Psychiatry & Psychotherapy Podcast - How to Help Patients With Sexual Abuse

Episode Date: April 18, 2019

On today's episode of the podcast, I interview Ginger Simonton, a PhD student finishing her dissertation. We will cover her in-depth research on alleviating the symptomology of childhood sexual abuse. We will specifically be talking about the link between women who have been sexually abused, never given a chance to heal, and how it has affected their mental and physical health, and programs that can benefit them. What is childhood sexual abuse? "The CDC defines the act of CSA as "inducing or coercing a child to engage in sexual acts" that include "fondling, penetration, and exposing a child to other sexual activities" (2017)." The facts: 88% of sexual abuse cases happen with someone the child knows (Finkelhor, Ormrod, Turner, & Hamby, 2005) 20-30% of women experience some form of sexual abuse before they reach 18 years old (Pereda et al., 2009; Stoltenborgh, Van Ijzendoorn, Euser, Bakermans-Kranenburg, 2011; Bolen & Scannapieco, 1999; Holmes & Slap, 1998; Finkelhor, 1994) 20-40% of survivors have no adverse effects later in life (resilience is the norm) (Paras, Murad, Chen, Goranson, Sattler, Colbenson, Elamin, Seime, Prokop, & Zirakzadeh, 2009) By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video. Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder

Hello and welcome to the psychiatry and psychotherapy podcast with over 32,000 mental health professionals listening every episode. Why? Because we need to stick together to survive the mental health field. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. Okay, so today I am here with Ginger Simonton and soon-to-be PhD Ginger Simonton. She is finishing up her dissertation. She is submitting an article. to be published. And we did a prior episode called How to Fix Emotional Detachment. And so this will be kind of like part two of that.

Or it'll be kind of a standalone as well, I would say. But what we are going to be talking about is trauma. We're going to be talking about how trauma affects the body. And we're going to be talking about real patients that we've treated together and the outcomes of the program that we run. here in Loma Linda, and lessons we're learning, family therapy. We may talk about more things than this. So, Ginger, welcome back to the show.

Thank you. I'm excited to be here doing this again. Yeah. So tell me what would be the abstract of your article. Okay. So my article unfolded with two specific aims, but I would say that the general premise would be to study whether or not are meant. program could ameliorate the symptomology that's associated with childhood sexual abuse,

the biopsychosocial symptomology. So it's very well known in the literature that women who have a history of particularly severe childhood sexual abuse have an increased propensity for biopsychosocial health problems, specifically a number of issues that arise by migraines, bladder problems, hypertension, as well as comorbid, depression, and anxiety, PTSD symptoms, all of these result in issues in sociolational health as well that begin in childhood and extend then over the life course. And so my dissertation looked at the ability of a biopsychosocial model to ameliorate the symptomology that's associated with childhood sexual abuse. Yeah, I've also seen that and people I've worked with and the people,

we've worked with together. It's like, you know, they go back to the parent or, you know, someone. And the parent responds with silencing them, shaming them, know that didn't happen, that couldn't have happened. Or the opposite, like, oh, that happened to me. That happens to everyone. Get over it. So the parents are in their experience or they're denying of the experience. The parents are in their own experience, rather, or they're denying the child's experience.

That is completely accurate, and unfortunately that's a finding in the extant body of literature around childhood sexual abuse. And there are a number of hypotheses, but there's no one surefire answer as to why many women who were sexually abused as children end up with daughters who are also sexually abused. And I like the example that you gave, like this happened to me. So this happens to everyone. One of the findings that we had, particularly through the case study, is that women who had been sexually abused who were in our program, their mothers had been sexually abused as well. And then when they came forward with a story, the mother had no desire to protect them, no language as to how to validate, no capability of fostering resiliency. And so the patterns that were established in childhood spiraled into adulthood completely unchecked until they got to our program. Yeah.

And so tell me a little bit from your research how chronic trauma can influence the body. Well, what we found is many women who did not have those resiliency factors in childhood came from what we coined multidimensionally unstable families. multidimentially unstable families essentially is like what it sounds. If you think about it as the home being the bedrock of familial stability, women in our study came from homes where there was no structural stability. There was extensive comorbid abuses, parental alcoholism, re-victimization, just a whole host of issues that had happened to these women. we found what was so fascinating is that suicidal ideation and suicide attempts beginning as early as 10 years old were probably the first recognition that there was a symptomology associated with the childhood sexual abuse.

So that was sort of the first line, the first symptom consequence that presented itself was that the child didn't want to live on the earth anymore. They wanted to get away. They had to find a way to escape. That was one of the most fascinating findings was that suicidal ideation or suicide attempts were that first indicator. Well, because the systems continued to move as systems do in these feedback loops and patterns, as women aged and this prolonged stress really took root in their body, the body broke down because of the result of stress inside the body.

So by the time they came to us, Dr. Peter, we're seeing still the suicidal ideation, right, the dreaming of not being on this earth. We're also seeing the disassociation that began in childhood so that the child could remain safe and leave their body to endure the abuses that they experienced. And we're seeing the body break down in the face of cortisol and the other cascade of stress-related hormones through the illnesses that you described. Yeah. And so what the unfortunate aspect is that a lot of people have one body organ system that will break down first. Like the first thing that happened was I got migraines. And then as I'm getting this story, then, you know, they went to a doctor and they got put on, you know, some medications. And then, you know, because the chronic stress didn't get resolved, then that the next body system kind of broke down. So then I got chronic pain. And then, you know, maybe they got put on opiates or something. So now they're on topamax for the migraines and opiates. And now they're actually cognitively not fully present, right? And then the third body system got hit with like depression or whatnot. And so now they're, you know, they're thinking, well, I'm depressed.

