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The Missing Piece
Bodywork for Adult Survivors of Childhood Sexual Abuse

By Shirley Vanderbilt

Originally published in Massage Bodywork magazine, February/March 2006. Copyright 2006. Associated Bodywork and Massage Professionals. All rights reserved.

It has only been within the past few decades that victims of childhood sexual abuse have gained recognition, validation, and appropriate treatment, but the process has been somewhat of a roller-coaster ride. From the mid-1970s into the 1980s, there was a rapid increase of identification of abuse victims, along with development of support programs and agencies to handle reports and treatment. With the rise of reported cases, some considered it an epidemic, although more likely it had always been epidemic but ignored. Disclosures came not only from children, but also adult survivors whose memories of childhood trauma had been locked away, only to emerge within a supportive, therapeutic relationship. What followed was a legal knee-jerk response in which some mental health professionals were accused of evoking false memories in their clients. Casting doubt on survivor amnesia or delayed recall became a focus in court trials, further traumatizing victims on the stands.

Having emerged from this unfortunate setback, we now have the benefit of a growing body of scientific research showing evidence of a neurobiological response to trauma and the fragmentary way in which trauma memory is stored in the body. These body memories persist long after abuse occurs and continue to be held even when survivors have made significant strides in cognitive retrieval and resolution of their trauma issues.

Christine Courtois, Ph.D., clinical director of The Center: Posttraumatic Disorders Program at the Psychiatric Institute of Washington in Washington, D.C., explains the uniqueness of this particular type of trauma, with elements not only of violation and control, but most often a betrayed relationship and intensified entrapment over time, from which the child feels unable to physically escape. In response, they may resort to defense mechanisms such as repression, denial, or dissociation. "Although the victim may make a psychological escape, the body is left 'holding the bag,' so to speak."1

Treatment for survivors of childhood sexual abuse is a highly specialized field, in part because of the complexity of issues involved in both the original trauma and in the psychological and physical symptoms that can emerge in the aftermath. Psychiatrist Judith Herman, in her groundbreaking book "Trauma and Recovery" (1992), writes, "Repeated trauma in adult life erodes the structure of the personality already formed, but repeated trauma in childhood forms and deforms the personality."2 The end result is an adult who has established coping patterns outside of the realm of normal development and usually presents with a laundry list of somatic and emotional complaints.

Psychotherapy has been and continues to be the first-line order of treatment for these survivors and is imperative to assist them in working through deep-seated impairments in trust, relationships, and self-perception. For many, the adaptations they created to cope with the abuse will later emerge as maladaptive barriers to healthy functioning in adult life. While verbal therapy is critical to retrieval and integration of the fragmented mind, there is another aspect to recovery that has more recently gained attention and validity: that of retrieving the body as well.

Recognition that the body holds the scars of trauma has led to increasing use of bodywork as an adjunctive treatment for survivors. In addition to traditional massage, some therapists have developed specialized modalities, such as Chris Smith's Trauma Touch. Other somatic therapies integrating aspects of body awareness and emotional release as part of a body/mind approach are also helpful. An offshoot of this trend has been the exploration of integrating psychotherapy and bodywork, as a collaborative approach between two professionals or provided by a single therapist qualified in both areas. In all cases, no matter the modality, it should be stressed that the client remain under the care of a psychotherapist.

Robert Timms, Ph.D., and Patrick Connors, CMT, became early pioneers in this field during the late 1980s, combining psychotherapy with bodywork for childhood sexual abuse treatment. The psychophysical model they created, consisting of a team approach to therapy sessions, is explained in full detail in their book, Embodying Healing: Integrating Bodywork and Psychotherapy in Recovery from Childhood Sexual Abuse (1992). What brought the two together in this venture was a bodywork session. While on the massage table receiving treatment from Connors, Timms had sudden recall of being sexually abused at the age of six. The memory remained locked in his body for 40 years, despite his own training as a psychologist and years of personal therapy with other psychotherapists. "The memory produced in that massage session was a powerful and emotional discovery for me," Timms says. "For the first time, many aspects of my life made total sense."3

As the bodywork sessions continued, both Timms and Connors became aware of the immense gains made in Timms' own health and recovery, and the seed was planted for combining resources to help Timms' psychotherapy clients. The model they developed -- teamwork between psychotherapist and bodyworker -- allows each therapist to stay within the realm of their practice while integrating their work in sequential or combined sessions.

