THEGRIEFTHATDARE NOTSPEAKITSNAME

PARTI:DEALINGWITHTHERAVAGESOFCHILDHOODABUSE SANDRAL.BLOOM,M.D. EMAILFROMAMERICA PSYCHOTHERAPYREVIEW2(9),SEPTEMBER2000

Whensomeoneclosetousdies,societygenerallyacceptsandeven expectsustoundergoaprocessofmourning.Physicaldeathpresentsa tangibleandcomprehensibleloss.Traditionally,mourningisnotjustan individualriteofpassage,butasociallyconditionedandapproved pathwayforrecoveryfromlossenablingustoletgoofthosewhohave died,andprepareourselvesfornewattachments. Largelyunrecognizedisthenecessityandvalueofgrievingforother kindsoflossesbesidesthoseassociatedwithactualdeath.Acommon denominatorforadultsurvivorsofchildhoodabuseandneglectareless tangible,butnonethelesssignificantlossesofhope,ofinnocence,of loveandofjoy.Foradultsurvivors,thelossesthataccompanychild maltreatment,arecloakedinsilence,lostintheshroudsofhistory,and largelyunrecognized.Buttheselittledeathslingerasunremoved splintersinthesurvivorspsychefordecades.Ingeneral,theexpression ofgrieffortheselossesisunaccepted,rejected,deniedandstigmatized. Childneglectrepresentsparticularchallengesfortheadultsurvivor becausevictimsmustgrieveforthingstheyneverhad,andthusnever hadthechancetolose. Thelossesthataccompanychildhoodexposuretoterrorandviolence canonlybegraspedwithinthecontextofattachmenttheory.Bowlby recognizedthatgriefandmourningoccurininfancywheneverthe responsesmediatingattachmentbehaviorareactivatedandthemother figurecontinuestobeunavailable(Bowlby,1960,p.9).Hediscussed howtheexperienceoflossofmotherintheearlyyearsisan

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 antecedentofrelevanceinthedevelopmentofpersonalitiesproneto depressiveandotherpsychiatricillnessesandthattheseconditionsare bestunderstoodassequelaeofpathologicalmourning(Bowlby,1960, p.11).Asfarbackas1963,Khandiscussedtheideaofcumulative trauma,andtheimpactofprotectivefailures:cumulativetraumaisthe resultofthebreachesinthemothersroleasaprotectiveshieldover thewholecourseofthechildsdevelopment,frominfancyto adolescence(Khan,1963).Hewentontodiscusshowthiscanleavea personvulnerabletobreakdownlaterinlife. Bowlby(1963)identifiedfourmainvariantsofpathologicalresponsesby bereavedadultsandothercliniciansandresearchershavebeenbusily extendinghisworktoshowtherelationshipbetweendisrupted attachmentinchildhoodasaresultofmaltreatment,theexperienceof loss,andthedevelopmentofadultpathology,especiallydepression(de Zulueta,1994).Thefirstvarianthedescribedasanxietyanddepression, whichhesawasthepersistentandunconsciousyearningtorecoverthe lostperson,originallyadaptivebecauseitproducedstrongmotivation forreunion.Thereisalongestablishedconnectionbetweenchildhood lossanddepression(Bowlby,1980).Adamhasrecentlyreviewedthe strongconnectionbetweensuicidalbehaviorinadolescentsandadults anddisruptedattachment(Adam,1994).Thereisalsoagrowingbodyof literatureconnectingchildhoodmaltreatmentwithawidevarietyof physical,psychological,andsocialdysfunctioninchildhoodandin adulthoodandthereisnowasignificantbodyofliteraturereviewing variousaspectsofcomorbidity(Ellasonetal,1996;Grady,1997;Koss, Koss&Woodruff,1991;Lesermanetal.,1996;Salmon&Calderbank, 1996;vanderKolk,1996).Additionally,therearewellestablished connectionsbetweenchronicdepressivedisorders,somatization disorder,anxietydisorders,andvariouspersonalitydisordersespecially borderlinepersonalitydisorderandchildhoodexposureto overwhelmingandtraumaticevents(Kessleretal,1995;Solomon& Davidson,1997). Bowlbyssecondvariantwasthatofintenseandpersistentangerand reproachexpressedtowardsothersortheselfandoriginallyintendedto achievereunionwiththelostrelationshipanddiscouragefurther separation;Inthelastdecades,investigatorshaveconcretizedthe relationshipbetweeninsecureformsofattachmentinchildhoodand theevolutionofpersonalitydisorders(WestandKeller,1994).Fonagy

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 andcolleagueshavehelpedilluminatetheimportantrelationship betweendisruptedattachmentandborderlinestates(1998), Inhisfourthvariant,Bowlbylookedattheabsorptionincaringfor someoneelsewhohasalsobeenbereaved,sometimesamountingtoa compulsion.Linkagesmaybemadebetweenthisincompleteformof grievinganddysfunctional,evenviolentrelationships.Othershave lookedatbothhighlyconflictedfamiliesandviolentcouplesfromthe pointofviewofdisruptedchildhoodattachmentrelationships(Henry& Holmes,1998;Roberts&Noller,1998),whileMain&Hesse(1990)and Solomon&George(1999)haveprovidedabundanttheoreticaland evidencebaseddatashowinghowthedisruptedchildhoodattachment relationshipsofparentscanbecarriedoverintothewaysinwhichthey parenttheirownchildren. Bowlbysfourthvariantfocusedonadenialthattherelationshipis permanentlylost,adenialthatcouldlinkattachment,grievingandthe spectrumofdissociativedisorders(Bowlby,1963).Recently,Liottihas writtenaboutthedevelopmentofdissociativedisorderswithinan attachmentframework(1995,1999). Still,whenitcomestoactuallytreatingvictimsofchildhoodabuseand neglect,onlyrarelydoesonediagnosticcategoryfit.Theoverlapping symptomsandcomplexclinicalpicturecharacteristicofadultswhohave experiencedchildhoodmaltreatmentismorecomprehensibleifwe formulatetheproblemasoneofcomplexposttraumaticstress disorder(Herman,1992;vanderKolketal.,1994).FieldtrialsforDSM IV(AmericanPsychiatricAssociation,1994),demonstratedthatthere aresignificantdifferencesbetweensurvivorsofdisasterswhosuffer fromposttraumaticstressdisorderandchildhoodsurvivorsof maltreatment.Thesedifferencesfallintosevenmajorcategoriesof dysfunction:alterationsinregulatingaffectivearousal,alterationsin attentionandconsciousness,somatization,alterationsinself perception,alterationsinperceptionoftheperpetrator,alterationsin relationstoothers,andalterationsinsystemsofmeaning.These symptomclustershavebeendemonstratedtodifferentiateacuteadult onsettraumasyndromesassociatedwithdisastervictimsfromadult victimsofchildhoodinterpersonalviolenceandabuse(VanderKolket al,1994). Whenviewedfromthepointofviewofthegriefliterature,difficulties withmanagingaffectandalterationsinattentionandconsciousness