My body hurts all the time. I get these chronic migraines. I just feel horrible. And then, you know, they end up going into just, you know, a med management thing. And then they could put on medications for depression. but it doesn't get to the underlying core conflict, right? And maybe they get referred to a therapist and they have a bad experience with a therapist

or they have a good experience with a therapist, but they don't really, you know, it's like just attaching to someone is so difficult maybe that they don't really get to the trauma very quickly. And so the common person that comes into our program has multiple body organs that have, you know, chronic medical issues going on that are all surrounding the stress, kind of this chronic stress response. So when you first kind of are engaging someone like this, like what are the

steps that you go through sort of help them through this? I absolutely love how you broke it down as far as like systems of the body beginning to break down. And I believe that a strong correlation And with that is the fact that many of the patterns that happen with these women in childhood continued well into adulthood. So being victimized in childhood, they ended up with partners who also victimized them. So domestic violence and spousal rape and all these recurring power imbalances that moved with these women as they, you know, transitioned across the life course. So by the time they come to us, we find that they're so totally and completely disconnect. from their physical body, that the first step is going to be starting to enable them to have

some connection with their physical body. Because our patients have learned since they were, for our female patients, they've learned since they were little girls to leave the body, that the body is the enemy, the body is the conduit of pain. Although an interesting finding is that our patients, through a very, very comprehensive review of our patient records, we didn't have any knowledge. notes or indication that patients were able to make a connection with their physical body in childhood, even situations that would have been very physically painful, such as sodomy,

vaginal penetration, very, very seldom, if ever, did we find that women made any connection when they were recanting or deconstructing trauma to the physical pain of what happened to them. And what we found was that because of the incredible power of disassociation, it's learned in childhood, that there was no comment about the fact that that hurt my body, that there was any physical consequences. And so women had been carrying this uncharted territory inside their body for generations by the time they get to us. And so establishing a relationship between the mind and body is very, very tender, very, very delicate work.

And yet what it does is it allows us to, I guess I would say, release or untrap the stress that's being held within the body around these very, very sensitive issues, these bodily memories that these women have of pain and trauma that have led to meanings about themselves that are very, very unfortunate. And I tell this story not to be blunt or graphic, but we treated one woman together. And she had a history of child and sexual abuse plus a long history of other physical abuse and neglect. And like she truly believed when she started to make meaning of herself and talk about how she visualized herself, I was asking her, well, what does that say about you? You know, who are you? And she said very bluntly, I am just a piece of shit.

and that's how she conceptualized herself. And that was really how she saw herself in the face of her lived experience. And so as we start to break that meaning apart, obviously to turn her into someone, help her to become someone of health, making that mind-body connection and untrapping that stress and trauma from the body is the very first step. Yeah. Wow. If someone said that, you know, that would be, I think it would be, I think I would say something like that must that would be incredibly devastating to see yourself in that in that way and you know the disgust the shame that you must feel is just really intense how did you respond to her when you when you heard that like what were the words that came out of your mouth

I still feel stunned when I recant the memory because it was so explicit I think I took a moment of pause in And truly the self of the therapist moment to be completely transparent. It took me a moment of pause. And then I just wanted to her to be heard in that place and to feel validated that I had heard her story, that I had heard the underpinnings of how that had been created and then co-authored over time. So to actually recollect what was said, I think it was more like, that must be a very painful narrative for you to carry. that must be very painful meaning because that has biopsychosocial implications for her. But I also have to give her the space to share with me the honesty of her experience. I don't want to layer on.

Like, I don't want to tell her, well, that's not true or I don't see you that way. Or I want to really sit with her in that place. How does it make your body feel? You perceive yourself as a piece of shit. How does that make your body feel? Because that's the underlying issue. right? What is the implications of a narrative like that on the physical body? Yeah, I want to pull out some of the things that you're saying because you talk about meanings

and narratives. And so this is language we use from early on in the program. So she already had these meanings. She already had these words and what they mean. But I think it would be important for you to explain to people who don't use this language. Like, what are we talking about here? So because I'm a human being, I'm constantly making meaning. of my world. That's how human beings operate. As I interface with you, even doing this podcast, I'm making meaning of this experience. This is adding to the, you know, to my, I perceive this to be adding to my value. This is a positive experience. I'm making meaning of this even as you and I are sitting here. We're always making meaning of things. And this is building and building.

when I'm a child and I've had an extensive amount of abuse, I'm making meaning therein of my lived experience, right? So if I'm receiving information from my caregiver, my parent, that I'm not worthy, that I'm not good enough, that I'm dirty, that I'm not whole, then that stays with me over the course of my life until someone calls it into question. That's what I mean by meaning. So what is that? So if someone said to me, Ginger, what does it mean for you right now to be engaging in this podcast? I could say, well, it means that I'm, you know, becoming more of a professional or it means that I could be proud of the work that we're doing together. It's just as simple as that. Yeah, yeah.