"In sexual abuse, the body is involved -- it is invaded, its value distorted; it is used, made into a vehicle for physical pain, unwanted or confusing sexual responses, or dissociative absence," Timms and Connors write. "In a sense, the survivor's body, or at least the survivor's comfort and ease with his or her body, was stolen. Since the body was integral to the trauma, it must be integrated into the healing process."4


The Adult Survivor
As many as 20 percent of female clients walking into a massage therapist's office could be a survivor of childhood sexual abuse, even the therapist herself. In a 1998 national survey of women, the incidence was reported as one in five,5 but those were just the ones willing to disclose. Estimates on prevalence can vary widely depending on location, population, and definition of the term, with some as high as 50 percent.6 Research has shown female victims traditionally outnumber males, but as noted in recent news reports, many young men are also turning up as victims.

The sexual abuse of a child covers a wide range of behaviors on the part of the perpetrator, from actual physical contact to non-contact types of victimization, such as flashing or peeping. The degree to which the victim is traumatized is not so much determined by the type of abuse, but rather by a correlate of factors such as age of the victim, relationship to the perpetrator, and feelings of shame, guilt, or fear related to the trauma, as well as other circumstances like long-standing abuse or captivity.7,8

Quite commonly, the traumatized victim resorts to defensive coping mechanisms that can carry into adult life. Dissociation, described by researchers Kolk and Fisler as "a compartmentalization of experience," allows the child to disconnect, in essence "check out" mentally while leaving the body behind. Memory is then stored in fragments, not as a whole, but rather as isolated sensory and emotional experiences. With any future stress can come a tendency to escape through dissociation and a separation from awareness of the body's experience. "While dissociation may temporarily serve an adaptive function, in the long range, lack of integration of traumatic memories seems to be the critical element that leads to the development of the complex biobehavioral change that we call Posttraumatic Stress Disorder," Kolk and Fisler write.9 In addition to dissociation, another common defense is repressing memory, in some cases to the point of amnesia. Even if cognitive memory is present, survivors may use distortion to alter their perception and minimize the significance of the abuse.10

Herman also points out the effects of child abuse on regulation of bodily and emotional states. Chronic hyperarousal and attempts to adapt can lead to disturbances with sleep and digestion, eating disorders, and other forms of body distress. Survivors are prone to experience depression and anxiety, and in some cases resort to self-mutilation to block out emotional pain.11

As the child grows up, the fragmentation of self, both in body and mind, increases fragility as the adult tries to navigate life with maladaptive defenses. What occurs, Timms and Connors say, is a gradual breakdown of defenses, surfacing as problems in relationships, jobs, substance abuse, or even thoughts of suicide.12 Compensatory efforts no longer work, and as Herman says, "the underlying fragmentation becomes manifest."13


Psychotherapy-Bodywork Connection
As Timms and Connors point out, because the body was integral to the trauma, it is also integral to the healing process. In the past, psychotherapy was a stand-alone treatment, and it remains a necessary element for processing and reframing the psychological effects of abuse. But with the growing understanding of body/mind connection, there has been increased interest and practice of providing adjunctive bodywork to facilitate wholeness. For some clients, after years of verbal therapy, there comes a time when they need and want to reclaim the body.

It is important to note that not all survivors are appropriate candidates for this approach, and it is the psychotherapist's responsibility to determine if and when they are. Several factors come into play, includ-ing ego strength, level of dissociation, potential for psychosis, and the readiness of the client to explore this option for resolution at a deeper body level.14 "I wouldn't want to recommend it for clients who dissociate at the drop of a hat," Timms says, nor for clients who are hostile and angry. Those who are depressed, touch-deprived, or living an isolated or lonely lifestyle are likely good candidates, he says.

