STAIR笔记 - 原文 前言（preface）
创伤笔记汇总： https://www.douban.com/note/766173988
Preface
WHAT IS THE INTERRUPTED LIFE?
There is an avalanche of data that tell us something survivors of abuse already know themselves: Functioning in day-to-day life is much harder for them than for those who have experienced a safe and secure childhood. Perhaps less well known to them are the reasons why. Throughout this book we highlight and specify ways in which childhood abuse can derail the normal course of development and deprive the individual of important learning experiences that foster healthy and effective life skills. These include basic and complex skills such as the capacity for sustained attention, the capacity to express feelings effectively and appropriately, the capacity to use emotions as a guide for action, and the capacity to relate well to others and to enjoy relationships. Interventions for children and youth who have experienced abuse are sensitive to these consequences and include strategies that repair and enrich emotional and social competencies, with the goal of realigning the young client back on the normative trajectory of development.
But what of the adults who lived through an abusive childhood without help? Those who come to treatment often express concern about long-standing emotion management and relationship problems. And yet, there is no program or intervention that addresses their concerns. Instead, the suffering of the adult survivor is typically organized by diagnostic status and symptom categories. The interpersonal and other difficulties are viewed as secondary to evident symptomatology: If the depression or anxiety is resolved, these other difficulties are expected to dissipate. The scientific community’s careful tracking of the compromised social and emotional competencies caused by maltreatment ends with studies of teens and young adults. There is a remarkable disconnect between the observations made by child mental health professionals and the clinical world that treats the adults who were once abused children.
This book provides a treatment program that takes into account the long trajectory of disadvantages experienced by many abuse survivors that precedes their arrival into the therapist’s office. The concept of the “interrupted life,” which guides this treatment, refers to the disruption caused by abuse to self-regulation and interpersonal capacities that otherwise would have been expected to develop. The treatment is intended to provide the survivors with emotional and social skills they did not have the opportunity to obtain due to the diminished presence of a competent, caring, nurturing parent and the burden of managing the abuse, often alone or in secrect. The first module of this treatment, Skills Training for Affective and Interpersonal Regulation (STAIR), has been explicitly developed to generate and strengthen social and emotional resources for effective living.
A treatment for trauma would be incomplete if it did not address the equally profound although more recognized problem of posttraumatic stress disorder (PTSD). PTSD symptoms and associated disturbances such as depression, dissociation, anger, and feelings of shame and loss are indicators that there is “unfinished business” in the processing of traumatic experiences. Traumatic events, by their very nature, overwhelm the individual’s capacity for understanding and analysis. The challenge to understanding is made even greater because the emotions associated with the abuse—terror, humiliation, and betrayal—are extremely painful and thus often avoided. Traumatic memories, when they remain unprocessed, are expressed through intrusive memories and reexperiencing, which interfere with the capacity to live meaningfully and fully in the present. Moreover, this processing work is a prerequisite to the integration of such memories into one’s autobiographical narrative, the existence of which provides a coherent sense of self and one that is continuous across time. The inability to experience oneself as coherent and existing through time is another way in which life is “interrupted” for the trauma survivor.
Narrative Story Telling (NST) provides a structure and strategy for approaching, managing, and organizing traumatic experiences that have been unaddressed but are still quite alive with emotional power. NST begins with the emotional processing of fear memories using traditional imaginal exposure techniques (Chapter 6). However, this work is extended in two ways. First, we have developed and systematically employed “contextualization” strategies, grounded in recent models of autobiographical memory, to organize and construct a “narrative of self” (Chapter 7). Second, through these strategies, the client and therapist are able safely and effectively to explore and organize a sense of self around two critical affective themes that often burden the abuse survivor: shame and betrayal (Chapter 22) and loss and grief (Chapter 23).
Finally, the phrase “psychotherapy for the interrupted life” has a third meaning, one that alludes to a particular hope for the client. It recognizes that the management and consequences of abuse create circumstances in which the gifts and talents an individual may have had were irrelevant, unrecognized, or underdeveloped. In regenerating important life skills and a coherent and revitalized sense of self, we hope that the clients can, in essence, resume the realization of their hidden potential.
WHO CAN BENEFIT FROM THIS BOOK?
This book provides an evidence-based treatment for mental health providers who work with survivors of childhood abuse. These survivors include women and men who have experienced sexual abuse, physical abuse, and neglect. The treatment was originally developed for women, but it also has been successfully used with men and with clients of varied ages (including children and adolescents) who have experienced maltreatment in early life and multiple forms of interpersonal violence (see Chapter 8).
