Acknowledging complexity in the impacts of sexual victimisation trauma

ACSSA Issues No. 16 – February 2014

The manifestation of complex trauma

Complex trauma differs from the "memory imprint" of PTSD in two aspects - the circumstances of the trauma event/s and the effects this has on core aspects of a person's sense of self (e.g., cognitions, mental health, emotional stability, and personality).

In relation to the first aspect, part of this is about the length, frequency, and severity of abuse. It is also about the contexts in which such abuse occurs. Child sexual abuse is fundamentally located within familial, care, and social networks, particularly for girls.1 Boys are more likely to be abused outside the home and appear to be at greater risk in institutional settings or an extra-familial environment (Crome, 2006). Boys are also more likely to be abused by a same-sex perpetrator, to experience violence, and more likely to be abused by multiple perpetrators (Cashmore & Shackel, 2013). Within the relevant contexts, perpetrator tactics involve secrecy, complicity and threat. In other words, they are contexts of "captivity", in which perpetrators attempt to create accommodating or "willing victims" (Herman, 1992, pp. 74-113). These two elements together (the nature of the abuse and the context in which it occurs), actively impact on the construction of the self - emotionally, cognitively, and relationally. Repeated trauma in adulthood "erodes the structure of the personality already formed" whereas repeated trauma in childhood "forms and deforms personality" due to the many adaptations developed by survivors to cope with sexual abuse by a guardian figure (Herman, 1992, p. 96). There is an emphasis in the literature on the impact that early onset repeated sexual abuse by a caregiver or guardian has on the development of attachment systems (Liotti, 2004; Van der Kolk et al., 1996).

Expanding research continues to connect developmental dysfunctions and childhood abuse that can result in poor mental health and emotional functioning. There is interest in the link between stress responses in children and atypical development of neuroendocrine and immunological functions. These developmental issues have a relationship to the psychological and behavioural problems associated with childhood abuse. The connection appears to tie structural developmental differences, that can result in an increased risk of psychopathology, to the type of stresses experienced in abusive situations (Cashmore & Shackel, 2013).

The trauma literature also identifies issues of attachment and child development as being a key factor in the development of complex trauma symptomatology, whereby early onset trauma has a particular impact on the developing brain, especially when the trauma is prolonged, repetitive and unrepaired (Kezelman & Stavropoulos, 2012). Where early caregiving relationships are dysfunctional, either as a source of trauma or an inability to nurture and protect a child, the child's developmental competencies in the areas of sense of self, agency, communication, and interpersonal relationships can be negatively impacted, thereby setting the scene for many of the problems associated with complex trauma (Cook et al., 2005).

Forming primary attachments to caregivers who are "either dangerous, or from [the victim's] point of view, negligent, [developing] a sense of basic trust and safety with caretakers who are untrustworthy and unsafe" and maintaining a sense of control in situations of unpredictability (Herman, 1992a, pp. 101-102), requires a range of adaptations and survival strategies that can manifest in a variety of ways such as denial, dissociation, fragmented/disordered attachment or self blame (Briere & Spinazzola, 2005; Herman, 1992a; Luxenberg, Spinazzola, & Van der Kolk, 2001; Van der Hart, Nijenhuis, & Steele, 2005; Van der Kolk et al., 1996; Van der Kolk et al., 2005).

Although these are often adaptive reactions at the time of experiencing abuse, in the longer term they may become maladaptive alterations in functioning. Based on clinical and empirical research, six "symptom clusters" are involved in a complex trauma response:

