A Further Discussion with Elizabeth S. Bowman

Elizabeth Bowman responds to further questions from Christian Feminism Today editor Letha Dawson Scanzoni

Editor’s Note: This article is part of the six-part discussion of childhood sexual abuse from the Fall, 2008 issue of Christian Feminism Today, which began with an article about Margaret Meier’s cantata on healing from childhood sexual abuse.

Scanzoni:  Could you explain to us what dissociation is and why children who are sexually abused sometimes dissociate?

Bowman:  Dissociation is splitting of conscious awareness that enables the mind to keep emotions, events, and physical sensations out of awareness in a separate part of the mind. Dissociation is the mental escape people take when physical escape from an intolerable situation is not possible.

The trauma theory holds that abused children dissociate to escape intolerable physical or emotional pain from abuse.   

The betrayal trauma theory posits that children dissociate knowledge of sexual abuse by parents because of the strong biological need of children to remain close (be psychologically attached) to a caregiver for safety and survival. Knowing that a caregiver is frightening or dangerous creates a bind for the child who needs to approach the caregiver. Amnesia for the abuse leaves the child free to maintain attachment. 

The sociocognitive theory, held by some cognitive therapists and by an organization of parents accused of childhood sexual abuse, holds that dissociated memories of child sexual abuse are an artifact of suggestions by naïve therapists to suggestible patients.

Scanzoni:  Why do the memories of childhood sexual abuse sometimes “go underground” and emerge many years later in adulthood?   What are some ways the repressed memories might manifest themselves even before they are recognized?

Bowman: As explained in question one, completely dissociated memories are not available to consciousness while the child is dependent on parents for nurture and survival. After the child is an independent adult, physical and psychological safety motivations for keeping memories dissociated diminish in strength, allowing the person to possibly tolerate their return to consciousness.  Such repressed or dissociated memories often emerge when a strong reminder enables the person to connect consciousness to the neural networks in their brain that store those memories.

One strong reminder is the parent’s experience of their own children at the age the parent was when their own abuse started. Other reminders include: seeing movies or TV shows about incest or rape, becoming sexually active, encountering smells, people, or places reminiscent of the abuse, anniversary reactions of severe abuse, or the death of the abuser of whom they were still unconsciously frightened.

Repressed memories can manifest themselves indirectly in physical sensations of pain, nausea, vomiting, gagging, or other symptoms that represent return of some physical memories of abuse experiences. Other indirect manifestations of sexual abuse memories include strong unexplained fear or disgust reactions to sex or reminders of abuse (smells, sights, sounds, or particular sexual activities), persistent unexplained insomnia or nightmares, persistent physically unexplained sexual disinterest, inability to experience orgasm or painful intercourse, or inability to tolerate the presence of the abuser.

No single symptom exists that is a certain indication of repressed memories of sexual abuse. Usually a combination of symptoms exist.

Scanzoni:  What are some ramifications of memories that are recovered long after the sexually abusive incidents occurred?  (Ramifications for survivors, perpetrators, and families.)

Bowman: Ramifications of recovered sexual abuse for survivors can include intense feelings of horror, terror, physical pain, humiliation, shame, insomnia, anxiety, depression, re-experiences (flashbacks) of the abuse, anger at abusers, deep sadness over the damage to the survivor’s life, sexual dysfunction, disrupted intimacy with partners, and inability (at least initially) to keep a relationship with the perpetrator(s).      

Many survivors develop posttraumatic stress disorder (PTSD) after recovering memories.  Eventually, survivors who are appropriately treated recover and regain joy, peace, and self-esteem. A few can re-unite with family perpetrators, especially in those uncommon cases where the abuser takes responsibility and apologizes.

Ramifications for incestuous perpetrators vary, depending on their reaction and how the survivor handles disclosure of their abuse. Most abusers deny the accuracy of the recovered memories. Some sue the survivor or her/his therapist for slander. Some assault or threaten to kill or smear the reputation of their accuser.  Some extrude the survivor from the family, leading to permanently broken relationships. Some polarize family members as they gather allies in denying the abuse allegation and labeling the survivor as “crazy.”   A few apologize or admit privately to their spouse, the survivor, or family that the abuse occurred. Many minimize it, deny its significance, or rationalize the abuse as their right or as helpful to the survivor.

The survivor’s family of adulthood is often affected financially by the cost of therapy and by the survivor’s diminished ability to work during times of extreme distress. The family may be affected emotionally by the survivor’s disrupted sleep, emotional reactivity, and diminished capability for intimacy.

Members of the family of adulthood may also experience intense anger at perpetrators and want to cut off their relationship with them or keep them from unsupervised contact with the survivor’s children.

Scanzoni:  What are some ways that  you, as a psychiatrist specializing in trauma, treat patients who come into your practice for therapy as they deal with recovered memories of childhood sexual abuse?

Bowman: The primary treatment is psychotherapy, usually individual, but sometimes with couple’s sessions to help spouses or domestic partners with questions and coping.  Psychotherapy for recovered memories of trauma should occur in three stages, beginning with physical, social, and emotional stabilization of the survivor, then exploration of returned memories and their attendant emotions, and finally assistance with reconnecting to life, self, and relationships. Plunging into exploration of trauma before stabilizing the survivor can do more harm than good. 

Psychotherapy for recovered memories of childhood sexual abuse is usually lengthy (minimum one year of weekly or twice-weekly sessions, with a typical course of two to three years when treatment is complicated by coexisting mental illnesses or ongoing life stresses). 

I also use hypnosis to help survivors build ego strength and to help them temporarily keep recovered memories from continual awareness, to slow the rate of memory recovery, or to control nightmares between therapy sessions.

I don’t recommend using hypnosis for recovering repressed memories; it carries the risk of unwittingly contaminating the memory with subtle suggestion.  I use EMDR (eye-movement desensitization and reprocessing), a therapy technique of bilateral alternating stimulation of the two sides of the brain for speeding processing of trauma memories with less duration of emotional or physical pain.

In persons with significant coexisting depression, severe anxiety, or intolerable insomnia, I use antidepressant medications or short-term sleeping medications.  These techniques work for all trauma work, regardless of whether memories were recovered or continuously available.

One last word about the cantata: Throughout this work, I was impressed with the skillful use of scripture to show progression from anger at being abandoned by God to finally being able to affirm God as a “good object” who reliably comforts survivors.  This realistically represents actual therapy where spirituality must be healed from the devastation of abuse.

Editor’s note: In addition to her comments here, Dr. Elizabeth Bowman was one of the religious and mental health authorities who took part in a panel discussing the cantata on childhood sexual abuse. You can read those comments here.

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Elizabeth S. Bowman, M.D. is a psychiatrist in private practice in Indianapolis, Consulting Psychiatrist for the Indiana University Epilepsy Clinic, Adjunct Professor of Neurology, and former Professor of Psychiatry at the Indiana University School of medicine. She is the former coeditor of the Journal of Trauma and Dissociation.

© 2008 Evangelical and Ecumenical Women's Caucus