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 mayreflecttwoofthefinaladultpersonalityoutcomesfortwoof Bowbyssequelaeofpathologicalmourning.Theunrelentingyearning andsearchingforthelostloverelationship,andthedefensesbuiltupto protectagainstthisyearningcanbeseenasanunderpinningformany ofthesymptomsthatleadpeopletoseektreatment.Thepersistent angerandreproachoriginallyintendedtoachievereunionand discouragemoreseparationarecommonproblemsforvictimsofabuse inalloftheirrelationshipsandstronglycolorthenatureofthe therapeuticalliance.Alterationsinselfperception,inperceptionofthe perpetratorandinrelationshipswithothersallcanbeunderstoodinthe contextofanexpectabledevelopmentaloutcomeinthefaceof disruptedearlyattachments.Traumabondingisarelationshipthatis basedonterrorandthetwistingandmanipulationofnormal attachmentbehaviorinserviceofsomeoneelsesmalevolentintent. Successfulgrievingmeanslettinggoofthesepatternsaswellasletting gooftheformerabusiverelationships,eventhoughtheserelationships arealsoassociatedwithadeepsenseoffearandforebodingattheir loss. Somatizationmayrepresentnotonlytheeffectsofprolongedstressbut alsothelongtermeffectsofsuppressedgriefonthebody.Disrupted systemsofmeaningcanbeunderstoodasthelogicaloutgrowthof growingupwithinintimatechildhoodcontextsofmistrust,deceit, hypocrisyandcruelty,thatareembeddedwithinalargersocialcontext thatinsiststhatchildrenaretobevalued,loved,cherishedand protectedfromharm.Achildsexposuretodeliberatemalevolenceat thehandsofaprimarycaretakerpowerfullyconfusestheabilityofthe childtocorrelatehisorherownexperienceofrealitywiththerealities ofotherpeople.Thecontradictionsareoftenshattering. Whileattachmenttheoristshavebeencarefullyformulatingtheoryand analyzingdatafromtheperspectiveofdevelopmentalpsychopathology (Cicchetti&Lynch,1995),cliniciansandresearchersintheoverlapping fieldsoftraumaticstressstudiesandthanatologyhavebeenbroadening ourunderstandingofwhathappenstopeoplewhoaretraumatizedand thewaysinwhichtraumaticbereavementdiffersfromnormal bereavement.Jacobshasdescribedtraumaticgriefinrelationtoany deaththatispersonallydevastatingandischaracterizedbytraumatic separation.Traumaticgriefhasbeenshowntobeassociatedwith impairedroleperformance,functionalimpairment,subjectivesleep disturbance,lowselfesteem,depressionandanxiety,aswellasahigh

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 riskofcancer,cardiacdisorders,alcoholandtobaccoconsumption,and suicidalideation(Jacobs,1999).Otherauthorshavelookedatthe variouswaysthattraumaticbereavementandexposuretodeathand dyingaffectvariouspopulationsandagegroups(Figley,1997;Figley, Bride&Mazza,1999),whilestillothershavelookedatthewayentire communitiesgrieveaftermasstragicevents(Zinner&Williams,1999). Rando(1993)haswrittenextensivelyaboutthetreatmentof complicatedmourningandhasconnectedunresolvedgrieftomanyof thesymptomsofchronicandcomplexposttraumaticstressdisorder. Shehasalsolookedatthedifficultiessurvivorsencountermourning someonewhohasvictimizedthem,asissooftenthecaseinsurvivorsof childhoodmaltreatment.AtleastsinceLindemannsseminalwork (1944),theconnectionbetweenthenormalsomaticmanifestationsof griefandsymptomsofcomplicatedmourninghavebeenrecognized (Engel,1961;Rando,1993). Nonetheless,althoughtheliteratureisbynowrichandpersuasivein conceptualizingtherelationshipbetweentraumaticlossanddisrupted attachment,relativelylittlehasbeendetailedaboutthelossesthedo notinvolveactualdeath,butthatdorepresentextraordinarylossfor adultswhoweremaltreatedaschildren.Theselittlelossesoccurin thecontextofalongstandingpatterncharacterizedbytheabsenceof sustainingandlovingcaregiverbehavior.Aschildren,ourpatientsoften hadparentswhowerephysicallypresent,butthenatureoftheir parentingwassoabusiveand/orneglectfulthattheirlossesarenot evenseenaslossesatall,butawayoflife. Overthecourseofthenexttwomonthswewilllookatthegriefthat accompanieschildhoodabuseandneglectmoreclosely.Thenext columnwillfocusmorespecificallyonthelossesthatadultsurvivors mustworkthroughintheprocessofrecoveryandsubsequently,wewill lookattheprocessofrecoveryfromthesekindsoflosses. REFERENCES Adam,K.S.(1994).Suicidalbehaviorandattachment:Adevelopmental model.InM.B.Sperling&W.H.Berman,(Eds.),Attachmentinadults: Clinicalanddevelopmentalperspectives.NewYork:TheGuilford Press.(pp.275298).

