Healing The Invisible Wounds of Trauma

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Healing the invisible wounds of

trauma: a qualitative analysis
a
Ryan Jim Sy San Diego
a
Counseling and Educational Psychology Department , De La
Salle University , Manila, Philippines
Published online: 08 Jun 2011.
To cite this article: Ryan Jim Sy San Diego (2011) Healing the invisible wounds of trauma: a
qualitative analysis, Asia Pacific Journal of Counselling and Psychotherapy, 2:2, 151-170,
DOI: 10.1080/21507686.2011.588243
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Asia Pacific Journal of Counselling and Psychotherapy
Vol. 2, No. 2, September 2011, 151170
Healing the invisible wounds of trauma: a qualitative analysis

Ryan Jim Sy San Diego*
Counseling and Educational Psychology Department, De La Salle University, Manila, Philippines

(Received 31 November 2010; in final form 4 May 2011)
Children and adolescents are the primary victims of sexual abuse and exploitation. The
Downloadedby[112.198.77.123]at11:1320November2014
present study is a qualitative exploration of their trauma experiences and trauma healing.
Five female adolescents joined a trauma-focused, cognitive behaviour ther-apy session.
Findings through interpretative phenomenological analysis showed that female adolescents
experience of affective dysregulation, cognitive distortions, sense of betrayal and self-
degradation influenced their capacity to live a meaningful life. Healing process themes such
as resistance, re-experience of trauma, struggles and ther-apeutic changes are evident. This
study shows the complexity of healing traumatic experiences specifically for adolescents as
it contributes to a lived experience of trauma.
Keywords: trauma; interpretative phenomenological analysis; trauma healing
Background and aim

Sexual abuse is one of the most debilitating social deviancies in our society. The
Department of Social Welfare and Development (DSWD) for the Philippines compiled
cases of sexual abuse that occurred during the year 2009. Because of the number of cases
and the diversity and impact of the abuse on children and adolescents, the department divided
the cases into two categories: (1) sexual abuse; and (2) sexual exploitation. The sexual abuse
category included rape, incest and acts of lasciviousness, while the sex-ual exploitation
category included victims of prostitution, paedophilia, pornography and cyber-
pornography. Of the 6522 child abuse cases dealt with by the DSWD during 2009, there were
1898 cases of female sexual abuse reported, with only 31 cases reported for males. Also, there
were 107 cases for female and 23 cases for male sexual exploitation. The remaining 4463 cases
were victims of child labour or illegal recruitment, or had been physically abused or maltreated
without involvement of sexual abuse or sexual exploitation of minors (DSWD, 2009).
The top regions in the Philippines with the highest reported cases of sexual abuse and sexual
exploitations are significant regions owing to their industrial and economic condi-tions. Region IX
(Zamboanga peninsula) has 298 cases of sexual abuse and 40 cases of sexual molestations. Second
in the number of reported abuse cases was Region III (Central Luzon) with 299 cases of sexual
abuse and 17 cases of sexual molestation. Third in rank among the highest reported cases was
Region VII (Central Visayas) with 224 report cases of sexual abuse and 9 case of sexual
molestation. One hundred forty-six cases of sexual
*Email: ryan.sandiego@dlsu.edu.ph
ISSN 2150-7686 print/ISSN 2150-7708 online

2011 Taylor & Francis Ltd.
DOI: 10.1080/21507686.2011.588243
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152 R.J.S. San Diego
abuse belong to NCR (Metro Manila). This region also had 29 of the highest reported cases for
sexual molestation (Department of Social Welfare and Development, 2009).
Based on the age-grouping of Filipino minors who had experienced sexual abuse and
molestation, those from 0 to <1 year old, and from 1 to <5 years old had the lowest reported number
of cases compared with the 894 reported cases for the 14 to <18 year old group. There were 634
reported cases of sexual abuse among 10 to <14 year olds, and 317 cases for 5 to <10 year olds.