And I think this is important because we talked about how people who have those horrible meanings that they create from these horrible events, then they find, other experiences throughout their life that reinforce these meanings. So if their partner is violent towards them, it just reinforces it once again. And even in their life with professionals, sometimes it can get reinforced. If the professional is, I don't know, there's different situations that patients will talk to me about, how like, oh, you know, I saw this specialist and they kind of like were very curt towards me. and they just kind of like told me it was all in my head, and then they marched me out of the room, you know, and very sort of dehumanizing experiences.

So, yeah, I think it's really, it's really powerful to look at those meanings and to start to create language around that. That's what we do. We try to create language around, you know, here's a person who had these bad events that then creates an illness narrative, is that what we call it,

and then throughout their lives, that gets reinforced, that gets reinforced. And one of the things that was kind of a new thing to me when I first started in this program was as a medical professional, it's also possible to reinforce an illness narrative. Yeah. So we want to be careful that we don't make them think that, oh, I am bipolar. or oh, I am, you know, this mental illness that then basically allows them to then look at themselves in a way that is not a unique human. Can you speak to that a little bit? Well, I know that when I'm doing therapy, my response is twofold. The first I would say is when I'm doing therapy, I personally don't like my patients to use clinical language because if someone says,

I'm depressed or I'm anxious, those tend to be very loaded words. And depression can be experienced differently across every person. And so if someone tells me, I'm depressed. My first question after that is, and so what does depression mean to you so that I have a better idea as to how they're actually experiencing that? And the other component is as far as the, oh, and then to speak about, like you said, the labeling of like bipolar. I have, you'll hear patients who have been in the system for a long time, say, you know, I have MDD, I have GAD, I have PTSD, a big favorite is, like you said,

I have bipolar. That's a big favorite. And so I think that if you take like Adler's idea on, on diagnoses, I think that's the best thing to put. Diagnoses, I believe in my opinion, are ways of conveying information from one professional to another. So I can say to you a patient has major depressive disorder, we're sharing symptoms, right? We're telling a cluster of symptoms from one mental health professional to another. When a patient hears that and they internalize that, that becomes a part of their meaning. That becomes a part of how they perceive themselves. So now they're not necessarily normal.

Now they have MDD or now they have borderline or whatever it might be. And so no longer do they have the same level of responsibility, accountability, or functioning as someone who may not have that diagnosis. So that's my first thought on the second piece that I loved what you said was the involvement of the larger health care system in co-creating illness narratives. We see this all the time when we treat people with PNES activity. So we could easily call them pseudos seizures, non-epileptic seizures that impact people often with a history of trauma. They go to the ED, the emergency department, and because there isn't necessarily a physiological or a neurological, it's not, I'm not saying this well. They don't have epileptiform activity. So if you attach an EEG to their brain, they're not actually having a physical seizure.

epileptiform activity. Now, when you look at them, they look like they're having a seizure. And so a lot of times it goes on for years that they'll be going through ERs and medical systems and neurologists and being treated, being treated with real strong medications. And, you know, like one example is if all of the body is moving and they're able to talk at the same time, it's practically impossible for that to happen if it's an epileptic seizure. So a lot of the time, people who are in these sort of psychogenic seizures, the events will go on for like an hour and they'll be moving their whole body. Now, if a person was having a seizure for a full hour, that would cause brain damage.

But we've had a lot of patients who have these psychogenic seizures, and they'll have them three, four hours a day. And it's just like their whole body's swaying back and forth. And they're kind of in this dissociative place. Sometimes they can talk. Sometimes they can't. So yeah, this is part of the problem. But tell me, go on with what you were saying?

So I guess you could say in a family of like myalias, chronic migraines, vertigo, things that take on a more somatic component, the seizure activity that you were just describing, individuals go to the doctor, they go to specialists, they go to the emergency room, and they're told it's all in your head. You know, they're given, like you said, a host of pharmaceuticals, right, to help to treat it. And then they leave feeling invalidated and they leave feeling like they're, quote, unquote, crazy because their bodies exhibiting these tremendous signs of stress and trauma.

And yet there's no medical reason. So when health care professionals interact with them and they say, well, this is all in your head or we don't have a reason for this. of saying, hey, what is your trauma history? Would your trauma history lend itself to a somatic activity that would mirror this type of symptomology or illness sale? Then they say, well, this is all in your head. And then the patients come to you and I, and they're incredibly traumatized because, number one, they already know that they have a host of issues, right, that they're dealing with biosachosocial issues. Then they're going to get treatment thinking that they're addressing it. and then they find out that they're making things up,

or that's how they're making meaning of it, that they're making things up. Yeah, one of the interesting things is that sometimes the medications work for a while, which can be really confusing to a patient. So, for example, Topamax sometimes can make someone feel better to some degree, or like an SSRI or an antidepressant, but they don't seem to be curative, and the problems may come back. and I know when I see psychoseasure

or psychogenic seizure patients, sometimes I can refer to them in my outpatient clinic here. And I'm so passionate about getting them into a program that's actually going to resolve their issues because I know, like, no, it really does take a team and it takes family involvement too. And one thing I want to really get to you now about is like, okay, tell me about what you found in the research,

