from her home life. She excelled academically and studied dance for several years. At the same time, she experienced difficulty with fitting in socially with the other children at school. She described herself as shy and feeling as though she was different because of her Chinese background. While school felt like a place of respite in some ways, Lorna continued to feel lonely. In college, she developed a few close friendships and attempted to create an identity that was separate from her parents and from other Chinese Americans. After graduating from college, Lorna worked in a bank for several years and then decided to pursue a graduate degree. During her years of working at the bank, she began to use marijuana regularly to cope with her feelings of loneliness, depression, and anxiety. The substance use increased in frequency after she had been raped. She eventually decided to seek help from a therapist to address her long-standing distress, after one of her professors noticed her anxiety in interacting with others.

When I first met Lorna, she talked about her difficulty in talking openly about the sexual abuse and the rape. She was unsure of whether or not talking about the sexual trauma would be helpful to her. Our initial work focused on establishing her personal sense of safety, as she joined Narcotics

Anonymous to help address her ongoing substance use. Lorna and I also worked on breathing and relaxation exercises to help her cope with her immediate feelings of anxiety. As our work progressed, we talked increasingly about the ways in which she coped with her traumatic experiences, including her tendency to avoid painful memories by disconnecting herself through substance use. Over the next several months, Lorna spoke more about her family life, and eventually details of her sexual abuse and rape. She tended to focus primarily on her feelings of shame and self-blame concerning the sexual abuse and often wondered why she was chosen by her aunt to be abused. She was not able to imagine the possibility of telling her parents about what had happened to her, as she continued to feel distant from her family and worried that they would blame her for the abuse. At the same time, Lorna hoped for a closer relationship with her parents, particularly since her relationship with her boyfriend had deepened. She was also concerned about telling her boyfriend about her sexual trauma both in childhood and adulthood. While exploring details of her trauma in therapy, Lorna stated, "I always wanted to hide what had happened to me, maybe so that I wouldn't have to believe that everything actually happened. Now, it feels like I can't escape it. It keeps creeping up no matter how much I want it to go away."

Lorna further struggled with her Chinese American identity, as she associated intensely negative feelings about her heritage with her abusive aunt, whom she remembered as a "traditional Chinese woman," at least in the perception of others in the family. She also had mixed feelings about speaking in Chinese, as she simultaneously wished to distance herself from her painful traumatic memories and connect with positive aspects of being of Chinese heritage. When her boyfriend who is White, European American, urged her to teach him more about Chinese culture, Lorna reacted with ambivalence even though she appreciated his efforts to build intimacy with her. As their relationship deepened, Lorna became increasingly anxious about her intimacy with him and worried that he may leave her if he learned about her sexual trauma. In a session during the second year of psychotherapy, she stated, "I don't know how I'm going to talk about the rape with him. I think he would think the sexual abuse was weird but not my fault. It might not be the same with the rape. He might think I did something to provoke this." I asked her if these concerns were more reflective of her own view of herself, and not only her concerns about her boyfriend's perspective. Lorna responded, "I feel like this could be me—someone who is responsible in some way. Maybe I could have stopped it. I don't want to think about losing him (boyfriend). He is the first person I feel safe with." We continued to discuss the ways in which Lorna was both traumatized by her aunt and her former boyfriend, how she had internally constructed her trauma, and its implications for her image of herself and for what was possible for her in the future.

As Lorna's work progressed further, she began to talk with her closest female friends about her sexual trauma and her concerns about her relationship with her boyfriend and was no longer using marijuana. She also began to explore friendships with a few Chinese American peers and to attend cultural events, such as Chinese music and dance programs. During this time, she also wondered about her attachment to me. She stated, "I'm feeling like I rely on you a lot more than what I thought when I first started seeing you." She talked about her concern that we would end the treatment before she felt ready. We discussed the ways in which our relationship at times felt as though she had little power, and we agreed that our work would end when she decided that she was ready to end it, and when we had adequate time to talk about ending the work. We also talked about the ways in which she may have experienced having a female therapist who is of a South Asian background, particularly when considering her abuse by a female caregiver. The issue of power in our relationship was critical to Lorna's feelings of safety and to addressing her anxiety, substance use, and loneliness, all of which were directly related to her sexual trauma.

CONCLUDING COMMENTS

Lorna's case illustrates some basic foundations of trauma-informed, psychodynamic psychotherapy as a path to recovery from sexual violence, including attending to the horrible realities of her sexual abuse and rape, her coping with these experiences, her ongoing concerns about safety, her internal constructions about the abuse and about herself, her resilience, and her relational life both within and outside of psychotherapy. While Lorna's recovery extends beyond our work together, my hope was that she is able to integrate her new insights to her life in an ongoing way. She decided to end treatment as she relocated out of the area to begin her career. Lorna stated in our last sessions that she would resume psychotherapy with another therapist when she felt that she could benefit from this work again in the future. Lorna's recovery, as with many other survivors of sexual trauma, is one that will involve continued negotiation of her traumatic past and internal struggles throughout life transitions, as she moves toward a more coherent sense of self and a more satisfying relational life.

While a psychodynamic path to recovery typically entails a survivor's engagement with psychotherapeutic treatment, aspects of this perspective can be integrated with other forms of healing from trauma. In particular, the psychodynamic focus on safety in relationships, coping and defenses used in the face of trauma, emotions and memory, internal constructions and meanings of traumatic experience, social context, and individual strengths are all relevant to healing from sexual trauma. Each of these aspects of trauma is especially important to explore in recovery, in light of the complex and multidimensional nature of sexual trauma.

STRATEGIES FOR SELF-CARE

1. Increasing safety

A. Identify and record in a journal people, places, and situations that are emotionally and physically safe.

B. Attend to your physical needs, such as eating a balanced diet, exercising, and getting adequate sleep.

C. Read literature informing you about the effects of trauma on the individual and/or his/her family.

D. Identify and engage in activities that decrease stress. These activities might include physical exercise (walking, jogging, yoga), dance, listening to music, playing a musical instrument, painting, watching a movie or a show that is a comedy, meeting with a supportive friend or family member.

E. Identify triggers (people and surroundings) that increase stress. What is a typical way that you would manage this stress? Write down in a journal or tell a supportive person in your life how you may try to use a positive coping strategy to deal with this stress.

2. Coping with traumatic memories

A. Write down in a journal memories of the traumatic event. If and when you feel that you want to read what you have written, read your journal.

B. Talk about your memories in a pace that is comfortable for you with a trusted friend or family member.

C. Allow yourself the time and space to think about the memories. You may choose to schedule a specific amount of time in the day or evening to reflect on the memories, so that you feel more in control of your memories.

D. Practice relaxation strategies, such as yoga, meditation, quiet reflection, and breathing.

3. Forming positive connections

A. Identify and write in a journal what you hope for in your future.

B. Identify your major goals in a relationship with a significant other. What is it that you hope for in a relationship with a family member or a romantic partner? What are your expectations? Write your thoughts in a journal or talk with a trusted friend or family member.

C. Continue engaging in activities that relieve stress as you take new risks in building new, positive relationships.

D. Discuss your concerns about your relationships with someone whom you trust.

E. Explore ways in which you may connect with broader social action. One example is to volunteer your time in an effort to promote safe and healthy relationships.

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