There were 73 cases of reported sexual molestation for 14 to <18 year olds, 37 cases for 10 to <14
year olds and 16 cases for 5 to <10 year olds. It is notable that, within the distribution of the child
abuse cases, the 14 to <18 year old group had the largest number of abuse cases, such as rape,
incest, prostitution and cyber-pornography, closely followed by the 10 to <14 year old group. The
10 to <14 year old group is of concern as this is the age group where incidents of paedophilia and
pornography were most likely to be reported (Department of Social Welfare and Development,
2009).
Considering the number of child and adolescent sexual abuse cases occurring in the
Philippines, it appears that insufficient attention is being provided to the intervention tech-
niques necessary for working with these children. The present research intends to explore and
hopefully add to the knowledge base of experiences of trauma among sexually abused
female adolescents. Also, based on their traumatic experiences, a trauma-focused, cogni-tive
behaviour therapy is tested qualitatively to promote growth and healing among the
survivors.
There are several Philippine-oriented studies exploring interventions in sexual abuse. A study by
Thennatil (2005) explores the phenomenon of child sexual abuse in women and studies the efficacy
of psychoeducation combined with creative imagery as an intervention to reduce the symptoms of
complex post-traumatic stress disorder. The study, although comprehensive in the treatment of
symptoms of complex post-traumatic stress disorder, only quantitatively analyses the results of the
experiment and does not look in depth at the experiences of the abused participants. Thennatils
findings are similar to those of Vergara (1995), who found, in her idiographic research, effects of
both cognitive-restructuring and visual kinesthetic dissociation on the perception of self and others,
and adolescent adjust-ment. Participants in the treatment groups showed improvements in the
perception of self and others and adjustment at the two and four week post-test, while the waiting-
list control group did not show any improvements in perception of self and others or in adjustments.
The problem with existing research is the limited data produced and the lack of an in-depth explanation regarding the role of
therapy in the healing process among sexually abused adolescents. More important are the personal experiences of each participant and
their own process of healing. Qualitative research in trauma healing is currently lacking in the Philippines. The purpose of this work is
the same as that of Thompson (2000), which is to increase the amount of research on the positive outcome of trauma recovery and to
provide information as to how sexual abuse and assault influence the life of the victim. Abused women and adolescents can overcome
the trauma associated with the abuse and can experience positive growth, thus enhancing hope among victims.
There have been studies of the qualitative methods of a group of Philippine therapist-researchers (Carandang & Sison, 2004).
These professionals have conducted studies with male and female adolescents who have experienced prostitution and sexually abused
street children, both male and female. The following studies shed some light on the phe-nomenological status of sexually abused
children and adolescents (Carandang & Sison, 2004).
Gonzales-Fernando (2000) explored the inner world of Filipina children with previous
involvement in prostitution. The research was conducted using projective techniques and in-depth
clinical interviews. The main finding was that an emotional split had taken place,
wherein the girls self-concepts, sense of womanhood and sexuality contained two separate
self-images. The self-images identified were the pleasure- and the need gratification-seeking
child-prostitutes and at the same time their own exploitation and self-degradation while they
allow others to abuse their bodies. Meanwhile, in another study, Laguisma-Sison (2000), using
a phenomenological approach on multiple case studies, focused on 12 Filipino boys with
previous experiences in prostitution. The findings showed that sexually assaulted Filipino boys
longed for a parent-like figure; they were insecure about their abilities and they felt
emotionally and physically neglected. As their method of coping, they manifested becoming a
parent to others to cover up their strong underlying need for nur-turance. The finding shows
the gravity of the trauma affecting their sexuality. In the study of Trivino (2000) on sexually
assaulted Filipino street childrens cognitive functioning, the results showed that these children
had a disempowered way of facing their problems. They employed evasion of and passivity to
conflicts, and they saw the world as chaotic and cruel. The intellectual abilities of the sexually
abused children were generally lower than their non-abused counterparts.