about how important the family involvement is and how important the spiritual community is. The family involvement was absolutely critical to patients improving overall health-related quality of life at an exponential level. Our treatment program demonstrated improved health-related quality of life in women with and without a significant level of familial involvement. However, women who had a partner, a sibling come in and support them as they moved through the trauma process and as they engaged in our multifamily group did so much better. They received the fullest benefit of treatment because they had a secure attachment that went home with them, a secure attachment that wasn't just myself or you, but a secure attachment that was able to aid them in being. heard, witnessing the story and the experience of someone who's experienced something as traumatic as childhood sexual abuse is absolutely vital to their recovery. We found that the women in our

study who had someone come in, a social support, a healthy relationship, someone with whom they had a secure attachment, come and share in their story and encourage them, act as a cheerleader, meet them in health, those women far exceeded the other group of women that unfortunately did not have that opportunity. That was a very significant finding that you and I were talking about before we started. Another finding that we had is the importance of a spiritual base and a spiritual community. So we found that a relationship with God was able to ameliorate some of the suicidal ideation that our patients had.

And also patients who we treat who had involvement in a church community seemed to demonstrate higher health-related quality of life at the time of intake and then incredibly high benefits from the MEND program over the course of treatment. That, of course, was demonstrated pre-de-post. So we found the incredible benefits of spirituality, that two-fold spirituality, a personal relationship with God, coupled with involvement in the church community, and then the ever-important systemic component, having a family member come in and sit side by side with the patient as they moved through this experience.

Yeah, I'm going to emphasize that, like how important it is to have people to walk with that are outside the therapy room in this, because they're there day in and day out, and what you guys do with them is amazing. You help them learn how to listen to the other person. and not shame them and give them empathy and be a safe person to process with. And that, you know, that changes the need also, I would say, to have illness as a way of connecting.

So one thing that I've found that I'm gonna just be very passionate about is it's so hard sometimes when we help someone and then we send them back to a rigid family structure that wants them to be ill. That is just heart. breaking for me because I see them then in my clinic a couple months after program and they've relapsed into the illness because the illness gives them connection. So if you're listening to this and your mental health professional, think about how you can build a team of involving the family.

And if you're a patient who's suffering from this, get your family member to listen to this, because it's going to be so important for them to be supportive of you in your journey, to give you empathy, to give you just kindness to hold your hand when you're crying, you know, and to not need to fix it, right, to not jump to like solving the issue or like, you know, I think a lot of times when people hear of trauma, they themselves get overwhelmed as well. I agree. I found that even as I was doing the case study and the regression analysis, I felt the stigma of childhood sexual abuse because when I would share the topic of my dissertation with

people, I felt shamed or silenced myself. Like people would say, why would you want to study that? That doesn't sound like any fun. That sounds miserable. You know, what would have made you choose to write, you know, 150-some-odd pages or 60 pages on, you know, severe childhood sexual abuse? And I was really fortunate to deconstruct that with. my chair who said what you're experiencing is just a tiny piece of what these women are experiencing

on a constant rate feelings of guilt and shame that have been perpetuated since childhood to now. And the interesting thing is when you talk about illness being an important part of the family system or the couple relationship, oftentimes illness serves a very important role and that's ensuring that the woman is in a one-down position with her partner. So illness is a very good way of making sure that the caregiver partner keeps a one-up position and the woman stays down, which we found to be one of the factors of coming from a multidimensionally unstable family was that women continued to partner with people who would bully them, continue to partner with people who victimized them and harm them. Well, it's much easier to victimize them. Well, it's much easier to victimize

a sick woman, right, if we're looking at like biopsychosocial health and health-related quality of life, someone who has an illness narrative, someone who maybe isn't capable of working, someone who maybe believes they're incapable of going to school, it's much easier to bully or take a power position on a woman like that than the woman who is moving forward in health. So if my partner doesn't want to have to address their own personal issues that move towards anger and violence, then keeping the woman ill becomes incredibly important. That's really good. You said a couple things there that really jumped out. One was going back to school, going back to work. Right. And I can think of, I have the pleasure to follow some of our

patients for years after they finish the program because we've been doing this. I've been doing it for about five years now, this specific program. And some of them have to be. Some of them have gone back to school and some of them have, you know, moved forward in their careers. There's one person that I worked with individually that didn't come into the program, but she went from making around 20,000 year to making about 130,000 year just within the course of like working through some of her stuff. That's so awesome. Because she became assertive and had boundaries and didn't see herself as needing to be in a one down relationship, right? And so she was able to take ownership of like,

oh, you know what, I'm a bright, intelligent woman, and I can go out and, you know, get a job that will appreciate that. So I've had a number of situations like that that just like really give me excitement. And it really shows the value also of the work that you do, Ginger, when this kind of stuff happens. Because when not just one person, but the whole family is influenced for the better.

You know, you could have a family. There's this one lady in particular that just emailed me. And not only was she transformed, but she's a grandmother. And her daughters and her grandchildren are all thriving. I mean, literally thriving. They're all moving forward. It's like the whole family just like had this huge breakthrough. Oh, that's so awesome.