Currently, there are a variety of ways in which this work is approached, including outside referral to bodywork practitioners or single-therapist work in which the psychotherapist includes bodywork or body awareness in the therapeutic sessions. While the single-therapist model has its merits, Timms and Connors say their psychophysical model in which the roles of the bodyworker and psychotherapist are more clearly defined, "best insures the safety of the client and offers the highest level of skilled interventions in the process."15

Returning to body awareness is a key goal for all of these approaches, but the process goes beyond simply reintroducing touch at a level of safety. "It bypasses the rational cognitive system of the brain and lets you go directly into the memory," Timms says. In the psychophysical model, bodywork is used to facilitate emotional release of muscle memory, which can also aid in retrieval of repressed or amnesic memory. When this occurs, the psychotherapeutic component is in place to help the client to work through and benefit from this stage of healing.

"The common element we see in trauma is betrayal: The more severe the degree of betrayal of trust, the greater the psychological damage to the child, and the more trauma for the adult survivor," Timms and Connors say.16 The issue of trust becomes of prime importance in facilitating the healing process as does enhancing the client's ability to set boundaries.

"The massage therapist has to find the appropriate touch for each individual client," Timms says. He recounts the case of a woman so traumatized "she had shut down almost everything about her body." After five years of psychotherapeutic work, Timms introduced her to bodywork with Connors. But even at that point, with a trusting relationship with Timms, her fear was so extreme that touch in the first few sessions was limited to massage on one hand only.
With the communication inherent in teamwork, the therapists can keep tabs on these and other issues as work progresses. Bodyworkers engaged in this type of therapy should have some basic understanding of the psychological dynamics involved and can be guided by the psychotherapist to respond appropriately, Timms says, thus increasing therapeutic effectiveness. "You have a moral, ethical, and legal obligation to keep the client safe, and the more educated and understanding you are, the better," he says. "Intuitively you can tell when something is going wrong in the client and you might want to temporarily discontinue massage until you find out what it is."

Timms says it's the immediacy of touch, and the caring and nurturing it conveys, that makes it highly therapeutic. In his own teamwork with Connors, he's seen miraculous examples of survivors who had been shut down in their body and after bodywork, were able to regain that connection.


Body-Oriented Therapy
The healing benefits observed in the psychophysical model, as well as other bodywork approaches for childhood sexual abuse survivors, are similar to those documented in studies of body-oriented therapy conducted by Cynthia Price, Ph.D. As a psychotherapist and massage therapist with a background in women's healthcare and counseling, Price's interest in research led to doctoral training in nursing science, during which she developed a body-oriented therapy protocol for sexual abuse survivors. Having worked extensively with this population, she noted their avid interest for including bodywork in their recovery and wanted to test its efficacy.

Prior to Price's studies, only one other trial using a standardized bodywork protocol for sexual abuse survivors had been published (Field et al., 1997). In that report, massage therapy was found to decrease depression and anxiety, not a surprising result as this effect has been shown in other massage research. Although the intervention elicited no improvement in the massage group's attitudes toward touch, the increased negative attitudes and behavior toward touch in the comparison relaxation group suggested massage at least attenuated that measure.17

Price's body-oriented research began with a single-case study of a woman with combined childhood physical/sexual abuse history,18 then moved on to a pilot program with eight women recovering from childhood sexual abuse in which body-oriented therapy was compared to wait-list control.19 From this second study, she also gleaned data on the characteristics of women seeking bodywork as an adjunct to their recovery process, publishing the results separately.20
For a follow-up, randomized trial with massage therapy comparison, Price recruited 24 women in recovery, most of whom had experienced childhood sexual abuse over multiple years. The study results showed both body-oriented therapy and massage to have positive effects for psychological and physical well-being. Body connection, which Price has identified as a motivating factor for these women in seeking bodywork, was also increased.21 But in the massage comparison study, an interesting difference emerged between the two groups in terms of their perceived experience. "The behavioral perspective piece for the massage group was some recognition of the relationship between their behavior in the world and their abuse -- taking care of themselves better," Price says. "For the other group it was less about an external perspective on their behavior and more about an internal sense of being, of knowing who they are."