The studies of both Laguisma-Sison (2000) and Gonzales-Fernando (2000) showed

significantly different effects of trauma on gender, sexuality and self-concept within the
narratives of sexually assaulted Filipino adolescents. The richness of qualitative research
provides a more in-depth understanding of human experience of traumatic events. Trivinos
(2000) study shows clearly that sexual abuse inhibits innate abilities and the development of
the person, resulting in poorer performance in social and cognitive tasks.
The trauma of sexual assault

For mental health professionals, sexual abuse pertains to contact or interaction between a child
and an adult when the child is used for the sexual stimulation of the perpetrator (or a third
person). Sexual abuse is committed when the victim is a person under the age of 18 years and
when the perpetrator is either significantly older than the victim or is in a position of power or
control over the victim. Thus, the perpetrator may be a member of the immediate family of the
victim. It can also occur outside of the family, instigated by strangers. Often the victim is
threatened with harm by the perpetrator. The abuse in this study included sexual exploitation
or sexual activities with a child under circumstances that indicated that the childs health or
stature was harmed. The abuse also included chil-dren used for the production of pornographic
materials, prostitution and human trafficking. According to Carandang and Sison (2004), even
when no physical contact occurred with the children or adolescents, but they were exposed to
obscene materials, this was consid-ered as psychologically abusive. Geldard (2005) pointed
out that sexual abuse of children is commonly perpetrated by someone they know and trust.
Such abuse may last for several years and often continues into adolescence. Sexual abuse can
often be found in the histories of adolescents with severe mental health disturbances (Atlas,
1997). Courtois (1999) stated that most sexually abused adolescents manifest hostility towards
others owing to the traumatic stress they have encountered. Most of them develop post-
traumatic stress disorders that incapacitate their social and personal capabilities. The stressful
and trau-matic experiences of varying magnitude inhibit the normal functioning of both
children and adolescents.
Trauma healing
Healing according to Monahon (1993) is a process of connecting and bringing together, it is a process of e
of regaining dignity. Phase-oriented treatment results from various mental health profes-
sionals development of their own concept of trauma healing. Courtois (1999) establishes three
main trauma intervention phases. The early phase is the establishment of intervention
parameters and procedures, the development of therapeutic relationships and a working
alliance with the victim. The second phase is known as the middle phase, where recondi-
tioning, mourning, resolution and integration of trauma are experienced by the client. The final
phase is the reconsolidation and restructuring of the victims life.
On the other hand, Hermann (1992) identifies three stages that trauma victims move
through as part of the healing process: safety, acknowledgment and reconnection. These
processes have guided the creation of many trauma interventions. The first step for the most
interventions is to provide a safe place; retelling their story can be therapeutic and allow those
memories to be incorporated into the victims life story. The second stage per-tains to
remembrance and mourning; there is a reconstruction of the trauma story to allow
transformation of the traumatic memory. The last stage is the reconnection; the victim fights
back, is able to find a personal goal to achieve and moves on to resolve the trauma.
Chus (1999) trauma healing phases are somewhat similar to Hermanns model, in which
the early stage of treatment begins where the victim has the capacity for self-care,
acknowledgement of the trauma and evidence of symptom control. The second phase is
described as abreaction, in which symptoms can be felt owing to the increase in internal
conflicts. The last phase is the consolidation of gain and increasing healthy interaction
with the world outside.
Given the following research studies on trauma effects, trauma of sexual assault and trauma
healing, the present study explores in depth the experiences the sexually assaulted and abused
Filipina adolescents by analyzing their trauma themes. Altogether, the emerging process of trauma
healing within a trauma-focused cognitive behaviour therapy is explored.
Method
To explore the experiences of sexually assaulted female adolescents, and to add to the existing
knowledge base on sexual abuse intervention among Filipino children and adoles-cents, the
researcher used an in-depth exploratory qualitative outcome study approach. This approach is
phenomenological in nature since the therapistresearcher has the opportunity to explore the
actual experiences of the adolescents (McLeod, 2001).