Well, we treated, for the first time, I think last year, we treated a husband and then a wife. And I think that was an incredibly amazing experience because it gave us an opportunity to treat that whole system. And I had gone in an email, I have to show it to you, but I had gotten an email from the wife a couple months ago that was talking about their getting back to work and going to school and setting new goals and living a life of purpose. I think that's what we're hoping for, right? Women who come to our program with a history of chronic illness with or without childhood sexual abuse, but specifically talking today about the research with a history of abuse. What's amazing, I think, is the opportunity to recognize that their body has a story to tell. So making connections with the body and then giving them a voice so that the body's story can be told into. totality, no matter how many times it takes, because we have to be mindful that women with trauma,

women with childhood sexual abuse, their memories aren't stored maybe the way that you and I's be where it's this very succinct memory and we can recant it with ease and we tell it to you one time and we feel validated and heard. Women with childhood sexual abuse that were not validated or were silenced and shamed or whose words were used against them, in childhood, they need to tell their story oftentimes several times. And it's our job to witness the body's story to let that trauma move up and off of the body through the voice. And I think that we're doing an effective job at that, giving the body a voice and letting that voice then become accurate and then lead them into a purposeful life, a life where

health-related quality of life is improved. And then we see those wonderful outcomes that we're talking about. Yeah. And some people are resistant to that process, by the way. It's not everyone who comes to us wants to relaunch their life. People get stuck and they don't believe it. They lose their hope that that's even possible. And this is where I also get fired up, man. Don't lose your hope. Don't lose your hope. I've seen the worst of the worst. Like people, like just that I've gone home and thought like all night about them, like just very troubled. And then, you know, two years later, three years later, it's like they've relaunched their life. They have an animal. They have an apartment. They, you know, have a job. And, and they no longer feel chronically suicidal.

You know, we're going to wrap things up. I think for the, for the, for the, for the the clinicians in here when we, you know, we're doing the who, right? We're doing the, yes, we're doing the World Health Organization. It's the questionnaire. Right. So it's the world health organization quality of life brief. So what that is is a shortened version of the larger World Health Organization Quality of Life survey.

It's a 26 item measure that assesses perception of, perceptions of health around physical, social, environmental, bodily symptoms. Right. Measures of health. And what we found is that it literally changes like what one standard deviation, one and a half? Like that's what we're talking about, right? I'll have to get it, we'll have to get it all. We'll put those details in the article.

Yeah. And if you sign up for the online resources or if you plug your email into one of my website things, when you publish your article, your dissertation? I don't know, can we put your dissertation on my website maybe and let people read it if they're interested? Of course. Okay, we'll do that. And yeah, I'm excited about future episodes with Ginger.

I'm hoping that she sticks around. She's very talented therapist. And Ginger, thanks for coming on. Thank you. Do you have any final words, final thoughts? final words and thoughts would yes I do actually my final words and thoughts would be oftentimes women with a history of childhood sexual abuse are labeled as difficult patients difficult to treat difficult because they have a lot of maladaptive patterns and yet I think that this opportunity to study them at such a robust level has taught me that instead of using words maybe like borderline access to cluster B I now feel more like having so much more grace and compassion with the fullness of their lived experience that I probably didn't have access to before.

And now I think a lot of that symptomology makes sense as trying to endure a life that I oftentimes couldn't imagine. I couldn't relate more to what you said about going home at night and thinking about them, especially making mind-body connections and giving patients an opportunity to share what their bodily experience was like, especially in the face of severe child and sexual abuse. I think it grew my ability to feel compassion, even with patients who present in very difficult scenarios. Can I ask you, and I think this is important to put it as like a disclaimer or like a contraindication,

have you ever had a patient who when they told their story, the sexual abuse was a part of their illness narrative in the sense that maybe they had bad therapy in the past that sort of was very suggestive that they had been abused. But when you heard their story, it just didn't resonate as something that they were actually struggling with. Are you saying that possibly like a prior therapist led to witness or something? Yeah.

That like co-constructed a memory? Yeah. Have you ever had that happen? It doesn't come to mind, but it's something that I'm so sensitive about because whenever we're deconstructing trauma, the body holds the answers to everything that we're looking for, but it is so, so important to make sure that I like to say, as a little cliche about that, we don't lead the witness. The story needs to be coming from the patient without my judgments.

put upon it without my perceptions put upon it. I do think that therapists can create hypotheses that end up landing on a patient and aiding in the co-construction of a story. And oftentimes people are desperate to be heard. They're desperate to find out why they feel so terrible. And so if someone can maybe weave in or co-create a tapestry around a possible memory, a possible narrative of abuse, then that can help maybe solve the problem that they're looking for. So I try to stay very, very, very far away from aiding patients in recreating memories, right? I try to only be an active witness in the story that their body has to tell. Yeah. And I think one of my sort of hesitancies was totally answered by you there, like not leading the witness. And I would also say, I think

there's other things that can create pathology of the psychosomatic illness that we're talking about. So we're really focused on one group of people in our program, but we have other people in our program who may have other types of, you know, nature versus nurture types of things that lead them to have like psychogenic seizures or chronic fatigue or fibromyalgia. And I think it's important to realize that it's not always child sexual abuse. So if you're listening to this and you're like, oh, I wonder if I was abused when I was a kid, I would say, if you were, it'll come, it'll come to you. Or you probably already know.