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 AmericanPsychiatricAssociation.(1994).DiagnosticandStatistical ManualofMentalDisorders(4thed.).Washington,DC:American PsychiatricPress. Bowlby,J.(1960).Griefandmourningininfancyandearlychildhood. ThePsychoanalyticStudyoftheChild,v.15:952. Bowlby,J.(1963).Pathologicalmourningandchildhoodmourning. JournaloftheAmericanPsychoanalyticAssociation11:500541. Bowlby,J.(1980).Attachmentandloss,VolumeIII:Loss,sadnessand depression. Cicchetti,DandM.Lynch.(1995).Failuresintheexpectable environmentandtheirimpactonindividualdevelopment:Thecaseof childmaltreatment.InD.CicchettiandD.J.Cohen(Eds.), Developmentalpsychopathology,Volume2:Risk,disorder,and adaptation.NewYork:Wiley. DeZulueta,F.(1993).Frompaintoviolence:thetraumaticrootsof destructiveness.London:WhurrPublications. Ellason,J.W.;C.A.Ross;K.Sainton;L.W.Mayran.(1996).AxisIandII comorbidityandchildhoodtraumahistoryinchemicaldependency. BulletinoftheMenningerClinic;60(1):3951. Engel,G.L.(1961).Isgriefadisease?Achallengeformedicalresearch. PsychosomaticMedicine.23:1822. Figley,C.R(Ed.).(1997).Traumatologyofgrieving:Conceptual, theoreticalandtreatmentfoundations.NewYork:Brunner/Mazel. Figley,C.R.,Bride,B.E.&Mazza,N.(1999).Deathandtrauma:The traumatologyofgrieving.NewYork:Brunner/Mazel. Fonagy,P.,Steele,M.,Steele,H.,Leight,T.,Kennedy,R.,Mattoon,G.,& Target,M.(1995).Attachment,thereflectiveself,andborderline states:ThepredictivespecificityoftheAdultAttachmentInterview andpathologicalemotionaldevelopment.InS.Goldberg,R.Muir&J. Kerr(Eds.),Attachmenttheory:Social,developmental,andclinical perspectives.Hillsdale,NJ:TheAnalyticPress.(pp.233278). Grady;K.T.(1997).Posttraumaticstressdisorderandcomorbidity: RecognizingthemanyfacesofPTSD.JournalofClinicalPsychiatry; 58(supplement9):1215. Henry,K.&Homes,J.G.(1998).Childhoodrevisited:Theintimate relationshipsofindividualsfromdivorcedandconflictriddenfamilies. InSimpson,J.A.&Rholes,W.S.,(Eds.),Attachmenttheoryandclose relationships.NewYork:TheGuilfordPress.(pp.280316). Herman,J.L.(1992).Traumaandrecovery.NewYork:BasicBooks.

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 Jacobs,S.(1999)Traumaticgrief:Diagnosis,treatmentandprevention. NewYork:Brunner/Mazel. Kessler,R.;A.Sonnega;E.Broment;M.Hughes;C.B.Nelson.(1995). PosttraumaticstressdisorderintheNationalComorbiditySurvey. ArchivesofGeneralPsychiatry;52:10481060. Khan,M.M.R.(1963).Theconceptofcumulativetrauma. PsychoanalyticStudyoftheChild18:286306. Koss,M..P.;P.G.Koss;W.J.Woodruff.(1991).Deleteriouseffectsof criminalvictimizationonwomen'shealthandmedicalutilization. ArchivesofInternalMedicine;151(2):342347. Leserman,J.;D.A.Drossman;Z.Li;T.C.Toomey;G.Nachman;L. Glogau;L.(1996).Sexualandphysicalabusehistoryin gastroenterologypractice:howtypesofabuseimpacthealthstatus. PsychosomaticMedicine;58(1):415. Liotti,G.(1995).Disorganized/disorientedattachmentinthe psychotherapyofthedissociativedisorders.InS.Goldberg,R.Muir& J.Kerr(Eds.),Attachmenttheory:Social,developmental,andclinical perspectives.Hillsdale,NJ:TheAnalyticPress.(pp.343365). Lindemann,E.(1944).Symptomatologyandmanagementofacutegrief. AmericanJournalofPsychiatry101:141148. Liotti,G.(1999).Disorganizationofattachmentasamodelfor understandingdissociativepathology.InJ.Solomon&C.George, (Eds.),AttachmentDisorganization.NewYork:TheGuilfordPress. Main,M.&Hesse,E.(1990).Parentsunresolvedtraumaticexperiences arerelatedtoinfantdisorganizedattachmentstatus:Isfrightened and/orfrighteningparentalbehaviorthelinkingmechanism?InM.T. Greenberg,D.Cicchetti&E.M.Cummings(Eds.),Attachmentinthe preschoolyears:Theory,researchandintervention.Chicago: UniversityofChicagoPress(pp.161182). NewYork:BasicBooks. Rando,T.A.(1993).Treatmentofcomplicatedmourning.Champaign,IL: ResearchPress. Roberts,N.&P.Noller.(1998).Theassociationsbetweenadult attachmentandcoupleviolence:Therolesofcommunicationpatterns andrelationshipssatisfaction.InSimpson,J.A.&Rholes,W.S.,(Eds.), Attachmenttheoryandcloserelationships.NewYork:TheGuilford Press(pp.317351). Salmon,P.andS.Calderbank.(1996).Therelationshipofchildhood physicalandsexualabusetoadultillnessbehavior.Journalof PsychosomaticResearch;40(3):329336.

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 Solomon,S.andJ.R.T.Davidson.(1997).Trauma:Prevalence; impairment;serviceuse;andcost.JournalofClinicalPsychiatry; 58(suppl9):511. SolomonandGeorge(1999) VanderKolk,B.A.(1996).Thecomplexityofadaptationtotrauma.InB. vanderKolk,B.A.,McFarlane,A.C.&Weisaeth,L.(Eds)].Traumatic Stress:TheEffectsofOverwhelmingExperienceonMind;Bodyand Society.Guilford;NewYork.(pp.378397). VanderKolk,BA.,Roth,S,Pelcovitz,D.andMandel,FS(1994).Disorders ofextremestress:ResultsfromtheDSMIVFieldTrialsforPTSD.Paper presentedas1994EliLillyLecturetotheRoyalCollegeof Psychiatrists,London,February2. West,M.&Keller,S.(1994).Psychotherapystrategiesforinsecure attachmentinpersonalitydisorders..InM.B.Sperling&W.H. Berman,(Eds.),Attachmentinadults:Clinicalanddevelopmental perspectives.NewYork:TheGuilfordPress.(pp.313330). Zinner,E.S.&Williams,M.B.(1999).Whenacommunityweeps:Case studiesingroupsurvivorship.NewYork:Brunner/Mazel.