The phenomenological methodology is the study of lived experiences and the ways
people understand specific experiences as they develop a worldview (Smith, 2003). The
basic assumption is that a person can narrate the structure and essence of shared expe-riences.
The purpose is to describe the meaning of a concept or phenomenon shared by several
individuals (Marshall, 1999).
Participants
From referrals ordered by the college dean, students in general psychology and personality
development were approached. Students who had any experience of trauma were encour-aged to
write about it. Six female students who reported sexual abuse with accompanying histories of
molestation were selected from the recruitment process. Participant A had been sexually abused by
her uncle since the age of 3; participant B was abused by a relative when she was 5 years old;
participant C was molested and abused from 12 years of age; participant D was sexually molested
from 7 years of age by her elder cousin; while participant E had experienced incest from the age of
10 by a family member. The last participant withdrew owing to physical illness. All participants
we re from low-income families, and
their parents had barely finished high school. Their age ranged from 15 to 18 years and all
were enrolled in a community college. All participants reported discontinuation of
molestation and sexual abuse, with two reporting their cases to the police authorities
while the remaining three had reported their abuse experiences to supportive relatives.
Recruitment
Qualified participants were considered as part of the study. Those students who had dis-
closed trauma experiences other than sexual abuse underwent counselling sessions within
class and during break periods with their guidance counsellors. They also participated in
the semesters sensitivity training. The criterion for inclusion was that each participant must be
an adolescent. Ages ranged from 16 to 18 years old. The participants attended interview
sessions first, facilitated by the therapist to determine whether they had the capacity to
understand and had the insight to reflect on their experiences. It also was important that the
participants had no physical deformities, mental retardation or substance abuse histories. The
therapist also excluded those individuals with mood disorders and any candidates cur-rently
taking psychotropic medications. All participants had experienced childhood sexual assault
in their past. The perpetrators in this research were all related by blood and were presently
residing within the participants residence except for one perpetrator who had moved to the
province as advised by the parents of the victim. Based on interviews with the participants,
these perpetrators were adults with a mean age of 30 at the time of the sexual abuse. They were
tasked to help with the household chores, and take care of the younger children of their aunt or
relatives. There were no filed criminal cases against the perpetrators and so they could move
from one place to another comfortably and continue their usual activities. The perpetrators
identity could not be disclosed in this research owing to the sensitivity of the cases.
Debriefing
Students who were referred were informed individually about the therapy sessions and they
were asked to complete a consent form regarding the duration of the treatment. The first
session that transpired was for orientation, the development of goals, setting the time frame
and expectations, and education on sexual abuse. An assignment such as keeping a journal and
the proper way of writing was also part of the meeting. Before the start of the treatment
sessions, the therapist administered three available inventories to the participants individually.
This was the pretesting of the participants in order to gather first-hand data regarding any
symptoms together with the results of the participants interview. The tests included a
behavioural inventory such as Impact of Event Scale Revised (IES-R), Beck Depression
Inventory (BDI) and Beck Anxiety Inventory (BAI).
Procedure
After the researcher had secured the status and willingness of each participant to join the treatment proce
treatment sessions. A treatment plan was developed using trauma-focused cognitive behaviour therapy (T
symptoms of sexual abuse and the trauma experienced by the participants. The intervention was devel
choeducation, cognitive restructuring and stress inoculation training. The intervention was
done first individually and then by introducing the individual into the group. The T-FCBT
method uses 15 therapeutic sessions that can be utilized and adjusted from 1 up to 2 h per
sessions as needed and is tailored by the therapist according to the personal issues of each
participant. Expression of feelings and coping skills, understanding of the relationships
between thoughts and behaviours, and exposure to traumatic events were the concerns of the
participants expressed during each therapy session.
Data analysis
In making sense of the journals of the participants, as well as the therapy notes and the
interview process, it was important to use interpretative phenomenological analysis (IPA).