This book is also for survivors themselves. We hope that each survivor may “see” something of themselves in the descriptions and stories told in the book and, more important, find the interventions and ways of approaching problems relevant to them. Ideally, survivors perusing the book can come to know what they need or want and be better prepared to search for an effective therapy that is appropriate for them.
THE TREATMENT PHILOSOPHY
The “orientation” of the treatment is a blend of principles from the cognitive-behavioral and the attachment–interpersonal–object relational traditions evolving from the work of Bowlby (1988), Sullivan (1970), Mitchell and Greenberg (1983), and Safran and Segal (1990).
The intervention techniques rely heavily on those from the cognitive-behavioral therapy (CBT) tradition. These include, for example, strategies for evaluating beliefs about oneself and the world, and use of role playing to facilitate new learning and behavioral changes. They also adhere to a philosophy implicit in CBT: that with practice, new ways of behaving, feeling, and thinking are possible. In this way, CBT is a remarkably practical and optimistic psychotherapeutic tradition.
The theoretical framework of the treatment falls squarely within the interpersonal tradition, particularly as it has evolved from the work of Bowlby. The use of this framework emphasizes the importance of early life attachments and the long-term consequences that disturbances in caretaking relationships have in adult functioning. The cognitivebehavioral strategies are the means by which the client identifies these problems and works toward change. For example, problems in relationships related to early abuse are described through the attachment concept of “internal working models of relating.” This concept is operationalized in the practical form of “interpersonal schemas,” a familiar tool used in many cognitive therapies, used here to assess and change ideas about self and other.
HOW TO USE THIS BOOK
This book is intended to provide therapists with the skills, competence, and confidence to effectively treat survivors of childhood abuse. We have provided a session-by-session guide to a treatment that is grounded in theory, tested in its benefits, and repeatedly refined over 15 years with feedback from our clients. The book provides practical “nuts and-bolts” guidance for all the technical aspects of the treatment. Equally important, the book is organized and written to highlight the rationale for the treatment and the primary goals behind each intervention so that the clinician can use STAIR/NST guided by the principles of the treatment as they fit the particular client rather than feel compelled to follow the phase, session, and interventions in a lockstep fashion.
The book is divided into three parts. Part I characterizes the effects of abuse in the context of an attachment–developmental framework; Part II describes the theoretical and empirical bases for the treatment rationale and outcome data reporting the benefits of the therapy; and Part III provides session-by-session descriptions of the treatment preceded by assessment and treatment guidelines. The book as a whole is intended to convey a way of thinking about abuse survivors that can facilitate effective therapy. Theory, research, and clinical service are unified under the theme that recovery from childhood abuse requires recognition and redress of a life history in which terrible things have happened, and, equally important, recognition and redress of a life history in which in which many important normative events and experiences have been absent or diminished.
In Part III, the Phase 1 STAIR targets the generation of social and emotional resources, while Phase 2 NST aims to resolve PTSD and other symptoms. Many survivors have both types of problems and so will benefit from the use of both treatment components, but therapists can consider using only one or the other as suits the needs of the particular client at a particular time. Such judgments are aided by a review of treatment guidelines (Chapter 8), strategies for evaluating when to transition from skills training to narrative work (Chapter 18), and a review of the summaries provided in each session chapter. These “at-a-glance” summaries identify what matters most in the session (e.g., the development of emotional awareness) and why it matters. This is intended to liberate the therapist from the assumption that, in order to be successful, the session must be completed as described. Rather, the theme should prompt the therapist to ask: How significant is this problem for my client? How skilled is my client in each of these activities? Which of these strategies address my client’s current problems? Ideally, the therapist and client will work together to answer these questions. The selection of the interventions and the specific goals that are targeted are the result of a collaborative effort.
It is well known that the therapeutic alliance influences and enhances the benefits of any treatment, and this is particularly true for abuse survivors (see Cloitre et al., 2004). For this reason, the nature and role of the therapeutic alliance is integrated into several chapters of the book. Chapter 8 provides an overview of the value of the therapeutic relationship and strategies for building a good working relationship, particularly in the context of potential ruptures common in work with abuse survivors. Several sessions identify specific therapist attitudes and behaviors that support and facilitate effective implementation of the session interventions, for example, those related to emotional awareness (Chapter 11) and narratives of shame and loss (Chapters 22 and 23).
Finally, we hope the book is written with awareness of the need for the therapist to manage his or her own mental and physical health. We have highlighted the importance of therapist self-care and provided several references on the topic (see Chapter 8 and Appendix A). We hope that the philosophy and guidelines for treatment that are set out provide compassion and understanding for their clients’ condition and in doing so protect and empower therapists in their work.
