I want to live

processing abuse with the therapies of Stettbacher and Jenson

Appendix 2: Stettbacher, Jenson and scientific research

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The scientific foundation of the four steps

What can be concluded from my story? Konrad Stettbacher¹ and Jean Jenson² are not well-known names among psychologists — was I really cured by their methods? Is there any proof that their therapies work? Can I advise people to do these therapies or not? What do experts think to be good treatment for people suffering from a history of childhood sexual abuse? And what kind of problems do these people have? Was I an exception, with the kind of symptoms that were troubling me?

While studying Clinical Psychology at the Open University in The Netherlands, I started doing research into treatment of people with childhood sexual abuse. For this research, I have read a lot of scientific articles, and in those articles, I have looked for answers to these questions.

What are the consequences of childhood sexual abuse?

People with a history of childhood sexual abuse who seek help, often have symptoms that have been described in the diagnosis of complex posttraumatic stress disorder (CPTSD)³. This diagnosis is not part of the DSM-IV⁴ (the list of psychiatric disorders as used by psychiatrists and psychologists around the world) but has been introduced by the famous American psychiatrist Judith Lewis Herman³ as the diagnosis for people suffering from chronic trauma.

The DSM-IV4 does contain the diagnosis of posttraumatic stress disorder (PTSD), describing symptoms that emerge from a single traumatic experience in adulthood, like a traffic accident or rape. People suffering from PTSD are easily startled, have repeated, disturbing re-livings of their stressful experience, and try to avoid their memories. People who have had several traumatic experiences over a longer period as a child, like sexual or physical abuse, get more problems than just PTSD. Apart from PTSD symptoms, they also suffer from symptoms like self-harming and suicidal behavior, physical symptoms, social problems, dissociative symptoms (the generic term for experiences like not feeling real, “living in a fog”, “stepping out of your body” and memory problems) and feelings of loneliness, hopelessness, helplessness, shame and guilt.³ It is also known that their memories can be “different” from normal memories, for example physical re-livings.⁵ Another term to describe the results of chronic traumatic experiences is “disorders of extreme stress not otherwise specified” (DESNOS).⁶ The diagnosis DESNOS has the same symptoms as CPTSD — symptoms that are well recognizable in my story.

It is not known how many people suffer from CPTSD or DESNOS, since they are often diagnosed with another disorder, like PTSD, borderline personality disorder or dissociative identity disorder.³ Yet, the data tells us that a considerable part of the psychiatric patients do have a history of childhood sexual abuse: research shows that 36 to 70% of the female psychiatric patients has been sexually abused as a child.⁷Often they don’t tell about the abuse of their own accord during treatment, sometimes because they don’t see a relation between their problems and their history, sometimes because they don’t see their memories as memories or don’t remember, sometimes because they have bad experiences with talking about their history.⁸So, I wasn’t the only psychiatric patient with such a history, and not the only one who was silent about this.

What works and what doesn’t?

The first thing that is obvious from scientific research, is that “doing nothing” doesn’t bring any improvement when people suffer from CPTSD — people on a waiting list don’t show any progress.⁹ People who have problems because of childhood sexual abuse do not recover spontaneously, so my recovery in the years that I did self-help therapy probably wasn’t spontaneous either, but it has been the therapy that has helped me.

The next thing that emerges from scientific research is that the contact with the therapist is seen as a crucial part of the therapy.¹⁰ As I did my therapy totally alone, without a therapist, my progress is most probably the result of the therapy method that I used.

There are many therapy methods for people suffering from childhood sexual abuse. Exposure¹¹, EMDR¹², cognitive processing therapy¹³, John Briere’s self-trauma therapy¹⁴ and cognitive processing therapy working with “hot cognitions”,¹⁵ are all mentioned in scientific articles as good treatment for traumatized people. Some people do improve a lot using these methods, others a bit, and some don’t show any progress.¹⁶ For many people, the tested methods are not sufficient, but these people often got only six or eight sessions during research, while people normally do therapy much longer.¹⁷

What are these methods, the therapy methods that are described in scientific literature? Are there similarities between these methods and the therapy methods of Stettbacher and Jenson, or do Stettbacher and Jenson have a totally different approach? Which advantages and disadvantages do the various methods have?

