SEXUAL TRAUMA AND THE BRAIN
I am a drama therapist who could not function properly without art, music, movement, and poetry. All of the other art modalities intersect with drama, prepare for it, enhance it, empower it, develop it, and release it. I have found this to be particularly true when working with clients who are recovering from sexual trauma.
Because sexual trauma runs so deep and creates so much overwhelming shame and confusion within the survivor, addressing the emotional wounds caused by the manifestations of sexual abuse requires the choice of therapeutic methods which can create emotional distance and a safe container. Survivors of sexual trauma are not just “resisting” when they avoid dealing with their issues or when say they can’t access their emotions because they feel numb. They are not just “overreacting” when they lash out in anger, experience flashbacks, or display other emotional outbursts in or outside of the therapy session. Their behavior is a direct result of the biological changes that have occurred in their brains in response to their traumatic experience.
Studies reveal that trauma material is not encoded in the brain’s long-term memory system in meaningful narrative form as non-traumatic experiences are, but is dissociated into somatic sensations, undifferentiated, free floating affective states, and visual images that can break through to consciousness in nightmares and flashbacks (van der Kolk et al, 1996; van der Kolk, 2002). This is experienced as threatening and overwhelming as if the trauma were happening all over again in the present moment, not as a past event (van der Kolk et al, 1996; van der Kolk, 2002). An immediate lack of emotional distance is created the minute the survivor starts accessing the past trauma, whether triggered by chance in everyday life or on purpose in therapy.
Words are inaccessible when the brain is in a traumatized state. Brain scans reveal that while remembering trauma, survivors’ right hemispheres, where negative emotions are processed, become active and Broca’s area in the left hemisphere, where words are processed, shuts down (van der Kolk, 2002). This literally leaves trauma survivors in a speechless condition. Bessel van der Kolk, one of the world’s foremost authorities on traumatic stress reactions, says, “When people get close to reexperiencing their trauma, they get so upset that they can no longer speak….Fundamentally, words can’t integrate the disorganized sensations and action patterns that form the core imprint of the trauma.” (Wylie, 2004, 34-35). As a result, he currently advocates nonverbal therapeutic approaches to trauma material (Wylie, 2004; van der Kolk, 2002).
VISUAL IMAGES TO ART TO WORDS
If clients do not have access to words, it makes sense that the subject of the trauma is best broached through images. Likewise, if clients feel mentally, physically, and emotionally overwhelmed when approaching traumatic memories, it makes sense that a less embodied, more distanced therapeutic modality be used. Art therapy is often a better initial approach to identify and express an experience that was horrific beyond words and somatic in origin. The visual images have been preserved in unconscious, nonverbal memory and can serve as the tools to bring the unconscious to light. The resulting art work acts as a safe, distanced container that can hold the feeling and the memory of the experience for the client.
Putting the trauma into words so it can be understood, translating those words into metaphors, and integrating the meaning that is created back into one’s life history is necessary for healing. Humans are narrative-making creatures and we cannot integrate an experience into our mental schema and emotional make-up until we can make sense of it for ourselves within a worded story of our life (Dayton, 1994, 1997, 2000; Herman, 1992; van der Kolk et al, 1997). The art work, because it physically exists, can capture the essence of the image and feeling in a way that does not feel overwhelming. It can then be returned to in future therapy sessions as a resource for putting the experience into words and creating metaphors. The therapist can say, “Tell me about this,” or “Tell me more.” What often begins as a description of the object turns into an explanation of what it means at a symbolic level or a narrative of the traumatic experience itself. Therapeutic work can move into the other distancing containers of movement, music, drama, or poetry later when the client has been able to get past the hurdle of acknowledging the traumatic experience to the self and to witnesses (therapist alone or therapist and group) and has moved a little further into the healing process. At all points the client can feel in control because she made the image herself, she is able to step back from it to observe it, and she uses her own words to describe what it means to her.