This is an analysis of how individuals make sense of their lived experiences. It aims to provide
a detailed exploration of personal experiences as well as a close examination of how
participants make sense of them. The main use of the IPA analyses is to focus on meanings,
particulars of experiences, states, events and objects expressed by participants, towards an
understanding of what the particular participants think or believe about the topic under further
exploration (Smith, 2003).
Using IPA, the following procedures were completed:
(1) The process of IPA started with explorations of the shared experiences among the
participants. The journals and interviews as well as the therapy notes were used to identify
their shared experiences, using three independent raters. The indepen-dent raters comprised
a masters-level clinical social worker with experience with sexually abused children and
women; a trauma desk researcher who compiles the departments abuse researches for
hospital documentation; and a trauma counsel-lor with a masters degree in psychology.
The practice of auditing was an important part of the process because it revealed patterns
among independent raters.
(2) There were no preset categories that might affect the result of the research; the output
of the team was checked by an auditor. The external auditor was a member of the
teaching faculty of the psychology department of a Manila-based university and had a
masters degree in clinical psychology. Using an external auditor helps to validate the
shared experiences. An initial coding of the shared experiences was found to cluster
meaningfully into themes. Categorization of the themes was done to form a higher-
level order known as the superordinates. The auditor checked the relationships that
were formed among the extractions
(3) To reduce bias the researcher conducted cross-validation with the participants in which
the participants reviewed the results and the emerging themes to clarify the output.
(4) After the cross-validation, a cross analysis per case was done followed by a write up of
the narrative accounts with an emphasis on the shared experiences among the
participants.
Results
The wounds of trauma
The first part of the results showed the participants journey in their trauma experiences. Major
trauma themes were divided into (1) affect dysregulation, (2) Cognitive and percep-tual
distortions, (3) sense of betrayal and disgust and (4) self-degradation (see Table 1). These
themes were believed to be the primary wounds of their sexual assault experiences.
Affect dysregulation
Any event or place reminiscent of the abuse could elicit a negative feeling or thought. Any
stimulus from the environment, whether an automatic thought or not, further enhanced the
participants experiences of a heightened sense of alertness. Participants experienced
disturbance of events, even in their dreams when sleeping. A flashback of events, if not prop-
erly confronted, was considered unfinished business. Experiences of suddenly waking for
unknown reasons, heightened fear and felt threat in dark places were evident. The shock that
was felt by the participants was capable of causing them to be petrified. They felt that they
could not move because of intense fear. They could not even breathe. Because of a heightened
and intense fear, they could not even cry. Participants expressed feelings of sadness because of
the abuse. This sadness took on many forms, one of which was self-depreciation. These results were
also evident in behavioural manifestations of crying spells, suicidal ideations and self-mutilating
activities.
I would always cry and prefer to be alone. I really wanted to die ever since. I would even hurt
myself for I am already so useless. I still remember, whenever he would touch me, I would
resist. I remember everything. (P 1)
Because of what happened, I became more elusive, more sensitive. Most of the time, I
would dream I am being raped whenever I sleep. I would always get shocked whenever I
wake up, agitated, afraid, bothered in the dark, but before it was not like that. (P 3)
Across cases, participants developed indirect aggression towards the perpetrator, and a feeling
of discreet vengeance that the perpetrator needed to pay for what he did. Participants became
verbally aggressive even at the slightest mention of the perpetrators name. They wanted to
take the life of the perpetrator. Anger was evident among the participants because they did
not want to forgive the perpetrator; it was also a sign of vengeance, to show that
irreparable damage had been done There were signs of indirect plans to hit or even
annihilate the perpetrator.
I can never forgive him even if he asks for it, never will I! He (perpetrator) bastardized me! I want
to hurt and kill him! But I failed! Maybe it is because I was still young and innocent back then. (P
5)
The desire to get even, however, did not push through because of limitations such as
incapacity to handle the situation or being too young and immature, inhibiting the
participants from acting out the plan.
Also, participants experienced weaknesses that were related to their emotional expression.