The body-oriented protocol differs from standard massage in that a number of elements are added to focus on sensory and emotional awareness, with the goal being an integration of body and mind. Addition-ally, the combined hands-on and verbal therapy utilized in the approach is administered by master's level psychotherapists who are also licensed in massage. This therapeutic work is an adjunct and not a replacement for the participant's ongoing work with their individual psychotherapist.

Within body-oriented therapy are a graduated series of steps, taking the client from body literacy and the development of language to describe what they are experiencing, to body awareness exercises, and then into "delving" practice in which they maintain presence in their awareness. In body literacy, which also involves massage, Price says, "The work really is about being present -- to bring their attention to what is happening to their bodies." The next stage, body awareness, is an intermediary step, moving from more external to internal awareness, using specific tools to attend to the subtle differences. "For example, participants were asked to concentrate on moving their breath on exhalation down through a limb and to feel the movement of the breath as it flows through the limb," Price says.

Delving, the longest piece of the intervention consisting of the final four sessions, also incorporates elements of the first two stages. "Again, it was an incremental movement," Price says. "It was bringing awareness down inside the body and (for) as long as they could maintain presence in that place," whether it be a place of peace or tension, or related to abuse. "There was a guided process to pay attention to various sensory modalities -- how it felt, certain textures, whatever they were aware of -- to get as much information and just be in that place with no agenda but to be there."

Therapists in the study were given a protocol for handling dissociation -- how to identify, assess, and address it -- an important skill in this or any type of bodywork, Price says. "From listening to audio tapes of sessions, in the massage group there was no obvious indication of dissociation. It didn't show up in massage in ways that were obvious to the clinician or got in the way of the therapy." These participants were more focused on being present and attending to the experience of massage which stimulated behavioral awareness -- for example, "increased awareness of ways in which they were not connected to their bodies, of the relationship between their abuse and their lifestyle behaviors," Price says.
Because of the focus on body and emotional awareness in body-oriented therapy, some flashbacks and dissociative moments did occur and were addressed therapeutically in the session. "An important distinction is that because the body-oriented therapy group was being asked to pay attention at a completely different level and discuss their experience with the therapist, there was an opportunity to attend and learn about individual dissociative response," Price says, "for example, the experience of 'leaving' the body due to emotional discomfort."

Body-oriented skills, such as delving, help the client to experience being in their body without dissociation. Staying with their inner connection, observing, and accepting it, can bring a sense of inner control and peace. The responses of this group indicated they continued to use body awareness techniques after the study, to maintain that inner connection and awareness. "I think certainly there is a relationship there," Price says. More awareness of the dissociative process, the triggers, and what happens in the body when it occurs increases curiosity and comfort in attending to it, she says, while avoidance of this inner experience can contribute to ongoing dissociative patterns.

Although the body-oriented model has only been used by Price in her research, her long-term goal includes funding for larger studies. If efficacy is found for a larger sample size, it might generate interest for including this type of work in healthcare venues such as treatment facilities and clinics, she says. Comments from some of the subjects' psychotherapists, while not included in the study data, indicated improvement in the client's recovery process, as did the subjects' reported responses.


Embracing Change
At least two conditions are necessary for clients to transform old patterns of passivity: increased awareness and a desire to change," Timms and Connors say. Therapeutic touch enables survivors to move awareness from their head, or intellect, to living and feeling in their own bodies. This self-awareness leads to embodiment, in which they can be fully present physically and mentally.22

As a backlash to abuse, aversion to touch leaves some victims touch-deprived. "I think touch deprivation for women who are not in a partnered relationship is an important benefit of bodywork," Price says. "It involves learning that touch can be pleasurable, and experiencing being receptive -- taking in the touch." Even those in a relationship and receiving touch may have difficulties with intimacy and feeling comfortable sexually. "Regard-less of the partnered piece, it's important. It goes hand-in-hand with all pieces of the pie -- regarding self-awareness, the experiences of safe touch, letting themselves take in the pleasure of touch, but also putting themselves in control of the experience of being touched." In establishing that control for the client, the therapist has an important role, regularly checking in and encouraging clients to attend to and express their needs.