SEXUAL TRAUMA AND ADDICTION
While I was working with recovering drug addicts at Second Genesis in Washington, DC, a long-term residential substance abuse treatment center, I found that the vast majority of my clients, both male and female, had experienced multiple sexual traumas. Van der Kolk states that about one-third of traumatized people eventually turn to alcohol or drugs to relieve themselves from the emotional symptoms caused by their trauma (van der Kolk, 2002, 38). I discovered as I listened to my clients’ stories that many were survivors of childhood/adolescent incest or rape and almost all of them had prostituted themselves during their addiction in order to procure drugs. If you needed to get high and you didn’t have any money, sooner or later you ended up prostituting yourself formally for money or informally as a barter for drugs. It was hardest for the men to admit to this, since most of them identified as heterosexuals but had engaged in homosexual acts. The vast majority of potential customers interested in buying sex on the street were men who were looking for either heterosexual encounters or homosexual encounters. While everyone felt shame about their street behavior after they got sober, the heterosexual men had real difficulty coming to terms with their prostitution experiences, as it was cognitively dissonant with their life-long internalized beliefs about their sexual preference. African-American males had the most problem as their community is traditionally macho and homophobic.
Additionally, addicts who ended up imprisoned had often endured rape while incarcerated, sometimes gang rapes by other inmates or sexual alliances forged with one particular inmate to gain protection from gang rapes and abuse at the hands of prison staff. This set up existed in male and female prisons. Although protection through sexual alliances was a practical matter of survival behind bars, it was still experienced as extremely shameful and traumatizing, particularly for males. The Bureau of Justice Statistics did its first survey of sexual violence in prisons in 2004. The statistics reveal that proportionally more male prisoners than female experienced and reported nonconsensual sex acts and that 42 percent involved staff-on-prisoner violence. Actual figures identified only 2,090 incidents in the six-month period of the survey, but as the survey was completed by prison officials in relation to reported sexual violence and not gathered directly or anonymously from inmates, the true figures of all cases of rape, sodomy, and harassment are undoubtedly higher (BJS, 2006).
On one hand, if residents did not admit to their past sexual traumas, especially those incurred while they were active addicts, treatment staff did not feel they were fully addressing the goal of Phase 1 of the program (Accepting the Need to Change) or Steps 4 and 5 of the 12 Steps of AA/NA (Narcotics Anonymous, 1988):
Step 4: We made a searching and fearless moral inventory of ourselves.
Step 5: We admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
On the other hand, residents were not supposed to focus on healing from their sexual traumas while in drug treatment because the philosophy of the therapeutic model required that they focus on recovery from their drug addictions first. The idea behind this focus makes sense at first glance. Residents were in treatment primarily for their addiction, so that was what the therapeutic contract identified and prioritized. Overseeing government agencies and managed care organizations that pay for treatment like to see very specifically identified goals and objectives on treatment plans that refer directly back to the identified treatment issue they are funding. Many staff members were recovering addicts themselves who had earned their certification in addictions counseling, but were not trained in dealing with sexual trauma. Many of them were still young in their own recovery from substance abuse and had not yet addressed their own sexual trauma issues. When I brought up the need to deal with abuse issues in our treatment team meetings, I was told focusing on them would take away from addiction issues and we hardly had enough time to work through them. The official word from above was that healing from sexual traumas or any other traumatic experiences prior to or concurrent with addiction were supposed to wait until the recovering addicts had been clean and sober for a minimum of a year, otherwise their sobriety was at risk.
However, this caused a very big Catch-22. One of the major reasons these clients had become addicts in the first place was to numb the emotional pain caused by their sexual (and other) traumas. Stopping the drugs meant not just struggling with the symptoms of withdrawal and the cravings created by their physical and psychological addiction; it also meant that with sobriety the old feelings from the trauma that had been numbed away for so long started to come back.
Many residents were not able to handle learning to live without drugs, developing the social and emotional skills they had not practiced for years while “on the street,” holding at bay all the feelings of guilt and shame for their addictive behavior (cheating, lying, stealing, neglecting children and spouses, betraying friends and family) while doing drugs, and handling the feelings generated by their unresolved traumas. It was too overwhelming. Second Genesis had a very high success rate as far as drug treatment programs went (33%), but many people absconded and relapsed before they ever finished the program, and I have always believed that some of them left in order to medicate their trauma symptoms, not because they couldn’t resist drug cravings.