They felt numbness and shock owing to the painful event. short period of dissociation while
suffering at the hands of the perpetrator surfaced as participants mentioned that they
experienced being out of their own body, and not even feeling any sensations to any touch
on their body.
I cannot move, sometimes I hardly breathe, my tears wont shed, even if it should, Im so afraid. I
do not know why I could not cry, all these with my fear. Whatever I do, I feel like a stone,
especially I am aware that I will be maltreated again soon. (P 2)
I really feel tired, paralysed, and always day-dreaming, everything is in my mind. I also notice
that I became cold to him, I do not even see him as my uncle, and Im so disgusted whenever he
would approach me. Sometimes, I would see myself lying, lifeless; I became numb of each touch
and abusive act. (P 3)
Cognitive and perceptual distortions

Participants experienced various problems with their mental processing. Thoughts would
not run through their head or they felt that their heads were empty. There were times
when they had problems with concentration. Studying was difficult and they were
annoyed by the disturbance.
I cannot even think, neither study properly in my house for I am easily distracted. I feel like I am
lifeless, even a robot for I just follow whatever he tells me. (P 5)
Participants mentioned that they tried to escape verbally and intellectually by denying that
the abuse had happened, and they even attempted practices of minimization and normal-
ization by maintaining that the abuse was something that they could manage on their own.
When their sense of trust was diminished, for an instant, three participants felt fear and
depression brought about by the illogicality of their thoughts.
For me, what happened was not really a big deal, I can handle myself. If you are to ask me, I
managed to forget what happened before, since those were not really important. I am okay now. (P
2)
In addition, derived from their sexual abuse, there was an imagined sense of threat from the
environment which forced them to experience feelings of being trapped.
After all the things I went through, I am still disturbed, thinking of my world trapped in dark-ness
and fear, like in a dark cave. Those people who maltreated me were strangling me. I know I have a
different outlook in life because I am moving in a very congested and problematic situation. (P 4)
They even experienced stagnation in their daily activities. As the social environment was
perceived as harmful and threatening for the participants, they had limited chances of inter-
preting their life as something worthwhile, and their worldview often seemed dull, heavy and
agonizing.
Sense of betrayal and mistrust

Prominent among participants was fear of men and the expression of emotions towards
them. Participants were afraid that, if they engaged in social activities with men, the abuse
might happen again. The sexual assault brought about disgust and caused a negative con-
ceptualization of intimacy and sexuality, causing the participants to experience difficulties
in expressing themselves or even committing to a relationship.
If I have a boyfriend, maybe he will do the same like what the rapist did to me. I really feel totally
disrespected, and I abhor that feeling. In instances like that, I am having goose bumps. Whenever I
would have sex, I view it as if my femininity is always disrespected. I consider each guy bad for I know
he will do something bad to me, I do not trust them anymore. (P 1)
This also brought about physiological manifestations like goose bumps and skin reactions
among the participants. Even in therapy sessions, the participants had to face the inevitable
transference, specifically if the therapist was male. During the therapy sessions some par-
ticipants could not look into the eyes of the male therapist, and they failed to concentrate when
the male therapist asked questions.
There were two revealing issues accompanying the sense of betrayal among the par-
ticipants. The first form of betrayal revealed was the felt betrayal of trust in ones parent.
Significant others like parents were considered as the main source of hope and support,
but in the case of these participants, they thought that the abuse was brought about by the
negligence of their parents.
I feel like as if my parents were giving me away to that person (perpetrator), they dont even know
him! I feel like I am betrayed by my own parents, they put their trust on the wrong person; they
dont even know that person (perpetrator) abused their own daughter! (P 2)
The second felt betrayal occurred as created by the perpetrators. These perpetrators were
related to the participants by blood and were tasked to take good care of them. Betrayals
among participants were experienced because the earlier established trust and respect were
broken owing to sexual abuse and molestation.