Exposure and EMDR

Exposure involves giving words to memories and feelings — comparable with step 1 and 2 from Stettbacher’s therapy, and also part of Jenson’s therapy. The main aim of exposure is the disappearance of fear (extinction). This fear is aroused by telling in detailed about the memories during an exposure session, and it vanishes when the client stays in the fearful memory for a longer period (30-45 minutes) while using relaxation of muscles and breathing retraining.¹¹ For survivors of childhood sexual abuse, gradual exposure (systematic desensitization) is preferred: clients establish a hierarchy of fear-inducing stimuli and start with recalling the least distressing memory. Then, during several exposure sessions, the client processes increasingly fear-inducing memories or aspects of memories.¹⁸ A difference with Stettbacher’s and Jenson’s therapy is that, before the exposure session starts, the story that is going to be told is recorded precisely, and during the sessions the therapist will guide the client through her memories by asking questions.

Therefore, exposure requires a clear, accessible history. For people who have little awareness of what happened to them, maybe this therapy method can’t be used.

When working with EMDR, people also describe their feared memories, but they are more free to tell what comes to mind than when using exposure. They can determine for themselves which memory they will talk about, and may go from one memory to another,¹² like in the therapy methods of Stettbacher and Jenson. Using EMDR, people are being distracted while feeling intense emotions, for example by following the therapist’s finger with their eyes as it passes back and forth in front of their face. Apparently, having to use working memory while reliving traumatic experiences seems to be what makes EMDR work.¹⁹ This also happened when I did my self-help therapy, since I had to guide myself through the four steps.

Reliving traumatic memories, as happens during exposure and EMDR, has been shown to be effective in treating acute adult traumas: PTSD symptoms diminish this way.²⁰ Not all researchers think this kind of therapy is suitable for people suffering from childhood sexual abuse, having more and more difficult problems. Some people warn that symptoms of complex posttraumatic stress disorder can be exacerbated by exposure,²¹ and some therapists choose present-centered treatment that avoids trauma focus. ²² However, several researchers conclude that clinicians are unjustly afraid of using exposure therapy when they treat patients suffering from PTSS or childhood sexual abuse.²³The long-term benefits of exposure and EMDR are superior to those found in present-centered treatment.²⁴

Because of the risk of worsening symptoms, exposure treatment for people with complex posttraumatic stress disorder is often organized into phases, where phase 1 comprises taking care of a more or less safe and stable personal environment, phase 2 consisting of the processing of memories by exposure or EMDR, and phase 3 the building of a new life with regards to social contacts and jobs.²⁵SStettbacher and Jenson also advise not to start therapy in a situation that is instable or not safe,²⁶ and to avoid sudden, major changes in one’s life (job, relationship etc.) when processing memories.2

Some people say it’s not a good idea to postpone processing memories until the second phase of therapy, since it’s the processing of traumatic experiences that brings the desired stability.²⁷Looking at myself, I think I would never have been admitted to the second phase, considering the limited therapeutic treatment offered in the first phase.²⁵ Without processing memories, I most probably would not have reached the required level of dealing with my feelings without regressing into maladaptive behavior such as self-harm, suicidality or dissociation — although I can never say for sure, not having done this therapy.

An important difference between exposure and EMDR on one hand and my self-help therapy on the other hand, is the fourth step: articulating needs. This fourth step is missing in exposure and in EMDR. I noticed that this step of telling what I needed, has helped me to reach a feeling of relaxation. The third step (thoughts) is part of exposure and EMDR, but not in the systematic way that Stettbacher’s therapy presents this. It was this step that led to rapid improvement when I first worked with Stettbacher’s four steps.