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THEGRIEFTHATDARE NOTSPEAKITSNAME
PARTII:DEALINGWITHTHERAVAGESOFCHILDHOODABUSE

SANDRAL.BLOOM,M.D.
EMAILFROMAMERICA

PSYCHOTHERAPYREVIEW2(10),OCTOBER2000
Adultswhoweremaltreatedaschildrencarryaroundwiththemthe impactofdelayed,unresolved,stigmatizedloss(Sprang&McNeil, 1995).Accordingtothedescriptionsofstigmatizedgrief,theincidents givingrisetothelosshappensuddenly,areassociatedwithviolence, resultinothersfearingcontagionandblamingthevictimandresultin victimsbelievingtheyshouldhavedonesomethingtopreventthe events,orthattheydeservewhathappened.Severalofthe characteristicsofstigmatizedgriefdescribethesituationofabused children.Insomecases,asinsexualabuse,thelossofasecure relationshipwiththeparentcanbequitesuddenandunexpected.Child abuseisclearlyassociatedwithviolenceandthevictimsareusuallytold thattheyhavedonesomethingtodeservetheviolence.Theirparents andsocietyatlargetendstoblamethemandfrequentlytheyaretold thatiftheyhadbehaveddifferentlytheycouldhavepreventedit.Social denialofthemagnitudeoftheproblemusstillaprominentfeatureof oursocialenvironment. Victimsgriefisdelayedbecausemostabusedchildrenlearnhowto adapttoevenastonishinglydifficultcircumstancesinordertosurvive, buttheydopayaprice.Alatercrisisorlossinadultlifemayunmaskan underlyingvulnerabilitythathasbeenlurkingbeneaththeapparently normalsurfaceoftheirlivesforyears.Thelossestheysustainare unresolvedbecauseformostsurvivorsofchildhoodabuse,thereisno clearlyestablishedandsociallyacceptablepathwayforgriefresolutionif actualphysicaldeathhasnotbeeninvolved.Theirlossescannotevenbe acknowledgedasloss.Theirgriefisstigmatizedbecauseitisseenasa blemishofindividualcharacter(Goffman,1963).Thelossesassociated

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 withchildhoodmaltreatmentthatareonlyrecognizedorsurfacedin adulthoodarenotconsideredlegitimatereasonsforgrief,bythelarger society.Theyarenotlegitimatemourners. AccordingtoDoka(1989),whohaswrittenaboutdisenfranchised grief,therearethreegeneraltypes:thoseindividualswhose relationshipsaresociallyunrecognized,illegitimate,orinotherways unsanctioned;thosepersonswhoselossdoesnotfitthetypicalnorms ofappropriateness;andthosepeoplewhoseabilitytogrieveisin questionorwhoarenotconsideredtobelegitimategrievers.Victimsof childmaltreatmentexperiencemanylossesthatcarrywiththemno sociallegitimacy.Inthecaseofvictimsofsexualabuse,thelossesthey sustainareoftennotonlyunrecognizedbutaredeniedbythe perpetratorandbyotherfamilymembers.Victimsofotherformsof maltreatmentarefrequentlylabeledaswhinersorcomplainerswho manipulateotherswiththeirvictimmentality.Asfornormative appropriateness,thesocietyatlargebarelyiswillingtodealwithdeath asalegitimatecauseforbereavementbehavior.Thesocialattitude towardsmostotherlossesisgenerally,getoverit.Andevenamong therapistsandotherwisesupportiveothers,theremaybegreat resistancetoempathizingwiththegriefthatvictimsfeelatfinally havingtogiveuparelationshipwithsomeonewhohasbeenabusive, dangerousandcruelorlettinggoofabehaviorthathashelpedthem copeandfeelincontrol,evenifthatbehaviorappearscrazy.Theyare notlegitimategrieversbecausethelossestheyexperienceareusually notconsideredappropriatecausesforgrief.Afterall,theysurvived, didntthey? Itispossibletolookatthevarietyoflossexperiencesthatsurvivors mustrecoverfromthroughthelensofcomplexposttraumaticstress disorder(Herman,1992;vanderKolketal.,1994).FieldtrialsforDSM IV(AmericanPsychiatricAssociation,1994),demonstratedthatthere aresignificantdifferencesbetweensurvivorsofdisasterswhosuffer fromposttraumaticstressdisorderandchildhoodsurvivorsof maltreatment.Thesedifferencesfallintosevenmajorcategoriesof dysfunction:alterationsinregulatingaffectivearousal,alterationsin attentionandconsciousness,somatization,alterationsinself perception,alterationsinperceptionoftheperpetrator,alterationsin relationstoothers,andalterationsinsystemsofmeaning

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ALTERATIONSINABILITYTOMANAGEEMOTIONS
Childrenrequirelovingandempathicrelationshipsinordertodevelop properly.Theimmaturecentralnervoussystemneedscaregiverswho arewillingtoserveasprotectiveshieldsagainstoverwhelmingarousal. Thehallmarkcharacteristicofallformsofchildmaltreatmentis empathicfailure(Weil,1992).Whenexposuretoabuseandneglect corruptsthefamilyenvironment,childrenloseorfailtodevelopthe abilitytomodulatetheirownlevelofemotionalarousalandasaresult theyareforcedtousewhatevercopingskillstheyhappentohitonthat calmsthemdown.Oftenthosecopingskillsareselfdestructivedrugs, alcohol,aggression,selfabusebutthesebehaviorswithinthechildor theadultscontrolarepreferabletothenoxiousexperienceof overwhelmingdistress.Theinabilitytomanageemotionsinarelational, constructivewaymeansthatlateryoumustgrieveforhowmuchmore difficultlifeisandhasbeenforyouthanitisforotherpeople(Lossof abilitytomanageemotionslikeotherpeople).Itmeansthatyoulosea senseofbeingsafeandsecureintheworld,ifyoueverhaditinthefirst place(Lossofasenseofsafety).Theprolongedeffectsofexposureto overwhelmingstressmeansthatitisverydifficulttofinishthegrieving processthatenableyoutomakemoresuccessfulrelationshipsbecause beingabletogrievemeansbeingabletotolerateandworkthroughvery painfulemotionalexperiences(Lossoftheabilitytocomplete mourning).

A L T E R A T I O N S I N A T T E N T I O N A N D C O N S C I O U SN E S S
Exposuretochronicstatesofphysiologicalhyperarousalinterfereswith thecapacitytolearn,tovoluntarilydirectattention,andtomaintain focus(Perry,1994;Putnam&Trickett,1993).Traumatizedchildrenhave littleabilitytoselfprotect.Confrontedwiththemassivephysiological hyperarousalthataccompaniesexposuretoviolence,thereislittlethey candotofightbackortoflee.Buttheycandissociatefragmenttheir experienceinawaythatprotectsthemagainsttheveryrealdangerof physiologicaloverload.Butthepricetheypayforthisprotectionis substantialmemories,feelings,identityarefragmented.Thissenseof anintegratedselfissomethingthatadultsraisedinfunctionalfamilies simplytakeforgrantedandistrulyknownonlyinitsabsence(lossofa senseofwholeness,selfintegrity).