You probably already know, but also if you're in therapy, like, it'll come as a bodily, a bodily sensation and the meanings that attach to that maybe, the memory. But there are some therapists that lead the witness in a way, and that's something to talk about. and, you know, psychiatrist, pastors, spiritual leaders, like all those types of people, when all they see is through this one lens. And so, you know, a lot of times it could be, you know, other types of things. So I think that's where, you know, we as a team kind of think together, like, oh, what else could be going on.

And sometimes it takes a week or two weeks to kind of get a good feeling about what's leading to someone having the type of pathology that's presenting. So a lot of times it's not just like on the first visit. It's obvious. Yeah, I'm thinking about any other disclaimers. Yeah. So if you're listening to this and you're like, well, I have a lot of those symptoms? Have I been sexually abused?

I would say, you know, touch base with a mental health professional. And think through, you know, ways of not leading the witness. If you have a therapist that has led you, then also can. consider how that might influence things. I think that's important because the body knows the answer. The answer to all of our questions lives within our body. As human beings, we're incredibly resilient. And we have the answers to the questions that we're looking for within our body.

And so typically people know that they've been, the people I work with, they know if they've been physically, sexually, emotionally abused. or experienced neglect, it isn't something that we're actually coming upon for the first time. By the time they get to our level of care, people have fully actuated, at least at a memory and understanding that that happened, maybe not the totality of meanings associated with it, but people tend to know if that's happened. And so I totally agree with you, if you are listening to this podcast and you're thinking, well, I have fibromyalgia or I have chronic migraines. That's in no way saying that, you know, you experience something that you may not be

aware of. It's just saying that there is a correlation or an association between certain types of illness activity and childhood traumas. Yeah. Okay. So in one sentence or less, try to answer these rapid fire questions, okay? Sure. You've got the wrong person with you if you want one sentence or So let's say on just, you know, the initial evaluation, they mentioned that there was some sexual abuse. How would you first ask them about that further? Working as a clinician with them all the time or if I'm like a physical health provider. Let's say you're a therapist or psychiatrist who is going to be doing psychotherapy. Oh, okay.

So I think I would begin the process of going towards the sexual abuse. by just starting with their story. Can you start talking to me a little bit about your story? The story that the body has to tell. So questions, you know, what are your earliest memories of your childhood? Because I don't want to come at this too directly because that brings up too much for the patient. And they're still trying to figure out if they're going to trust you with this. So I want to start very slowly and gradually.

Can you tell me a little bit about your family? system. Can you tell me a little bit about your mom? Was your dad present? I'm starting to grow a narrative, grow a larger story, a larger dialogue around what the family actually looked like. When the patient gives information about their family of origin story, you're going to find a multitude of places to start to come in closer to the abuse, right? They're going to give indicators places where they were not protected, openings where they were vulnerable, people were not taking care of them. When you start to get those openings, then you know to move in closer to the actual sexual abuse trauma. Okay. Yeah, that's good. So what are some of the common things that

you're going to be doing once they're talking about the actual trauma, like as a therapist? What are the things that you do? What are the techniques you use in your work? So for me personally, a big thing that's in the literature right now is the importance of witnessing. Many of our patients who have childhood sexual abuse have never been heard. Their stories were never validated. They were re-traumatized when they were silenced by their families. So I want to create a space where I can successfully and accurately bear witness to their story. So when their story comes out, I'm listening, I'm validating.

How does that make your body feel when you share about these things? I want to be in a position to develop a secure attachment with that patient so that they feel comfortable to continue sharing their story with an alternative narrative. So when they share it with me, the goal is going to be that the story is validated and a retramatization pattern does not occur. So I want to make sure that they feel safe and that the process goes very, very slowly so that they don't feel rushed. Okay. How do you handle hearing the graphic stories, the horrible stories, how do you handle not being traumatized in that process? Do you want me to speak accurately? Yes.

Okay. This is something that I'm working on. It isn't easy. I'm very right-brained, very empathic. It has become, because I've been so saturated. the literature for childhood sexual abuse and then in our work together. Of course, I am very up close and personal with these patients and their stories. The most recent example that I've had is through my research, I found that patients don't often make somatic connections. They don't make

connections as to how their body experienced even severe childhood sexual abuse. So a patient may have been raped or sodomized, but they don't have language for how that felt for their physical body. So finding that I recently asked a patient about how her physical body responded to penetration when she was very, very young. And her response was traumatizing to me. It was more than I had ever heard before, including that somatic component, was more than I was truly in that moment, maybe even prepared.

So I'm very blessed because here we have a multidisciplinary team. and I have many supportive colleagues. And so I found one of my colleagues who also has done a lot of childhood sexual abuse. And I went to her and I closed the door and I cried and I still feel emotional talking about it right now. But I shared that with her. And then her immediate comeback after she bore witness to my story, her comeback was, what are you going to do to go home and show yourself love? How are you going to take care of yourself so that you can continue to move forward?

forward in this healing work. And so we devised a plan as to like how I could effectively do that because this is absolutely critical, this idea of traumatization and retramatization to the therapist is absolutely a paramount component. Yeah, that's really good. I think that's really important. And also in like treatment team, we try to, you know, we try to process through and sort of put things out like that. Has treatment team been helpful for you in that journey at all?

