Last month one of my client couples gave birth to a child. Always a joyous event, this birth had particular significance to me. When I first started seeing this couple, just over 2 years ago, they had had virtually no sexual relationship in some four years. At that time the wife, a survivor of childhood sexual abuse, longed for a baby. The husband pined and bristled for a sex life. Both seemed a distant dream. Restoring a regular, reliable and satisfying sexual life was a primary goal of the therapy and achieving it a major milestone. This baby brought a new meaning to the term “love child” and was one of those awesome rewards of the difficult work we do.

Sexuality is among the most challenging issues in recovery from sexual trauma. When I first ventured into that area, I was dismayed to find that the literature reflected the same major oversight as had the early theory and practice of general sex therapy. Somehow it did not see fit to address the relationship as either a significant factor or potential resource in the maintenance or healing of the sexual problem. The books I read focused on the trauma survivor, who was saddled with the responsibility for the problem and who got all the attention. The non-sexually abused partner was essentially entreated to be supportive and patient, and wait. What this translated into for the average couple, was that the abuse survivor got all the blame and all the help. The partner got off the hook in terms of personal work, but received little else. Getting to know these couples, I rapidly discovered that the persistence of the sexual impasse is decidedly dynamic and relational.

Locating The Dynamic

Once in the room with survivors of sexual abuse and their intimate partners I made two major discoveries. First of all, survivors of childhood sexual abuse invariably partner with survivors of childhood neglect, at the very least emotional neglect. These children of alcoholic, depressed, mentally ill, overwhelmed, deceased or otherwise absent mothers in effect seem to have raised themselves, perhaps their siblings too. Often the sexual trauma survivor partner has a neglect history as well; and often the neglect survivor partner has experienced childhood trauma. But in each couple is one whose primary wound is trauma and the other for whom neglect is primary.

At its essence the experience of childhood sexual abuse is annihilation. The feelings and humanity of the child are disregarded, the perpetrator being preoccupied with self gratification. The child is in effect used and discarded, often treated as if nothing unusual has happened. Overwhelmed and uncertain, this child grows up with the core beliefs “I am unsafe in the world,” and even more importantly “I don’t matter.”

The child of neglect grows up in an environment of deprivation. These children are left to fend for themselves in fundamental ways, and learn early not to think of other people as resources for them. They tell heartbreaking stories of finding ways of registering themselves for school in second grade; climbing on a chair to get themselves food; never ever having anyone interested in knowing how they feel. They are self reliant, resigned, and deeply anxious and conflicted about it. These kids grow up to believe “I will never get what I need in relationship.” Often unaware that they even have a story to tell, they think of the trauma survivor partner as the one with the pain.

My second discovery was the dynamic interaction of these core beliefs between the partners in the couple, which generally goes as follows: “Partner A,” the neglect survivor driven by the belief “I will never get what I need,” perceives or fears that needs will not be met, and becomes anxious, possibly angry.

“Partner B,” the trauma survivor, compelled by the belief “I don’t matter,” experiences that anxiety as demand, and fearing coercion/anihillation, withdraws. A experiences the withdrawal of B as proof: “my needs will be thwarted or ignored,” and becomes more anxious. B experiencing the heightened anxiety as increased demand withdraws yet further. A cycle of escalation ensues that goes on and on and on.

This dynamic is glaringly evident in the realm of sexuality, as sex is perhaps the one need that the neglect survivor might acknowledge or feel entitled to put forward as requiring the participation of another person. But in fact the dynamic is threaded through the entire fabric of the relationship. The two may keep each other thus triggered virtually all the time, their life together becoming a living minefield of their re-enacted childhoods. For this reason couple’s work may be essential to both of their recovery or even to keep them from getting worse.

The Work of the Therapy

Once identified, this dynamic provided both a starting place and a map for relationship work with survivors of trauma and neglect; and most specifically a way to approach the sexual conundrum. In effect, the work came into crystalline focus and what before seemed an insurmountable tangle became simple. Simple while also perhaps being the hardest thing all three of us, clients and therapist, will ever do.

Research, theory and practice around trauma has burgeoned in the last 10 years. We now understand that core elements of post traumatic stress are dysregulations of affect and attachment. Trauma, overwhelming the nervous system, disrupts its capacity to process experience and maintain a baseline physiological and emotional equilibrium. The system swings between hyperarousal, (anxiety and preoccupation with danger;) and hypoarousal (depression and dissociation) without the capacity to modulate. Interpersonal, particularly familial abuse distorts existing and future attachments, while also destroying the most powerful potential resource for soothing and safety when it is most needed. The wounding around relationship is perhaps the most tragic and severe of the sequelae of abuse. Research about neglect is nascent, with attachment theory having much to contribute, and findings are similar and parallel.

I find the theory and structured dialog of Harville Hendrix’ Imago Relationship Therapy to be exquisitely suited to this population. Grounded in attachment theory, Imago theory views current relationship difficulty in light of re-enacted or projected childhood experience. The structured dialog lends order and predictability to the potentially frightening task of expressing feelings, rendering it safer. The emphasis on coming to understand one’s partner’s world without necessarily agreeing, facilitates differentiation and boundary. And the rhythm of the dialog, the ebb and flow of understanding and being understood, appears to ease the dysregulated nervous system, and quiet the bodies of both partners.

The couple’s work consists of psychoeducation about trauma and neglect; and dogged conversation in dialog. Although there is no substititute for solid trauma work, much trauma processing also goes on in the couple’s work. Over time, both partners learn to recognize their reactions to each other as being largely expressions of their past. Blame and defensiveness are gradually replaced by compassion and safe connection. Sexual intimacy, rather magically emerges ultimately from that safety.

A necessarily cursory introduction to the most challenging work I have ever done, leaves much to say. Not for the faint of heart, this is undoubtedly the most awesomely rewarding work I do.

© 2003