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ALTERATIONSINRELATIONSHIPS
Abusedchildrenloserelationships.Somemaltreatedchildren,haveno onetorelatetofromtheverybeginningoftheirlives.However,many parentsareadequateinsupplyinganinfantsbasicneedsbutcannot handlethedemandsofagrowing,activechild.Forsuchachild,theloss oftheformerlynurturingparentcanbeexperiencedasadeathfor whichtherearenowords(lossofearlyattachmentrelationships).This lossofattachmentisdevastatinginitsimpactuponthecapacityto establishrelationalsafetyasanadult(Lossofabilitytocreatesafeand trustingrelationships).Anditisnotjustindividualrelationshipsthatare affected.Itiswithinthefamilythatwefirstlearnaboutpolitical,social andeconomicarrangementsbetweenpeople.Dysfunctioninthefamily relationshipswilldirectlycarryoutintotheschool,theworkplace,and thecommunityatlarge.Asaresult,manysurvivorsofsystematicabuse donotfeelasenseofplaceintheirsocialsystem,andtheydonotknow howtoachievesuchaplacewithoutpayingapricesimilartotheone theyhavealreadypaidintheirfamilies(Lossofmeaningfulplacein community).Historyrepeatsitselfinthelifeoftheindividualinsideand outsideofthefamilyandthenhistoryrepeatsitselfonthepartofthe wholegroup.

A L T E R A T I O N S I N S E L F P E R C E P T I ON A N D P E R C E P T I ON OF T H E P E R P E T R A T O R ( S )
Wedevelopasenseofselfesteeminthecontextofoursignificant relationships.Thebabylearnstoviewhimselforherselfwiththesame regardthatheorsheseesmirroredinthemothersandfatherseyes. Likewise,abusedandneglectedchildrencometobelievetheimageof themselvesthattheirparentscreate,animagethatoftenhasverylittle todowiththerealityofthechildrensabilities,skills,ordispositions. Theyaretoldtheyarebad,evil,orworthless,justliketheirfaithless AuntSadieorUncleBill.Repeataliefrequentlyenoughandpeople cometobelieveit.Childrenareparticularlyvulnerabletothiskindof parentalsystematicbrainwashingbecauseofthelargepowerimbalance thatexistsbetweenparentsandchildren. Asadults,peopleoftenmaintainthesameconnectionwiththeir parentingfiguresastheyhadasachildandconsequently,experience similarfears,powerlessnessandhelplessnessinthefaceoftheir parents,orinthefaceoftheirinternalimageoftheirparents.Wemay experiencethatinternalimageasthevoiceofconscienceandhave takeninternalizeditasourown,withoutfullyrealizingthatitisthe

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 internalizedvoiceofanabusiveparent.Asaresult,evenwithinourown mindswecontinuetoreenactthechildhoodtraumabetweenourselves andourparents.Asoutsiders,wemaylookatayoung,sixfoottwo man,intimidatedandquiveringbeforeafrailoldman,halfhissizeand failtounderstandthatthegrownmanisexperiencingthesameterrors aswhenhisnowfrailfatherwouldbeathimintosubmissioneveryday afterschool.Ourperceptionsofourselvesdonotjustautomatically changeaswemature,nordoourperceptionsofthepeoplewhohave perpetratedviolenceagainstus.Withoutworkingthroughthegriefand theangerconnectedtotherelationshipwecanremainterrorizedand humiliatedbypastfiguresinourlives,eventhoughtheymaybeoutof sightorevendead. Thesechildhoodexperiencescontinuetoimpactontheadultsself esteem,eventhoughgreatsuccessintheworldshouldrealisticallylead toheightenedselfesteem(lossofrealisticsenseofselfesteem). Parentsandsignificantotherswhohavebeenabusive,irresponsible, andneglectfuldonotprovideadequaterolemodelsforintimate relationshipsorforparenting,leavingthesurvivorwithgreatholes whererelationalwisdomshouldbe(lossofadequaterolemodels). Authorityfigureswhoroutinelyabuseauthorityandwhouseviolence toenforcetheirauthorityareunabletoteachgoodconflictresolution skillsandasaresult,adultsurvivorsoftenlacktherequisiteskillsfor resolvingtheinevitableanddemandingproblemsassociatedwith interpersonalrelationships(lossofproblemresolutionskills development).Thetendencytoreenactthepastrelationallymeansthat itisverydifficultfortheadultsurvivortoengageinlearningnewand healthierformsofinterpersonalengagement(lossoftheabilitytolet goofthepastandmoveon).Andfinally,growingupwithabusive parentingproducessuchalterationsindevelopmentalpathwaysthat manysurvivorsmissoutoneducationalandvocationalexperiencesthat couldhaveaffordedthemlifelongbenefit(lossofeducationaland vocationalopportunities).

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SOMATIZATION
Clinicalandpoeticdescriptionsofthemourningprocesshavealways beenstronglycoloredbythesomaticpresentationsofgrief.Thereisa growingbodyofliteratureconnectingchildhoodmaltreatmentwitha widevarietyofphysicalproblemsinadulthood.Inarecentsurveyofa largeHMOadultpopulationperformedbytheCenterforDisease

 ControlinAtlanta,morethanhalfofrespondentsreportedbelongingto atleastone,andonefourthreportedtobelongingtotwoormore categoriesofchildhoodexposurestoadverseexperiencesorACEs. Thesevencategoriesofadversechildhoodexperiencesincluded: psychological,physical,orsexualabuse;witnessingviolenceagainst mother;orlivingwithhouseholdmemberswhoweresubstance abusers,mentallyillorsuicidal,oreverimprisoned.Inthisstudy,there wasagradedrelationshipbetweenthenumberofcategoriesof childhoodexposureandeachoftheadulthealthriskbehaviorsand diseasesthatwerestudied.Peoplewhohadexperiencedfourormore categoriesofchildhoodexposure,comparedtothosewhohad experiencednone,had4to12foldincreasedhealthrisksfor alcoholism,drugabuse,depression,andsuicideattempt;a2to4fold increaseinsmoking,poorselfratedhealth,andgreaterthanorequalto fiftysexualintercoursepartners,andsexuallytransmitteddisease;and 1.4to1.6foldincreaseinphysicalinactivityandsevereobesity.The numberofcategoriesofadversechildhoodexposuresshowedagraded relationshiptothepresenceofadultdiseasesincludingischemicheart disease,cancer,chroniclungdisease,skeletalfractures,andliver disease(Felittietal,1998).Inanotherstudylookingattheconnectionin womenbetweenchildhoodadverseexperiencesandphysicalhealth,a historyofchildhoodmaltreatmentwassignificantlyassociatedwith severaladversephysicalhealthoutcomesincludingperceivedpoor overallhealth,greaterphysicalandemotionaldisability,increased numberofdistressingphysicalsymptomsandagreaternumberof healthriskbehaviors(Walkeretal,1999). Adultsurvivorsofchildhoodtraumaaregrievingeventsfromthelong buriedpastandgrievingforeventsthatmaynotbeconsidered appropriatecausesforgrief.Nonetheless,theirdescriptionsoftheir owngrievingprocessesrevealtousthatwhenlossisworkedthrough, thebodydoesagreatdealoftheworkalongwiththemind.Thebody rememberswhatthemindforgets,thebodykeepsthescore(vander Kolk,1994).Inthecaseofchronicgrief,thiscanmeanthelossofhealth andwellbeing.Intheparticularcaseofsexualabuse,itcanalsomean thelossofahealthyandfulfillingsexuality.