CASE EXAMPLE: THE BOX SELF-PORTRAIT WITH CAMILLE
For the first eight years I worked at Second Genesis, I was the itinerant drama therapist who traveled between the six residential facilities running a weekly drama therapy group in each. Later I worked full time as a primary therapist and drama therapist at Melwood House, the facility for women addicts and their children. Throughout these years other primary therapists came to me to share that they had difficulty getting their clients to deal with essential issues in individual sessions. Some clients resisted talking in group sessions about anything beyond the obvious (“I had a drug problem.”). I didn’t have difficulty getting drama group members to open up about issues or to talk in my drama group because through basic games and improvisations they began to feel very safe with each other and with me. Usually about the fifth or sixth session, I would bring in an art exercise which we used to facilitate NA Steps 4 and 5, the “searching and fearless moral inventory.” I called this the Box Self-Portrait. This exercise creates a literal and metaphorical container for clients’ issues in concrete three-dimensions. It illuminates for them the emotional dichotomy that exists for them as addicts and survivors: projecting a false identity to the world on the outside while hiding their real thoughts and feelings inside. Denial is a big issue in addiction and must be addressed before addicts can begin to “get honest” and “deal openly” with their issues. Dissociation is a big issue in trauma and must be broken through before the trauma can be consciously accessed and addressed. Exploring their feelings through the Box Self-Portrait helped reveal what was happening on the inside while also validating the existence of their outside defenses. In a sense, they could have their cake and eat it, too, because they were able to acknowledge their defenses and what those defenses were protecting.
I bought three different sizes/shapes of boxes from a local bakery supply store and brought in an array of art supplies: Magic Markers, crayons, construction paper, tissue paper, pipe cleaners, colored cellophane, scissors, tape, and glue. Each person picked a box that best represented them (a big rectangular box, a flat pie box, or a medium square box). They were to decorate the outside with colors, shapes, pictures, and symbols (no words unless they were involved in a symbol – like a STOP sign) to express all the qualities, emotions, behaviors, and personality traits – good and bad – that they show to others. They decorated the inside with colors, shapes, pictures, and symbols to express all the qualities, emotions, behaviors, and personality traits – good and bad – that they experience on the inside, but which they may or may not show to others. I always had to say “good and bad” or I would only get one or the other, depending on how the person was feeling about himself that day. A talent for drawing was not necessary in order to make the box very effective and striking because there were the options of cutting out paper, coloring designs, making three-dimensional objects to put inside or outside, or even cutting the box itself.
Drama group was two hours long. After a check in and a physical warm-up, the group members typically spent an hour creating their Box Self-Portraits. Then we went around the circle and shared them. Each person got to describe what the symbols on the box and inside the box meant.
What was inside the box was hidden from view as long as the box was closed, but when the box was opened, it became visible for the whole group to see. This often caused some anxiety for people who were willing to express what was happening on the inside as long as nobody ever saw it. My response to their questions about this while they were working was, “The rule for this exercise is you have to show us whatever you put in the box, but then you can close the box back up after you show us. If you don’t want to show us something, don’t put it in the box.” This was enough of a reassurance of safety for group members to move forward. I never had anyone refuse to open their box and share it with the group, partly because there was a great deal of pride generated in making this kind of self-portrait and partly because of the level of trust we had generated by that time in the series of sessions. While I’m sure there were plenty of unhappy experiences and ugly feelings that did not get put in boxes, no one avoided including at least some of their uncomfortable inside parts. If nothing else, I could always count on getting a depiction of the person’s drug of choice!
The sharing time was often the first time many had ever expressed either their abuse or the emotions they felt about it. One of the most dramatic examples of this was Camille, whose earliest memory at the age of 3 was of her older brother sexually abusing her, a practice he kept up the entire time they were growing up. When, as a teenager, Camille finally disclosed the abuse to her mother, she was not believed. Camille had to wait until her brother graduated high school and went out on his own for the daily abuse to stop. By that time she had such a low self-concept and lack of physical and emotional boundaries that she continued to allow herself to be used sexually by every man who came her way. In groups and individual sessions at the beginning of her treatment, she insisted that she wasn’t angry about anything, that she was, on the contrary, very happy and optimistic. Her rationale for this happy state of mind was that she had made it into treatment and was in the process of turning her life around.
It wasn’t until she made her Box Self-Portrait that she felt safe enough to express the truth. The outside of her box had a bright happy sun on it with flowers growing and birds flying in the air, but the inside of the box she had filled with a three dimensional sculpture of red, orange, and black tissue paper in the form of an erupting volcano. And underneath the volcano, drawn very small in faint crayon was a little girl, hidden, helpless, and trapped beneath it all.