"Asking for constant feedback puts clients in the position of being in control," Price says. They can assume ownership of their body and within this safe environment, determine the boundaries -- where, with what pressure, and when to be touched, or not touched at all. "It seems so simple and something many of us take for granted, but for this population, it can be very important work -- a big deal."

Through incorporating bodywork with psychotherapy, with increased awareness and embodiment, the survivor can find empowerment -- having the choice to discard blame or shame from their past and "reframe their cognitive perceptions of themselves both in relationship to the abuse and in their whole concept of touch," Timms and Connors write. "Clients have the experience of deciding if and when, by whom, and how to be touched, and of having those boundaries respected."23

"The self-awareness is so important," Price adds, "to feel on the inside how one is doing, to take oneself seriously, and trust and respect how one feels on the inside. That's where the work of body self-awareness goes beyond external awareness of the body, e.g., 'Is my muscle tight?' to the internal or somatic experience of the body, 'What is the inner experience associated with my muscle tension?'"


Resolution and Reclamation
These are but two models in a developing field combining elements of psychotherapy and bodywork in treatment for childhood sexual abuse survivors. Both Timms and Price emphasize the need for proper training in this work and beyond that, the importance of professional or peer supervision, not only for clarity and direction, but also as a source of personal support for the bodyworker or psychologist involved. These cases can be complex and taxing on the energy of the therapist.

"Resolution of the trauma is never final; recovery is never complete," Herman says. "The impact of a traumatic event continues to reverberate throughout the survivor's lifecycle." With each new life event comes the potential of a stress-induced return of traumatic memories.24

The important thing to remember is the significant impact this work can have in bringing wholeness -- as Timms and Connors write, to help victims become not only survivors, but thrivers. To give them opportunity and skills for a new kind of relationship to self and body so that "the traumas of the past can recede into historical perspective."25 With this, they will be better prepared for the challenges of their present life.


References
1 Timms, Robert, Connors, Patrick. Embodying Healing: Integrating Bodywork and Psychotherapy in Recovery from Childhood Sexual Abuse. Brandon, VT: Safer Society Press;1992. p. ix.
2 Herman, Judith. Trauma and Recovery: The aftermath of violence -- from domestic abuse to political terror. New York, NY: Basic Books; 1992, p. 96.
3 Timms, p. 2.
4 Ibid., p. 9.
5 Adult Manifestations of Childhood Sexual Abuse. American College of Obstetricians and Gynecologists. Available at www.medem.com/medlb/article_detaillb.cfm?article_ID= ZZZMXNDEKECsub_cat=351. Accessed Oct. 2005.
6 Field, Tiffany, et al. Effects of sexual abuse are lessened by massage therapy. Journal of Bodywork and Movement Therapies Jan 1997; (2): p. 65.
7 Timms, pp. 4-5.
8 Herman, pp. 96-101.
9 van der Kolk, Bessel A. Fisler, Rita. Dissociation and the Fragmentary Nature of Traumatic memories: Overview and Exploratory Study. Available at www.trauma-pages.com. Accessed Oct. 2005.
10 Timms, p. 51.
11 Herman, pp. 108-109.
12 Timms, p. 11.
13 Herman, p. 114.
14 Timms, p. 31.
15 Ibid., p. 22.
16 Ibid., p. 5.
17 Field, pp. 65-69.
18 Price, Cynthia. Body-oriented therapy as an adjunct to psychotherapy in recovery from childhood abuse: a case study. Journal of Bodywork and Movement Therapies 2002; 6(4): pp. 228-236.
19 Price, Cynthia, Body-Oriented therapy in sexual abuse recovery: a pilot-Test comparison. Journal of Bodywork and Movement Therapies. In press.
20 Price, Cynthia, Characteristics of women seeking bodywork as an adjunct to psychotherapy during recovery from childhood sexual abuse. Journal of Bodywork and Movement Therapies 2004; 8(1): pp. 35-42.
21 Price, Cynthia. Body-Oriented therapy in recovery from childhood sexual abuse: an efficacy study. Alternative Therapies in Health and Medicine 2005; 11(5): p. 46-57.
22 Timms, pp. 59-60.
23 Ibid., pp. 60-64.
24 Herman, pp. 211-213.
25 Timms, pp. 14, 48.




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