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ALTERATIONSINSYSTEMSOFMEANING
Humanbeingsaremeaningmakinganimals.Thestructureandfunction ofourmindscompelsustomakesenseofourreality.Inaveryrealway,

 weneedtoputeverythingweknowandexperienceintosomekindof logical,coherent,andintegratedframework.Outofthisframework,we developaphilosophyoflifeandderivethebasicprinciplesand assumptionsthatguideourdecisions.Itisexceedinglydifficulttomake senseoftheworldwhenyouhavenotbeencherishedandprotectedas achild,whentheverypeoplewhoweresupposedtoloveyouwerethe peoplewhoabused,neglected,andabandonedyou.Thisisparticularly truewhenyougrowupembeddedinasocietythatroutinelyinstructs youthatchildrenaretobecherishedandprotected.Victimsof childhoodabusemustgrieveforthechildhoodthatwasstolenfrom them,thattheyaregiventobelieveistheirbirthright(Lossof innocence,lossofchildhood).Moresubtleissuesofneglectmeanthat survivorsmustgrieveforwhattheydidnothaveandshouldhavebeen there(Lossofwhatwasntthereandshouldhavebeen).Earlyintheir lives,victimsofchildhoodabuseandneglectareexposedtothe commissionofdeedsonthepartoftheircaretakersthataredeliberate, harmfulandwrong.Thisearlyexposuretouncontrollableevilcanhave graveimpactonthechildsmoraldevelopmentandmakediscovering moralclarityevenmoredifficult(Lossofmoralclarity).Asaresultofall oftheseexperiences,manyadultsabusedaschildrenmakeconsciousor semiconsciousdecisionsnottoinflictthemselvesonanother vulnerablehumanbeingandsotheysacrificetheirowndesiretohave childrenandindoingso,theirownfuture(Lossofabilityand/ordesire tohavechildren).Thecompoundedresultmaybeajoylessness, difficultyinfindingpurposeormeaninginlife(Lossofpurpose, meaning,joyinlife,willtolive). Innextmonthscolumnwewilllookatwhatwearelearningaboutthe grievingprocessforadultsurvivorsofchildhoodadverseexperiences. REFERENCES AmericanPsychiatricAssociation.(1994).DiagnosticandStatistical ManualofMentalDisorders(4thed.).Washington,DC:American PsychiatricPress. Bloom,SL.(2000)TheGriefThatDareNotSpeakItsName,PartI: DealingwiththeRavagesofChildhoodAbuse.EmailFromAmerica PsychotherapyReview2(9). Doka,K.J.(1989).Disenfranchisedgrief:Recognizinghiddensorrow. Lexington,MA:LexingtonBooks.

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 Felitti,V.J.,Anda,R.F.,Nordenberg,D.,Williamson,D.F.,Spitz,A.M., Edwards,V.,Koss,M.P.,Marks,J.S.(1998)Relationshipof childhoodabuseandhouseholddysfunctiontomanyoftheleading causesofdeathinadults.TheAdverseChildhoodExperiences(ACE) Study. A M E R I C A N J O U R N A L O F P R E V E N T I V E M E D I C I N E 14(4):245 58 Goffman,E.(1963).Stigma:Notesonthemanagementofspoiled identity.NewYork:Simon&Schuster. Herman,J.L.(1992).Traumaandrecovery.NewYork:BasicBooks. Perry,B.D.1994.Neurobiologicalsequelaeofchildhoodtrauma:PTSDin children.InM.M.Murburg,(Ed.),CatecholamineFunctionin PosttraumaticStressDisorders:EmergingConcepts.Washington,D. C.:AmericanPsychiatricPress.(pp.253276) Putnam,F.W.andP.K.Trickett.(1993).Childsexualabuse:amodelof chronictrauma.Psychiatry56(1):8295. Sprang,G.&McNeil,J.(1995).Themanyfacesofbereavement:The natureandtreatmentofnatural,traumaticandstigmatizedgrief. NewYork:Brunner/Mazel. VanderKolk,BA.,Roth,S,Pelcovitz,D.andMandel,FS(1994).Disorders ofextremestress:ResultsfromtheDSMIVFieldTrialsforPTSD. Paperpresentedas1994EliLillyLecturetotheRoyalCollegeof Psychiatrists,London,February2. WalkerEA,GelfandA,KatonWJ,KossMP,VonKorffM,BernsteinD, RussoJ(1999).Adulthealthstatusofwomenwithhistoriesof childhoodabuseandneglect. A M E R I C A N J O U R N A L O F M E D I C I N E 107(4):3329. Weil,J.L.(1992).Earlydeprivationofempathiccare.Madison: InternationalUniversitiesPress.

