Sexual Trauma

(1) William White has conducted annual evaluations of Project SAFE since the Project’s inception in 1986.

Prevalence	Substance abusing women who have neglected or abused their children have a much higher frequency of childhood sexual abuse (45-95% of clients admitted across 19 treatment sites) than do women surveyed from the general population (16-34% range in most non-clinical surveys).
Clinical Vs. Non-clinical Populations	There are differences in the nature of the sexual abuse experiences ofwomen in clinical populations (women receiving substance abuse, psychiatric, eating disorder, or domestic violence-related services) compared to women in the general population who report having been sexually abused in childhood.
Comparative Factors	The distinctive aspects of the sexual abuse experiences of women in Project SAFE include specific traumagenic factors and the absence of protective/resiliency factors.
Traumagenic Factors	The majority of Project SAFE clients experience childhood sexual abuse that is characterized by the following traumagenic factors: early onset of abuse (pre-latency), long duration of abuse (most frequently measured in years), multiple perpetrators, perpetrators from within the family or whose presence was sanctioned by the family, violence or threat of violence as an aspect of the abuse experience, more boundary-invasive forms of sexual abuse, and disbelief or blaming as a response to breaking silence (with resulting continuation or escalation of abuse).
Protective/ Resiliency Factors	Most women in Project also lacked protective/resiliency factors that could have prevented their victimization or could have provided nurturing and healing experiences that could have potentially mediated the long term effects of early victimization.
Role in Substance Abuse	Clinical staff working in Project SAFE often view the etiology of substance abuse as a process of self-medicating the sustained effects of emotional and physical trauma.
Role of Trauma in Neglect/ Abuse	It is the general view of Project SAFE staff that the SAFE client is higher risk for neglecting or abusing their own children NOT because of the FACT of their own developmental abuse but because of the INTENSITY AND DURATION OF TRAUMA reflected in that abuse. This risk is further increased by the absence of natural healing experiences--the absence of indigenous systems of support. The issue is as much what these clients didn’t experience as what they did experience.
Asset-based Assessment	Much of what has been framed as the pathology of Project SAFE clients--impaired capacity for trust, manipulativeness, flight (early runaway behavior), disassociation--can be reframed in light of their early abuse as strategies of survival. The ability to discover strength and recognize one’s capacity for survival was an important foundation in the recoveries of Project SAFE clients.
Intergenerational Transmission	Many of the problems of Project SAFE clients, including problems of substance abuse and physical/sexual abuse, seem to be moving in an inter-generationally pattern of self-accelerating intensity. There is great concern within Project SAFE about the need to break these intergenerational cycles of transmission.
Intergenerational Risk	The children of Project SAFE clients are viewed as being at increased risk of sexual abuse due to the following factors: Some of the perpetrators who sexually abused Project SAFE clients also have access to their children. The propensity of Project SAFE clients to become involved in intimate partners who have multiple problems creates an "at risk" environment for their children. There is an increase in the number of SAFE clients who themselves report having been involved in the sexual abuse of others. Decreased supervision of children of drug using parents may increase the children’s exposure to a broad spectrum of victimizing behaviors. Having rarely experienced boundaries of appropriateness and having not been protected, Project SAFE mothers may have difficulties teaching such boundaries and affording such protection to their children. The dependence of a drug-using woman on her paramour for drugs, money and shelter contributes to the denial that this same partner may be physically or sexually abusing the mother’s children.
Patterning	The developmental trauma experienced by Project SAFE client often results in sexualized relationships with men and strained, often competitive or hostile relationships with other women. Project SAFE women describe as almost compulsive their propensity for involvement in highly toxic intimate relationships. This pattern carries into recovery and poses a significant threat of relapse.
Immediacy of Threat	In addition to a history of early developmental violence, Project SAFE clients often are at increased risk of sexual exploitation and sexual assault in their later developmental years. Given this phenomenon of patterning, concern related to the immediate safety of project SAFE clients is a critical issue, particularly when these clients attempt to sever their involvement in these toxic relationships. Linkages with domestic violence resources is critical for Project SAFE sites.
Motivation for Treatment	The developmental trauma of project SAFE clients produces an enormous capacity for pain and loss. As one outreach worker noted, "my clients don’t hit bottom, my clients live on the bottom!" As a result, hope-based interventions often prove more effective in initiating and sustaining treatment involvement than pain-based interventions. Motivation or lack of motivation at the time of initial contact is not a predictor of treatment outcome. Some of Project Safe’s most successful clients were among the most resistant and treatment-hostile clients at initial contact.