Color is an important element in art therapy as it symbolizes emotions. Some color symbolism is culturally derived. For example, in Western countries white symbolizes purity which is why brides wear white, but in many Asian countries, white symbolizes death and is the color worn by mourners. Some use of color is based on nature: fire is red, grass is green. Other uses are very personal emotional symbols, such as a client associating lavender with love because her loving mother always wore that color. Due to different associative experiences, one person may associate a color with one quality or emotion, while another associates the same color with something very contrasting. For example, someone who loves being near and in water might associate blue with relaxation and happiness while another might associate it with sadness, and another might connect it with fear. Some art therapists subscribe to the belief that certain colors always represent certain emotions, but I was trained in the psychocybernetic model of art therapy (Nucho, 1987), so I believe in asking clients to interpret their work to me, rather than putting my own symbolism on their images. This, I think, works well with trauma survivors because a large part of their therapeutic task in recovery is to make meaning of their own experience (Dayton, 1997, 2000; Herman, 1992; van der Kolk et al, 1997).
Camille reported that the red, orange, and black symbolized a volcano, its molten lava, and fire which, in turn, symbolized her rage. She was relieved to finally be able to express what she was feeling in (what she considered) an indirect way. In her mind she hadn’t actually said, “I’m angry,” but she was able to acknowledge the unacceptable emotion. Anger had not been an emotion that was allowed expression in her home at any time in her past or present.
Anger, like all emotions, is a survival signal that tells us when we are in potential danger and we need take action to protect ourselves from being violated (Bilodeau, 1992; Tavris, 1982.) However, anger is usually not expressed openly by survivors to their abusers or to their families, sometimes not even to themselves. Expression of it during or after the trauma could have put them in danger at the hands of their abuser. In case of incest, where there are family bonds and emotional connection at stake, expressing anger could put the survivor at risk of losing the love of the abuser to whom she still feels a loving connection. Instead survivor anger tends to be turned inward against the self, leading to depression, self-harm, or suicide attempts (Dayton, 1997, 2000; Herman, 1992). If trauma occurs repeatedly over a long period of time, the survivor can develop learned helplessness, a belief that action is useless and the only choice is to accept the abuse passively (Dayton, 2000).
Whenever Camille had expressed her anger in the years after she revealed her brother’s abuse, her mother and father had accused her of trying to hurt them and rejected her. After Camille made the volcano, she began to be able to talk about her family dynamics and to understand how her parents had been implicitly involved in the abuse by turning a blind eye to her situation. She began to acknowledge all the emotions – positive and negative – that she was experiencing on a daily basis. She went back to working through The Courage to Heal (Bass & Davis, 1988), a self-help book for survivors of sexual trauma, which she had tried unsuccessfully to work on during her addiction. Later in treatment, I had her write a fairy tale about the little girl under the volcano and explore how she got there and how she finally got out. Camille also began attending a weekly sexual survivors’ support group outside of the facility.
I was called on the carpet for allowing Camille to work on her sexual abuse issues so directly. The facility director said, “Residents aren’t ready to deal with sexual trauma while they are in treatment.” But I knew that if I didn’t help her deal with it while she was in a residential facility where there was lots of support – staff members and other residents to whom she could go to 24 hours a day – that once she moved out and the old feelings of guilt and shame returned, she would start smoking crack again in order to deal with the feelings.
Other residents also used the Box Self-Portrait to symbolize traumatic experiences in acceptable and safe ways. Using images instead of words, they felt as if they were being extremely honest and direct, while also being covert and indirect. They enjoyed being able to feel proud and sneaky at the same time. As addicts they put a great deal of energy into rationalizing, hiding behind words, and manipulating meaning for others and themselves through language. Graphic images bypassed their practiced verbal abilities and gave them an “out” for being honest since it was a wordless medium. It was simultaneously less real and more real, in part because it was an unfamiliar way of communicating, but also because it created a safe distance and communicated viscerally, as opposed to intellectually, through color, shape, and image. Great pride was taken in sharing images and then revealing their meaning through words. For many, it was their first truly honest attempt at a moral inventory they had undertaken.