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THEGRIEFTHATDARE NOTSPEAKITSNAME
PARTIII:DEALINGWITHTHERAVAGESOFCHILDHOODABUSE

SANDRAL.BLOOM,M.D.
EMAILFROMAMERICA

PSYCHOTHERAPYREVIEW2(9),NOVEMBER2000

Intheprevioustwocolumnswelookedattheconnectionsbetween grieving,traumaticgriefanddisruptedattachmentandthespecific lossesentailedinsurvivingchildhoodabuseandneglect.Thismonthwe willlookatrecoveryfromtheselosses. Ochberg(1988)hastalkedaboutsomeofthenecessarytasksrequired tocompletetheprocessofgrieving.Mournersmustbeabletoexpress theiremotions,understandthemeaningofthelostpersonorobject,be abletosurfaceandworkthroughtheambivalenceintherelationship, allofwhichwilleventuallyfreethemuptoattachtrustandlovetonew significantothersandfindappropriatereplacementsforthelost relationships. Thesetasksaredifficulttocompleteforadultsurvivorsofchildabuse andneglect.Beingraisedinabusivehomescharacterizedbydisruptive attachmentrelationshipsalmostguaranteesthatpeoplewillhave difficultyinmanagingtheiremotions.Theproblemsassociatedwith disruptedmeaningschemaswillmakeitdifficultforthemtounderstand themeaningofthelostperson,lostexperience,lostself.Trauma bondingmaymakeitfeelveryunsafetodealwiththeambivalencein theearlierrelationship,evenifitoccurreddecadesbefore.The consequentlackofresolutioninterfereswiththecapacitytoestablish new,safe,andlovingrelationships,toevenfindappropriatepeopleto loveinordertoreplacetheoldabusiveones.Somepeoplewillstay alooffromrelationshipsaltogethersoasnottobecomeinvolvedin moreabuse.Others,havingnootherinternalizedstandard,usethe abusiverelationshipsastheironlynorm.Inthiswaythepastbecomes

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 thepresent.Ashaslongbeenpointedoutinthefieldofgriefstudies, failuretocompletethetasksofgrievingcanimpairfuturedevelopment andadaptation(Engel,1961).

R E C O G N I Z IN G T H E P R O B L E M
Completingthetasksofmourningrequires,firstofall,therecognition thatoneissufferingfromunresolvedgrief.Forsurvivorsofchildhood abuseandneglectthisrecognitionandidentificationoftheproblemcan beaseriousbarriertoimprovement.Thestigmaassociatedwithmany ofthelossesforwhichpeoplemustgrievefurtherdecreasesthe likelihoodthattheirchronicsymptomswillbeunderstoodwithinthe contextofmourning(Bloom,2000a,b). Peoplesufferingfromchronic,unresolvedgriefcanpresentfor treatmentinmanydifferentways.Themostobviousandfrequent manifestationischronicdepressionthatrespondsonlypartiallyor episodicallytoantidepressantmedications.Thesepatientsarehigh utilizersofpsychiatricandmedicalservices,repeatedlyseekingout somekindofdirectionorrelief.Becauseofcurrentchangesinthe healthcaresystemintheU.S.thatminimizesanyformoftherapy exceptmedication,thesepatientsarelikelytoreceiveinadequateor poorcare.Chronicsuicidalityandapreoccupationwithdeathmaybe indicatorsofthesameproblem.Itisnotuncommonforpatientsto makeearlyprogressintreatmentandthenhitthewallofgrief withoutknowingthatiswhatishappening.Progressintreatmentslows, thepatientappearstobecontinuallycirclingaroundthesameissues thatgonowhere,andthetherapistmaybecomesincreasingly frustrated,bored,andangry.Theresorttoachangeinmedicationor addingmedicationsisafrequentresponsetothissituation. Chronicsomaticcomplaintsoftenaccompaniedbytheoveruseorabuse ofprescriptionpainmedicationsiscommon.Whenphysicalsymptoms areamanifestationofunresolvedgrief,thepatternmaybeoneof doctorhoppingordrugseekingwhilethepersonandtheirhealthcare providersseekaphysicalsolutiontoanonphysicalproblem.Theresult isboundtobeanincreasingleveloffrustration,chronicity,and compoundedrageonthepartofeveryoneinvolved. Theinabilitytoplay,havefun,experiencepleasureisafrequent accompanimentofchronicandunresolvedgrief.Theavoidanceof feelings,particularlysadness,aninabilitytocrywhilecontinuingtohold

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 ontoobjectsrepresentingthelossareothersignsofimpactedgrief. Unresolvedgriefmayalsomanifestthroughapreoccupationwith violencetoselfortoothers,includingchildrenandpets.Theremaybe attemptstoescapethesadnessthroughsubstanceabuse,compulsive sexualorotherrelationalbehavior,excessivereligiosity,orinvolvement incults,gangs,politicalactivities,workorothergroupsthatserveto divertattentionawayfromthewoundedarea. Continuingtobehaviorallyreenactnegativerelationshipsdespiteinsight andacommitmenttotreatmentcanalsobeasignthatthesurvivoris avoidingtakingonthetaskofgrieving.Theyawningdarkchasmthat griefrepresentsmayfeeloverwhelming,endless,abottomlesspit, particularlywhenthosefeelingsarenotidentifiedaswhattheyare feelingsofbereavementandlegitimizedaspartofthenormalprocess ofmourning.

EXPERIENCINGTHEGRIEF
Thehardestpartofthegrievingprocessmaybeallowingtheprocessto begin.Peoplewhoseattachmentshavebeendisruptedaresoill equippedtoprocesslossandhaveconfidencethatthepainmaycome butwillgoagain,thattheyoftenspenddecadesdoingeverythingthey canthinkoftoavoidconfrontingthepainofthepast.Havingtoyed aroundtheedgesofgriefforsomanyyears,theymayviewitas somethingtheycankeepatbayandneverhavetoresolve,notfully realizingjusthowmuchthepastisrobbingthemofavibrantpresent. Sothefirsttaskislettingtheexperiencehappen,feelingtheenormity anduncontrollednatureofgrief,andthen,comingtorecognizethatin strugglingtocontrolanactofnature,youaresimplyprolongingand beingcontrolledbyaprocessthatwouldotherwise,passon.Providing educationandsupportisanessentialpartofassistingsurvivorsto confrontthepainofthepast.Knowingthatgrievingisaprocessandnot apermanentstateofbeingiscriticalinformationtoholdontothrough thedarkesthours.Duringtheacutestages,whenphysiologicalarousal isatarenewedhigh,medicationmayhelprestoresomephysiological stability.

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LOSSOFPREVIOUSCOPINGSKILLS
Grievingforthepastlossesthataccompanychildhoodabusemeans givingupreliablecopingskills.Comingtotermswithlossrequiresan abilitytotolerateworkingthroughselfblame,survivorguilt,andnormal guilt.Aslongasthesurvivorisnotsafewithhimselforherself,s/he

 cannotlearntomanageaffectandwithoutlearninghowtosafely manageaffect,itisimpossibletosafelyworkthroughthegrief.Butthis doesmeansacrificinghabitsthathavehelpedmanageoverwhelming affectfordecadesthingslikedrugsandalcohol,compulsiveworking, smoking,destructiveeatingbehaviors,andselfmutilation.Thismeans thatbeforegriefworkcanreallybegin,thegroundworkmustbelaidfor newandhealthiercopingskillsthatinvolvebothselfsoothingand relationalsoothing.