Addiction to Chaos	Chaos is an enduring theme in the lives of Project SAFE clients before and during the early stages of treatment. Adults survivors of sexual trauma learn how to use chaos (emergencies) strategically for emotional defocusing and intimacy management. Relentless relationship building and sustained case management is required to get through this "therapy in the middle of a hurricane" stage.
Excessive Behavior	When project SAFE clients stop using drugs and bring their daily life into greater tranquility and predictability, they are vulnerable for the develop-ment of new excessive behaviors that ranged from eating disorders to gambling problems.
Diagnosis	Many project SAFE clients come with prior histories of psychiatric diagnoses including from depression, anxiety disorder, and quite frequently borderline personality. Many staff prefer to reframe the characterological disturbances of SAFE clients in terms of resilience rather than pathology. Viewing behaviors as temporally adaptive within a framework of traumatic stress disorder or Blume’s "post-incest syndrome" proved more empowering and less stigmatizing than the more pejorative option of borderline personality.
Pre-Treatment	Clients with histories of developmental trauma require a longer period of time to engage in treatment. The earliest stages of engagement are marked by constant boundary and rule testing and by great ambivalence regarding treatment involvement. It is essential that programs have the capacity to tolerate and work through this testing period.
Developmental Stages of Recovery	Addressing childhood victimization for most Project SAFE clients continues in different ways through early, middle and late stages of addiction treatment. This is NOT an issue that can be postponed until late stages of recovery. At the same time, it is essential that each client remain in control of when, where, and to what degree of intensity this issue is addressed. Some of the more common developmental stages in addressing sexual victimization include breaking silence about the victimization, sharing stories with other survivors, direct expression of anger to the perpetrator(s) (in some cases), linking sexual abuse experiences to other problem areas, identifying and self-correcting patterns of self-injury and self-sabotage, and reconstructing one’s personal story and personal lifestyle.
Shame & Relapse	Shame (and its impact on self-esteem) is described as a core issue of treatment within project SAFE--an issue that often drives a wide spectrum of self-defeating and self-injuring behaviors. Clients are at high risk to relapse in response to intense experiences of success as they were to experiences of failure. Achievement of major milestones in treatment thus becomes a high risk time for relapse.
Iatrogenic Revictimization/ Boundary Surveillance	Clinical staff of Project SAFE recognize that there is a danger in revictimizing their clients at both ends of the intimacy continuum. The potential for abandonment and over-involvement with these clients is quite high. Monitoring the migration toward either end of this continuum is essential for all care givers. Interventions which violate the defense structure of the client through invasive and coercive attempts at eliciting behavioral change recapitulate historical victimization. Such interventions are more likely to trigger aggression or flight than positive behavioral change.
Safety	Great care has to be taken to assure the physical and psychological safety of Project SAFE clients within the treatment milieu. Some clients have been so damaged (by male perpetrators) that they require a gender-exclusive environment in which to initiate their recovery. Some clients have been so traumatized in relationships of unequal power that they are more likely to initiate recovery in mutual aid groups or low intensity modalities within which the client has significant control over the degree and pace of emotional intimacy. Clients did best in women’s groups and in meetings filled with persons from the same geographical and cultural background. Clients did the least favorably in mutual support groups characterized by a weak "group conscience," e.g, sexualized rather than emotionally supportive relation-ships.
Victim Vs. Survivor	Most Project SAFE clients go through a "victim" stage in which their whole identity and life history is viewed in terms of the issue of victimization. Staff can learn to recognize and work through this stage rather than to try to avoid this stage.
Termination Problems	Project SAFE clients are hypersensitive to issues of loss and abandonment. Program "graduations" have to be carefully phased to avoid emotional regression and relapse. Anticipation of the end of treatment (and membership in the treatment community) and even anticipation of the end of DCFS involvement and the structure such involvement provides poses risks of relapse and have to be carefully managed.
Duration of Treatment	The fact that most Project SAFE clients required longer periods of treatment than other clients to achieve and sustain sobriety, emotional stabilization and positive parent-child relationships was related to four inter-related factors: 1) gross developmental deficits, 2) a high number, variety and intensity of presenting problems, 3) significant environmental obstacles to recovery, and 4) an extended period of testing that preceded full treat-ment engagement.