CASE EXAMPLE TWO: DRAWING AND MASK MAKING WITH GENA
At the time I was working at Melwood House, the entire residential treatment program lasted six months, and each drama therapy group was about three months long. Phase 1: Accepting the Need to Change was 1 month. Phase 2: Working on Recovery and Relapse Prevention was three months. Residents were usually assigned to drama therapy group in this second phase. Phase 3: Re-entry was two months. Then the women returned for after-care meetings one evening a week for several months.
Gena, one client on my caseload, waited until she was in her sixth month before she revealed that she had been incested as a teenager. Throughout her time in treatment, she had been compliant, but evasive. I knew there was something going on inside, but she wouldn’t let anyone in. She was what Second Genesis staff called a “people pleaser,” willing to work hard and do anything asked of her, to the point of denying her own needs in hopes that others would like her. She had difficulty disciplining her children because that meant confronting them and saying, “No!” She agreed with whatever others said and never put forth her own opinion to avoid confrontation and controversy. In essence, she compromised her own needs, wants, and desires in order to fulfil those of others; however, what happened instead was that she was used by them and then abandoned. She would not set limits on the negative behaviors that others performed in her presence and would “go along” in order not to make waves. This had the potential of jeopardizing her recovery, because if she got involved with the wrong crowd once she was out on her own, she could end up relapsing because she couldn’t say no. “People pleasing” is a survival behavior that develops in chemically dependent and abusive families. It works but at great cost to the self-efficacy of the “people pleaser.”
In the early months, Gena would do anything to avoid individual sessions with me, because – as it turned out – she was afraid she would reveal her traumatic secret and I would not like her anymore. She would always say, “I’m OK. I don’t want to bother you,” and would go on an errand or work down in the child care center. I would have to seek her out and tell her again and again that she was not bothering me; she deserved her individual session; furthermore, she was required to have one. Finally, the week before she was ready to move out, in her individual session she was talking about how even though she was getting ready to leave, she did not feel ready because she still felt uncomfortable. She said she could not describe it in words, but she felt it in her body. I asked her where this uncomfortable feeling was and she pointed to her chest. Then, I asked if she could maybe draw for me what it felt like. She quickly drew a little round ball with many spikes sticking out of it. It looked to me like an explosive mine. I asked her to tell me about it and suddenly she was telling me the story about how her mother and father had died when she was about eleven and she had to go live with her grandmother and grandfather. A year or so later her grandmother died. Her grandfather started “using her for his sexual needs.” And her uncle who lived with them found out. Instead of rescuing her, he demanded that his father share her with him. She seriously considered running away, but she did not know how she would survive on her own, so she stayed. And began hating herself. And doing drugs to numb the pain. None of this history was in her intake interview, nor had she breathed a word of it in any groups she had participated in the last six months.
When I asked, “Why didn’t you tell me about this before?” her response was, “I have never told anyone before, and I thought if I told you, you would think badly of me.” I immediately reassured her that it was not her fault, that she did nothing to deserve this treatment, and, of course, I did not think badly of her! She was immensely relieved.
I knew that having just revealed this horrible secret, leaving treatment would be experienced by her as a rejection. In truth, her revelation was quite literally a cry for help. I told her I thought we needed to bring this information to the attention of the director and the rest of the therapeutic team because maybe now was not the right time for her to move out, maybe she needed some more time in the facility to work on this important issue. She agreed. I requested that she be demoted to Phase 1 so she could start treatment over. My reasoning to staff was that she was only now finally able to be honest and could begin addressing her addiction issues. The rest of the staff agreed with me and she was able to stay for another six months.
Never a verbal person, art remained the best way for Gena to express how she felt, how she thought, and how she could change. One of the most powerful pieces she made during that time was a plaster of Paris life mask that expressed exactly how her history of abuse fueled her people-pleasing behavior. Again, the outside/inside metaphor helped her express the conflict between her feelings and her behavior. The outside of the mask was painted with images of love – a large heart covering her mouth showed she only said loving and pleasant words to others and another heart on her forehead showed how she only thought positive thoughts about others. But on the inside of the mask, the heart over her forehead was broken and the whole bottom of her face was covered with prison bars which held back the words she really wanted to say: No! No! No! No! No!