I think treatment team has been really helpful because I know that you're very committed to making sure that laughter is present in treatment team. And I think laughter is so cathartic in healing, making sure that, you know, we have very secure attachments with one another on the mend team. I think has been another very integral component. it. So I know that moments when I might be struggling, you know me well enough to pick up on that. So you'll circle around and kind of touch base and make sure that I'm holding up. And likewise, because we both are wearing many hats simultaneously. And so I think that's really the crux of it is the use of laughter, the importance of secure attachment with your colleagues. Those are two absolutely vital components. And I know that pretty much everybody on the men team is

committed to exercise in family and spirituality. And those are all, you know, mediating factors in making sure that we sustain our own health. I think that's really important to reiterate. So it's like, you know, when you go home, you know, to not feel like you always have to be doing, but that you can relax and enjoy your family and your spirituality and your recreation. And I think a lot of providers actually have a really hard time shutting down or tuning it out, switching gears. And I think those are things that we can do better at as a community. And the other thing I think worth mentioning is when I heard Marshall Lanham talk about DBT, one of the things that she said is she said, if you're not running weekly countertransference

groups, then you're not doing DBT. and there's a lot of community programs that don't really fulfill the criteria of what she calls DBT because one, they don't give the patients their cell phone numbers for various reasons and obvious reasons. And two, they don't do countertransference work on a weekly basis, like processing through how you're struggling with different patients or how you're feeling burdened by the stories. So I feel like that's an important aspect in any healthy treatment program. So if you're a psychiatrist in training and you're like, you know, I don't want to do therapy in particular, but I do want to run a program at some point, like learning enough to be able to run a treatment team so that the treatment team can be thriving is a journey that you should go on. I agree.

I agree. And everyone contributes. everyone contributes to that a part of our team and I appreciate how we've hired people who now you can go to because they're excellent therapists and you can go in process so it's like the full team coming around

and supporting that process okay so you're with the patient you're in their story you're listening you're embodying you're bearing witness I like that word Are there any other treatments that you've come across in the literature of treating childhood sexual abuse

that have shown that other techniques work or that, you know, what's the best evidence that you've seen as you've looked at this literature? That's a great question. I think setting our specific program aside, our program has a specific emphasis because we're looking at the biopsychosocial outcome. But there are other evidence-based programs that are considering the psychosocial components of health. And they are doing an effective job at that. Emotionally focused therapy for couples is research-based, evidence-based,

and they're doing an effective job bringing spouses in and having spouses support in the process. And their results have been, like I said, have demonstrated very strong findings. DBT has a very specific program. It's a residential program for individuals who are struggling with PTSD related to childhood sexual abuse. And that has demonstrated very effective outcomes as well, as has psychoanalytic support groups and systemic support groups. There was a study that was run in Europe, I believe, that looked at psychoanalytic support groups and systemically based support groups. And the outcomes for each group were highly positive. they were slightly higher for the systemic pieces, but they were also much more structured. So there were many other factors in the study that would have to be considered. But those three things, those three different therapeutic approaches were the ones that stick out to me the most. Are there techniques, specific techniques in those types of modalities that makes sense

to you as to why those would be also working? Well, particularly with the emotionally focused therapy for couples, they're bringing the spouses in, teaching the spouses to be effective witnesses in the trauma story so that when this was done with female survivors, so the female feels heard not only by the therapist, but by her romantic partner. And so when she goes home, she takes that systemic support into the home with her. And those outcomes have been highly positive and demonstrated what we have found here at men to be highly effective as well, which is the absolute importance of finding at least some person. It may not be a romantic partner. It may not be a parent, but some person that can come in and have at least the foundational ability to create a secure attachment with the patient, because that is what's going to truly move them into health,

is that secure systemic attachment so that their body can begin to experience healing. So what type of patient would you recommend that they go into like a day treatment program, like what we're talking about that we run versus more of just like a weekly outpatient program? This is an absolutely fantastic question because many excellent outpatient therapists

are treating individuals with a history of childhood sexual abuse and doing an amazingly fantastic job. However, patients who come from multi-dimensionally unstable families where their biopsychosocial health is being significantly impaired through the symptomology that you and I discussed earlier in the podcast and to where they're not able to stay safe, where the body is breaking down to where they've become medically fragile. those would be wonderful patients to refer out, at least until they become medically stable. That's what is a blessing for us is that we have you and MD, we have a nurse, we have

therapists, so we can make sure that medically fragile patients are secure and stable enough to process their traumatic experiences. So my suggestion is I also at times see patients in private practice and for patients where they're unable to stay safe or patients where the body is breaking down in the face of trauma to a point where you're seeing an extensive amount of symptomology, then my thought is refer to a higher level of care for stability and then they titrate down and come right back to you when the work is done. Yeah, my answer to that would be there's this kind of domino effect with certain patients where they get more and more medications on board where they're just cognitively not at a place where they can focus and concentrate

and do the work. So, for example, we have patients who come in on opiates, benzos, marijuana, cognitive doling medications up the wazoo. And in prior episodes on Sensorium, in prior episodes on delirium, I go through how these things affect our mind, which by the way, I think is the number one misunderstood or poorly understood thing by therapists is how medications and substances can dole the mind to make therapy really, really difficult. So in that case, I think a higher level of care would be indicated. Unless you had a really good competent psychiatrist, you know, psychopharmacologist who kind of knew what was going on and was able to start to make the changes. But honestly, when I see this level of complexity of patient in the out,

patient setting, it's really difficult because when you start to lower those medications, you may not be able to see this patient back for a month because my schedule is impacted. And you have to make very sort of exact changes and then be able to have therapists almost who can give me a heads up. Hey, you made that change yesterday. This is what's going on today. You might want to see them. And then I see them again.

and then I see them again. And then, you know, some people need to be detoxed. So they may come into our program. We build a connection with them after a couple weeks. And then we're like, I'm like, you know, these doses of meds are keeping them from doing their work. Let's send them to go detox. And there's some people who don't want anything to do with that. And, you know, we have that conversation.