He (perpetrator) is so evil, doing those things to me! I wish I will be the one to kill him because it
feels like he killed me already, my entire being, I even treated him as a sibling, a brother who can
defend me, but he is even the one who raped me! (P 3)
Betrayal of trust was evident, added to the burden of justice being denied, and there were no
means by which participants could punish the perpetrators. Sometimes parents decisions
were not logical because the perpetrators did not suffer the consequences of their abusive acts.
The perpetrators were merely sent home to the province to avoid a commotion.
Self-degradation
After the incident, victims of sexual abuse usually blame themselves for not doing some-
thing to stop the abuse from happening. They turn the blame against themselves, thus
leading them to self-hatred. The sexual abuse had caused severe trauma reactions among the
participants. They interpreted their experiences such that their bodies were used by the
perpetrator for sexual pleasure, and that the perpetrator had treated them like a sexual toy.
Almost all of the participants mentioned that they felt ashamed and that they thought that
others might accuse them of being sexually active. Added to that, there was a sense of lost
womanhood together with their loss of virginity.
I pity myself because I let him (perpetrator) degrade me, if I will look back, I will feel disturbed
because I acted so stupid, I am not even able to defend myself. I even blame myself because I did
not resist, why didnt I hurt him? Or even curse him; he did all the lascivious acts! Sometimes, I
even think if I liked the things he (perpetrator) did to me. (P 1)
The abuse represented shameful experiences for the participants. Participants thought
that they were dirty compared with other girls their age; they even compared themselves to
pros-titutes. Although the participants could hide their painful experiences, deep inside them
there were feelings of damaged self, emptiness and disgust because they thought that they
were dirty and used. In addition, the participants compared themselves with others to see if
these significant others perceived them as abnormal.
I am so dirty! I feel so disgusted with myself! I can even compare myself to the prostitutes. I feel
ashamed to others because my femininity is destroyed. (P 3)
Others might even think that I am bad, share gossips about me. I am like a colorless picture
because of the unfortunate event that happened to me. (P 5)
I feel that even though I am neat and clean outside, I am dirty and putrid inside. (P 2)
They devalued themselves because they thought that their situation was hopeless, and that they
would be unable to achieve life progress and changes. The assault experience also was
perceived as a threat to their own ability to establish relationships in the future. Needless to
say, this affects ones self-confidence in social and relational activities.
The experience of healing

The following themes emerged from the participants experiences from the start of therapy
sessions progressing towards the termination phases. Journals, interviews and therapy notes
were utilized to identify themes and superordinate themes. Healing processes were classified
according to progressive patterns based on how the participants identified themselves within
therapy sessions (see Table 2). The healing process came from the participants reactions
towards therapy, their personal struggles, and attempts at moving forward and finding
meaning.
Initial resistance towards therapy

Participants could not deny that, during the early phases of the therapy sessions, they showed
signs of inhibitions, lack of enthusiasm and even tension towards the therapy ses-sions. These
reactions are very common among victims of sexual abuse because they have experienced an
inability to handle traumatic problems and early apprehensions.
I feel irritated, long before that happened I feel okay, there is no need to meddle on the things that
happened on the past. I feel that this is too personal to let others know. I do not want to look back
to these events, it is hurtful, and why do I need to look back? My time is only getting nowhere in
this therapy session. (P 1)
It was evident during the early phases of the therapy that the participants were very hesitant to
disclose themselves. They considered the trauma already out of their conscious awareness and
that there were no good reasons for them to open up about it.
Re-experiencing of trauma effects

I observed that, during the third and fourth sessions of therapy, various physiological reactions
were reported by the participants. Initially, participants wanted to quit the therapy because of
their inability to cope with the physiological reactions that they thought sur-faced because the
experiences of the trauma being reactivated by the therapy sessions. Even during the initial
interviews, participants could not stop themselves from crying even when the questions were
not too personal for them to answer. They cried hard while disclosing their painful experiences.