FEARINGLOSSOFATTACHMENTS
Formanyadultswhowereabusedaschildren,thekeytorecoveryisthe restitutionofthecapacitytoattach.Butinallowingoneselftoattach thereisalsothefearoflosingthepreciousattachmenttoadepriving andabusingpastandthenlosingattachmenttoatherapistwhohas servedasthetransitionbetweenlossandrestoration.Implicitinthe processoftherapyisthisinevitableloss,becausetherapycannot substituteforthecreationofalonglastingsupportsystemthatyou donthavetopayfor.Thetherapistmustbecommittedtothepatients resolutionofgriefandtheultimateterminationofthetherapeutic relationship.Balancedproperly,thefearoflosingattachments,oflosing apotentiallybetterfuturethantheawfulpast,canbeapowerful incentiveforpositivechange.

L O S I N G AT T A C H M E N T S
Recoverycanmeanlosingattachmentsaswell,andalthoughthe relationshipsmaybehighlypathological,theyareallthepersonknows, andsomethingisbetterthannothing.Assurvivorsworkthroughthe griefprocess,theygraduallylearntoletgooftheabusiveattachments. Thismayonlymeansymbolicallylettinggo,butinothercases,thereis noalternativebuttoactuallywithdrawfromanongoingabusive relationship.

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G I V I N G U P T H E F A N T AS Y O F R E ST O R A T I O N
Insideeveryadultabusedasachild,thereisachildhopingtobe rescued,activelyfantasizingabouthowdifferentthingswillbe someday.Continuingthesymptomaticselfdestructivebehaviorisa disguisedwayofholdingon,ofwaitingfortherescuethatnevercomes. Grievingforthelossesofthepastmeansgivingupthefantasythat

 amendswillbemade,thatthelovelessparentswillturnintoloving ones,thatinnocencewillberetrievedthefantasyofrestoration.

WORKINGWITHTHENONVERBAL
Itmaynotbepossibletoresolvegrief,particularlylongstanding, unresolved,traumaticgrief,throughtheuseofverbalabilitiesalone. Fromwhatwenowunderstandaboutthewaythebrainprocesses overwhelmingexperience,weneedart,enactment,storyandritualto helpussafelyintegratetheverbalandnonverbalaspectsofour experience.Sotoo,aritualpassageformourningispresentinevery culture,throughouttime,inrecognitionofthehumanneedfor structureandorderandprocess.

THEVITALNATUREOFSOCIALSUPPORT
Socialsupportthroughoutthegrievingprocessisvitaltothecourseof normalbereavement.Justasvitalistherestorationofsocialsupportfor thevictimsofgriefthathasbeendisenfranchisedandstigmatized. Muchtherapeuticgroundworkmayneedtobeestablishedtohelpthe survivorrecognizeandgrieveforallthewaysinwhichtheirsenseof stigmatizationhasnegativelyimpactedonthepossibilityofrecovery beforetheycanevenbegintodealwiththesourcesoforiginalloss.To prepareforthegrievingprocess,therapeuticattentionneedstofocus onhelpingthesurvivordevelopasubstantialsupportnetworkthat extendsbeyondthetherapeuticalliance.

MAKINGMEANING
Wenowunderstandhowvitalitisfortraumasurvivorstomake meaningoutoftheirexperience(JanoffBulman,1992).Butmaking meaningoutofanabusivechildhoodisadifficulttask.Legitimizingthe needtogrieveforthelossesandidentifyingthoselossescanhelpplace theirexperiencewithinamoremeaningfulcontext.Connectingtheir personalsufferingwiththelargersocialandpoliticalcontextofhuman rightsandsystematicviolationofthoserightsalsohelpstorestorea senseofconnectnessandpurpose.

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MAKINGSENSEOFTHEINTERGENERATIONALNATUREOF ABUSE
Partofthestruggletomakesomemeaningoutoftheabusivepastis aboutthestruggletounderstandhow,ifnotwhy,thiscouldhave happened.Theautomaticquestionthatarisesinsomepointontheroad

 torecovery,iswhathappenedtomyparentsthattheycouldhaveso mistreatedme?Areviewoffamilybiographicalinformationcanhelp thesurvivorplacetheirownfamilystoryincontext,aswellas illuminatingthepastfamilialhistoryofrepeatedfailuresatresolving longstandinggriefandlossexperiences.Largelyunexploredishow unresolvedgriefgetspasseddownfromgenerationtogeneration throughtheintimatenatureoftheattachmentrelationships.

TRANSFORMINGTHEPAIN
Asthegrievingprocessprogresses,thedarknessbeginstoliftand survivorsbecomeinvolvedintheprocessofmovingon,notforgetting thepastbutnolongercompelledtorepeatit.Ultimately,wehopethat adultsurvivorsofchildhoodabuseandneglectwillbeabletotransform theirpainintosomethingofvaluetothemselvesandothers,whatJudy Hermanhascalledasurvivormission(Herman,1992).Thelossesthat adultsmustrecapitulateandworkthroughinordertorecover,arelong delayed,sometimestangible,butatothertimes,metaphorical,spiritual, ormorallosses.Whentheyhavesuccessfullytransformedthis engagementwithdeathintoengagementwithlife,nolongermusttheir livesserveasmemorialstotheunspoken,stigmatizedandunexpressed tragediesofthepast.

REFERENCES
Bloom,SL.(2000a)TheGriefThatDareNotSpeakItsName,PartI: DealingwiththeRavagesofChildhoodAbuse.EmailFromAmerica PsychotherapyReview2(9). Bloom,SL.(2000b)TheGriefThatDareNotSpeakItsName,PartII: DealingwiththeRavagesofChildhoodAbuse.EmailFromAmerica PsychotherapyReview2(10). Engel,G.L.(1961).Isgriefadisease?Achallengeformedicalresearch. PsychosomaticMedicine.23:1822. Herman,J.L.(1992).Traumaandrecovery.NewYork:BasicBooks. JanoffBulman,R.(1992).Shatteredassumptions:Towardsanew psychologyoftrauma.NewYork:TheFreePress. Ochberg,F.M.(1988).Posttraumatictherapyandvictimsofviolence. NewYork:Brunner/Mazel.

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