  • altered self-capacities: dysfunctions in the areas of affect regulation (i.e., regulating emotional states and reactions), distress tolerance, and behaviours and impulses (e.g., self-destructive behaviour, self-harming, excessive risk-taking, sexual involvement and suicidal ideation);
  • alterations in attention or consciousness: changes in memory function (e.g., amnesia) and the tendency for dissociation;
  • alterations in self-perception: perceptions about one's self as a stigmatised, ineffective or damaged self, internalisations of shame, guilt and responsibility, and minimising impacts;
  • alterations in relating to others: changes to the capacity to trust others, maintain personal safety and agency (e.g., re-victimisation experiences or dominating relationships), or victimising others;
  • somatisation: experience of persistent physical illness and difficulties relating to the digestive system, chronic pain, heart and lungs, and urogenital systems (e.g., headaches, irritable bowel syndrome, high blood pressure etc.); and
  • alterations in systems of meaning: changes to personal systems of meaning in relation to the world, one's purpose or self-efficacy within it, and the motivations of others (Briere & Spinazzola, 2005; Herman, 1992b; Luxenberg et al., 2001).

Reactions and behaviours such as dissociation, impulsivity, and substance use disorder are described as, or within, separate and distinct diagnostic categories in the DSM-5.

An array of social and cultural factors are linked to the development and experience of complex trauma. The interaction of particular social problems such as homelessness and the mental health impacts of complex trauma, mean that help-seeking for multiple treatment needs or access to multiple services is potentially overwhelming in its difficulty.

Table 1: Complex trauma response, expressions and relevant social factors
Symptom categories Components Expressions Social & cultural factors
Alterations in self-regulation and impulses
  • Affect regulation
  • Self-destructive
  • Suicidal pre-occupation
  • Difficulty modulating sexual involvement
  • Excessive risk -taking
  • High levels of self-harm
  • Substance abuse & addiction
  • Overwhelmed by anger
  • Casual & unprotected sex
  • Suicide plan
  • Eating disorders
  • Collective and intergenerational history of trauma
  • Low collective efficacy & community capacity
  • Social marginalisation
  • Social isolation
  • Poverty and homelessness
  • Victim-blaming attitudes
  • Negative social reaction to disclosure
  • Perpetrator tactics to silence, threaten victims
  • Perpetrators not held to account
  • Being a client in multiple, poorly integrated systems
  • "Trauma blind" services & responses
  • Rape-supportive attitudes in the community
  • Structural inequality between men and women
  • Racism
Alterations in attention or consciousness
  • Amnesia
  • Transient dissociative episodes
  • Depersonalisation
  • Clouded perception
  • Feeling/being dazed
  • Automation/being on "autopilot"
  • Difficulty remembering appointments, discussions, events
Alterations in self-perception
  • Personal ineffectiveness
  • Changes in personal identity
  • Disturbances in identity formation
  • Feelings of hopelessness & helplessness
  • "Malignant" sense of self (contaminated; guilty; bad; self hatred, shame)
Alterations in relations with others
  • Inability to trust
  • Re-victimisation
  • Victimising others
  • Perceives perpetrator as all powerful
  • Difficulty seeing danger signs/unsafe situations
  • Confused boundary setting
  • Conflictual relationships
  • Desire for a "rescuer"
Somatisation
  • Digestive system
  • Chronic pain
  • Cardiopulmonary symptoms
  • Conversion symptoms
  • Sexual symptoms
  • "Acid" stomach
  • Irritable Bowel Syndrome
  • Pelvic pain
  • Headaches
  • Unexplained symptoms
    (e.g., numbing, tingling)
Alterations in systems of meaning
  • Fatalism
  • World/people as malevolent
  • Loss of hope
  • Loss of belief
  • Lack of self-efficacy
  • Despondency, despair
  • Anger
  • Apathy

Source: Adapted from Herman (1992a,b), Luxenberg et al. (2001), and Haskell & Randall (2009).

Footnote

1 Nationally representative figures show that fathers, stepfathers and other male relatives made up half (51.6%) of perpetrators for girls, compared to one fifth (21.4%) of perpetrators against boys. Boys were more likely than girls to be sexually abused by individuals known to them other than family, such as family friends, acquaintances or neighbours (e.g., doctors, coaches, and clergy) (Australian Bureau of Statistics [ABS], 2006).