When asked what the two faces would say if the mask could come alive, she wrote:
FRONT
I’m looked on as
The one who’s always happy,
Smiling,
Always caring,
Always sharing,
Always willing to do whatever
For whoever.
BACK
But what I’m really feeling is
Frustration,
Angry, Guilty,
Because what I really want to say is
“NO, NO, NO,
PLEASE NOT NOW!”
But I’m afraid I might hurt your feelings.
Six months later Gena was truly ready to move out with her children and begin to try to live life on life’s terms. She had matured a great deal, and while she still struggled with “people pleasing,” she had begun to be able to hold herself and others accountable for their actions.
Conclusion
My experience suggests that traversing the bridge of healing involves careful movement from unspeakable wound to image to languaged story in order to unlock and release the trauma trapped in the heart and mind of a survivor. A journey that happens too quickly or which covers too much distance at once can cause re-traumatization or can scare the client into being unwilling to make the journey at all. Art, as a more primal expression than language, but a less embodied one than movement, can be a valuable tool, particularly in allowing the client an initial way of expressing what seems to be inexpressible.
WORKS CITED
Bass, E. & Davis, L. (1988). The courage to heal. New York: HarperCollins Publisher, Inc.
Beck, A.J. & Hughes, T.A. (July 2005). “Sexual violence reported by correctional authorities, 2004.” U.S. Department of Justice, Bureau of Justice Statistics Special Report. Retrieved January 30, 2006, from http://www.ojp.usdoj.gov/bjs/pub/pdf/svrcao4.pdf
Bilodeau, L. (1992). The anger workbook. Minneapolis, MN: CompCare Publishers.
Dayton, T. (1994). The drama within: Psychodrama and experiential therapy. Deerfield Beach, FL: Health Communications, Inc.
Dayton, T. (1997). Heartwounds: The impact of unresolved trauma and grief on relationships. Deerfield Beach, FL: Health Communications, Inc.
Dayton, T. (2000). Trauma and addiction: Ending the cycle of pain through emotional literacy. Deerfield Beach, FL: Health Communications, Inc.
Herman, J. (1992). Trauma and recovery. NY: Basic Books.
Narcotics Anonymous (5th ed.). (1988). Van Nuys, CA: World Service Office, Inc.
Nucho, A. (1987). The psychocybernetic model of art therapy. Springfield, IL: Charles C. Thomas Publisher.
Rizzo, T. (January 23, 2006). “New study sheds light on prisons’ sexual predators.” Kansas City Star, A1, A4.
Tavris, C. (1982). Anger: The misunderstood emotion. New York: Simon & Schuster.
van der Kolk, B. (2002). “In terror’s grip: Healing the ravages of trauma.” Cerebrum, 4(1), 34-50.
van der Kolk, B., McFarlane, A.C., & Weisaeth, L., eds. (1996). Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York: Guilford Press.
Wylie, M.S. (2004). “The limits of talk.” Psychotherapy Networker. 6(1), 30-41, 67.
APPENDIX
Sample of Therapy Plans for Drama Therapy Group at Melwood House
Session One: Introduction
Physical Warm-up
Name Game
Individual introductions to group and pantomime something you like to do
Mirrors
Session Two: Games
Check in (Identify an emotion)
Physical Warm-up
The Winds are Blowing
Partner Pantomimes
What Are You Doing?
Session Three: Nonverbal Communication
Mind-Reading
Physical Warm-up
Come-Go-Stay
Identify Personal Space
Making an Entrance
Tone of voice/Open Scenes
Session Four: Personal Inventory
Check in (What color are you?)
Stretch and write your names in the air
Make Self-Portrait boxes and share
Session Five: Setting Goals
Check in (What animal do you feel like?)
Pass the imaginary object and change it
Emotion statues (drama game)
Past-Present-Future Self Portrait Statues (drama game)
Session Six: Mask Making
Check in
Physical Warm-up
Make plaster of Paris Life Masks
Session Seven: Mask Making
Check in
Physical Warm-up
Design and begin painting masks
Session Eight: Mask Making and Exploration
Check in
Physical Warm-up
Finish painting masks
Writing: Imagine what the inside and the outside of the mask would say to you if it came alive. Write it down.
Session Nine: Performance and Closure
Check in
Physical Warm-up
Practice performing mask pieces
Perform mask pieces for invited audience
Graduation from Drama Group