But most patients will go detox. They'll come back to the program and continue their work. and they get better. And so that's exciting. Okay, so one more question here, and then I think we'll end on this one. Okay, so we talked about going back to safe people, like in your family. So how would you define a safe person? And if it's not a family member, could it be someone else?

It could definitely be somebody else. For us, in our work, we find women with many fractured relationships. So the safest person might not always be the romantic partner, but there could be a safe sibling. There could be a parent that is safe. There could be a friend that is safe. So my thought is someone who can come in and cultivate the basis of a secure attachment with that patient and also help them to move into health, right? Almost not necessarily an accountability partner, but maybe not that far off.

Someone who is sitting side by side with them on the outside. treatment, cheerleading their strides towards health, cheerleading their strides towards, like you said, reduced medications, reduced illness activity, more adaptively getting their needs met. So a secure person would be someone who truly has the best interest of the patient in mind, not somebody that has the best interest of the old maladaptive patterns in mind, which we see and partners at times where they want to keep, you know, that homeostasis. So what we want to do is disrupt that homeostasis and create and foster something that's new and healthy.

That can't always happen in our adult program because the other partner may not want to make those changes. If they can bring in a favorite sister, a favorite brother, who can continue to support them on the outside, make their body feel comfortable, make their body feel safe, and and secure, then I truly believe that even that is a wonderful starting place towards facilitating and engendering change. Okay, let's say someone was listening to this and they were like, I don't know if I have that person in my life, but I would like to build that type of relationship.

How would they go about making such a relationship a friend? Like, what would they look for in that other person? Like, because you know how like some people when they're, like, they end up in relationship. relationships that are similar to the dysfunction of their trauma. Right. And so it's like how do you, how would you help someone fight against that propensity to find a safe person? Well, I think that's an absolutely fantastic question, especially to a marriage and family therapist, because we're looking at those recurring patterns, those feedback loops that are playing out from childhood over the life course. So where I come at that from is looking at those early narratives, those early meaning-making experiences.

We talked about this a little bit earlier in the program as to people feeling like a burden or feeling worthless. Once we can go in and start to make changes as to how a person sees themselves, when they move from being completely unworthy to worthy, their relational patterns change. No longer do they need to be abused or victimized. Now that they're worth something, they can create systemic changes. They can bring new people into their life. It's very simply put, a victim, someone with a victim narrative, has to have a perpetrator. I can't be a victim or a martyr without a perpetrator. If I no longer am a victim, then I no longer need a perpetrator.

So at that point, I can bring someone healthy into my life. If my narrative is that I have no power, that I have no control, that I should be disempowered, then I have to bring someone in who's overpowering, right? I have to bring someone in who wants to take control. And illness fosters that need, you know, fosters that inability to have control. So once those early narratives are changed, then I don't, I can bring somebody in who's healthy. If I have power, adaptive healthy power, I don't need someone to come in and empower over me. I want someone to power side by side with me, right? Someone to move with me through synergy,

not somebody to come over and take over my life. So this is how I think we see these systemic changes happening is through changing those early narratives and then watching the patients grow and start to include people in their world who don't meet that old pathway. That's really good. That's really good.

And I think that may be our next episode right there because that is so interesting. how specifically some people like prefer almost the to be in the one down relationship or the one up relationship. There's some people who go the other direction and how to help people be in a sort of equal, you know, eye-to-eye relationship. And we see this all the time. We see it.

We saw it today actually. We did. And the way to summarize it without giving, any details that would expose anyone would be that, you know, Ginger said to someone, well, you can speak directly to me. You don't need to go to Dr. Puter because we're colleagues in this. And that's how we run the team is we're colleagues. So it's not a one-up or a one-down relationship. Either way, it's like, no, we're collaborating in care. And it kind of, you know, didn't allow the person to put me in a one-up relationship and therefore to sort of,

put ginger in a one-down relationship. I don't know. Do you think that's okay to include? I think that's awesome. I think it's an accurate depiction of how individuals, you know, conceptualize power, right? And how they're used to maneuvering and managing power maladaptively. And so, yeah, I think it's very powerful.

And I think it could be the basis of a whole new podcast because this relational component is vital to any story, that includes childhood trauma. Okay, so if you want us to do that episode, chime in. Chime in, jump onto my social media. I'll have a post for this episode. Put up your questions that you might have for a future episode

that you want Ginger asked or me asked. And yeah, thanks for listening. I appreciate the support. If you join the mailing list, you'll get an update for that next episode. And Ginger, it's been a pleasure. Always. Thank you.