Another difference is that exposure and EMDR only take place in sessions with a therapist, whereas Stettbacher’s and Jenson’s therapy methods can be provided in two ways: as sessions with a therapist, or as self-help that a client can use at home, at moments when the past is disturbing the present. I myself noticed that this offered me more useful therapy time (as I didn’t have to wait until a next appointment but could do therapy at home), and that this made my therapy more efficient (as I didn’t have to search for old feelings in a session, they were just there already). But most of all, this way of working gave me a tool to handle my daily problems — I was no longer at the mercy of recurring panic and fear, and emergency situations didn’t get out of hand anymore. The sense of control that the four steps offered me was extremely important when I started to realize that my “other world” really happened: I doubt if I would have made it without the four steps as a tool to handle my feelings. Treatment with exposure or EMDR wouldn’t have provided me with such a tool, and that would have been a disadvantage for me.

Cognitive Processing Therapy

In scientific research, it has been remarked that exposure does indeed help against fear, but that besides fear other feelings and thoughts also play an important role in traumatic memories, such as shame, guilt, anger, helplessness, humiliation and disgust.²⁸ Unlike fear, these feelings and thoughts don’t vanish when reliving them. Staying in them for a longer period, like happens during exposure, can be counterproductive: the feelings can be strengthened this way.²⁹ The advice is to process these feelings and thoughts through cognitive processing therapy (CPT).¹³

In cognitive processing therapy, three aspects of a memory are under discussion: the events that took place, the thoughts that came up, and the feelings of the victim that can be expressed in the therapy¹³ — equivalent to the first three steps from Stettbacher. In CPT, emphasis is put on what is the third step in Stettbacher’s therapy: becoming aware of, and changing your thoughts about the traumatic experience. The client learns to challenge beliefs and assumptions through Socratic questioning, like unjust feelings of guilt about what happened.¹³ Cognitive restructuring also takes place during EMDR, but mostly spontaneously from within the client and not by logical reasoning.³⁰ Unlike exposure, CPT is advised in the first phase of therapy,³¹ since it can help people to become more stable. That has happened with me, too: when I started doing self-help with Stettbacher’s therapy, it was this third step that brought immediate progress.

Some authors point out that ideas that are believed only rationally (“cold cognitions”) bring little change, while ideas that are deeply felt (“hot cognitions”) do bring change. They argue for another way of cognitive processing therapy, in which the new thought is inserted into the traumatic memory, and they advise to use for that the moments when memories are triggered,¹⁵ much like Stettbacher and Jenson use these moments.

Differences between CPT and Stettbacher’s four steps are the fourth step being absent from CPT, and the order of the steps. “Perceiving, thinking, feeling” in CPT is in Stettbacher’s therapy “perceiving, feeling, thinking”. The latter ordering seems to me the better one, since perceiving immediately leads to feelings that demand attention. Moreover, the feelings disappear during the step “thinking” (changing the meaning of the traumatic experience). It doesn’t seem a good idea to bring up the feelings again after that, since the goal of the therapy is to get rid of them.

Herman and Briere

In her book Trauma and Recovery³ , Judith Lewis Herman describes what should be done with traumatic experiences in the therapy: to give words to the traumatic images and the physical sensations, to verbalize the feelings and the meaning of what happened (“why?”, “why me?”, matters of guilt and responsibility and a new interpretation of the traumatic experience), and to take an ethical attitude that supports the dignity and value of the survivor.

This description of what should happen in a therapy corresponds with Stettbacher’s four steps. Herman doesn’t carry this through as systematically as Stettbacher and Jenson do (who stimulate clients to process memories on a daily basis), and Herman doesn’t give the four steps as a tool for moments when memories are triggered. But what she describes are the same four elements that form Stettbacher’s four steps.

Most similar to Stettbacher’s therapy is John Briere’s self-trauma therapy.¹⁴ In Briere’s therapy, the client learns to take several steps when negative feelings intrude:

1. Identify the triggers that cause flash-backs or intrusive negative feelings (e.g. a thought, or someone being angry at the survivor).

2. Search for a matching memory (e.g. abuse by an angry parent).

3. Identify one’s thoughts (e.g. “he hates me”/”I must have done something wrong”), and realize whether this is realistic from an adult point of view (e.g. “I didn’t deserve this”/”it wasn’t because I did something wrong but because he was drunk/was angry with my mother”). Cognitions are not labeled as “irrational”: they were logical when the trauma occurred. Now, looking back, it is possible to give another meaning to the traumatic experience. Also, there must be a disparity between the contents of the traumatic memory (danger) and the client’s experience of the current environment (safe).

4. Describe and express feelings (e.g. anger, fear, sadness).

Briere’s model holds that self-trauma therapy reflects the survivor’s own adaptive attempts to process memories by spontaneous re-livings. This way of working avoids activating more painful memories than can be tolerated. And the resolution of painful memories is likely to slowly reduce the survivor’s overall level of posttraumatic stress and associated dysphoria. As a result, successful ongoing treatment allows the survivor to confront other, increasingly painful memories without exceeding the survivor’s (now greater) self capacities.¹⁴

Briere’s step 1, 2 and 4 are similar to the description of Jenson’s therapy, and all of Briere’s steps are part of Stettbacher’s therapy. But just like CPT, self-trauma therapy uses the less natural order “perceiving, thinking, feeling” instead of “perceiving, feeling, thinking” as it is done in Stettbacher’s therapy. Also, Stettbacher and Jenson emphasize using the therapy method in daily life, more than Briere does, and self-trauma therapy lacks the fourth step. Briere does write that the survivor’s previous and current entitlement to integrity and self-determinism should be reinforced, but this isn’t a step in the therapy, like the fourth step in Stettbacher’s therapy.

Conclusion

The symptoms that troubled me can be recognized clearly in the scientific literature — I surely wasn’t an exception with the problems that I had. Also, I wasn’t the only one with a history of childhood sexual abuse that sought psychiatric help, and not the only one who couldn’t tell about this history.

Nowhere inn scientific literature did I read the names of Stettbacher and Jenson, but their ideas can be substantiated by other therapy methods. Almost all elements of Stettbacher’s and Jenson’s therapy methods have been described in the “official” therapies in scientific articles that describe exposure, EMDR, CPT (including the form that stresses “hot cognitions”), and Briere’s self-trauma therapy. Since these therapies have been proven to work, it is reasonable to suppose that Stettbacher’s and Jenson’s therapies can help to process traumatic childhood experiences.

But I think more can be said about the therapy as I did it. Yes, all elements of my self-help therapy, based on a combination of Stettbacher’s and Jenson’s methods, can be found in scientifically validated therapy methods. But compared to these methods, my self-help therapy was more complete and the elements were more coherent, and were carried through more systematically than any therapy method that I saw in scientific literature. And working this way, I found that it was this completeness that was crucial for my recovery. Learning to identify triggers, searching for a memory that matches my feelings or thoughts, and taking the four steps with this memory: what happened, how I felt, what I thought (then and now) and what I needed. Using only some of these steps, as happens during exposure, EMDR, CPT or self-trauma therapy, couldn’t help me escape from the fear and the pain — but using all the steps could. Only taking all of these steps brought me what I wanted: to be free from the fear and pain. And for that, I needed to take the four steps every day.

Since I wasn’t exceptional in the symptoms that bothered me, I would expect that more people will react in the same, positive way to the therapy. Maybe more people with a complex posttraumatic stress disorder could benefit from a therapy that includes all of these steps.

Therefore, I hope that, in addition to the existing scientific research on parts of the therapy as I did it, research will start on this whole therapy method. I hope that more psychologists and psychiatrists will be educated to help people with a history of childhood abuse, to help them process their memories, so no one will have to do a therapy on her own, like I did. Most of all, this way I hope victims will get a better life.

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