It is really painful, its hard to share everything I feel and experience, it seems like I avoid every
question referring to bastardization that happened to me. It was hard for me to go back to these
events, it is really hard! I felt like every scene is repeated, creating a flashback, every time I tell my
story. (P 4)
Other participants experienced a heightened sense of arousal while retelling their experiences,
such as sensitivities with the skin and automatic or sudden reactions during therapy sessions.
My knees are trembling, Im perspiring profusely, weakening, I do not know why I feel these
things when I share my stories to others. Sometimes, my paranoia on the things around me comes
back. I even feel that someone is staring at me when I walk alone. (P 5)
Along with the physiological manifestations owing to the recall of traumatic experiences,
participants also experienced a sudden decrease in their sense of security. They reported that
they experienced once again some form of social paranoia. These reoccurring experiences were
unexplainable and therefore not understood because they thought that this paranoia was only
active during the time when the abuse was still fresh.
Struggling with negative emotions

Based on the therapy notes and the individual journals of the participants, there were negative
emotions and difficulties experienced within the first five sessions of therapy. Participants re-
experienced struggling with the pain because of remembered events that were previously
buried in memory. Through confronting these images, participants were guided systematically
through them to find answers for different questions as well as to integrate bits and pieces of
the events within the memory into some organized whole. Difficulties in recall and an inability
to express congruent emotions were the main problems of the participants. It was very painful
and yet very challenging on their part.
Openness to healing
Strength and perseverance of the participants were observed as participants gained bit by bit
from their own personal struggles with their trauma. They realized that the trauma from sexual
abuse was something that they needed to confront and face with the goal in mind of improving
the self. Participants eventually became more open to discussing their experiences. They began
to cooperate well and showed a willingness to attend the sessions every other day.
I want to help myself; I find ways to understand these things, even myself. Slowly, I realize that
the things we do in every therapy session is helpful to me. Everything is getting back to normal; I
dont usually get to do think of detrimental things. (P 3)
I try to control the bad things I think about and it lessens my worries. Slowly, I learn to not be
ashamed of myself, I dont even need to blame myself, the ones who should be picked on are those
individuals who did me wrong. (P 2)
Some participants mentioned that they never thought therapy sessions would be their only
hope. At first, they thought that it would not do any good. However, they realized in time that
their perception of therapy was wrong. They found solace in and even comfort with the therapy
sessions because they had the opportunity to redirect their own thoughts and manage self-
defeating thoughts.
Therapeutic changes
There are subthemes identified within the therapeutic changes reported by the participants as
part of their healing process. These subthemes are essential for the process to take place. The
subthemes are as follows: (1) establishing a sense of self-control; (2) self-renewal; (3)
meaning making; and (4) social reconnection.
I observed that there were changes in the participants subthemes during the late phases of the
therapy sessions. Participants also reported changes in their thoughts, and even in their behaviour.
Their improvement was also evident in their journals and active participa-tion in therapy. This was
the phase where the participants gathered their inner strength for their own personal resources and
tried to maintain their psychological balance.
There was also a point where the participants started to realize several changes in the way they
thought and, more importantly, they began to realize that how they think affects the way they feel
and act. Some of the participants also realized that they were the ones who were re-victimizing
themselves through their own generalizations of their traumas and illogical thoughts. The
participants self-concepts were affected by the shift in their thought management. Now their
thoughts were positive. They experienced a change in thinking negatively and allowed themselves to
interpret the situation in another way. With the corresponding thought change, feelings and
emotions changed too.
9
The participants were very happy to experience again how they persevered and
struggled just to make themselves stable. Participants appreciated the changes that
happened to them. These changes came from establishing control and safety as well as
empowering themselves owing to their perceived positive changes. They knew now what
they could do and they knew how to seek social support.
The feeling is different when you feel that you know what happened to you and you accept it as it
is, and you know what to fight for, I even know that I should be strong. I have learned to relax
myself; I get to control my bad emotions. I can now feel my true self, moving out of the dark and
angry world I once belonged. (P 1)
They also realized that there were people around them ready to give them help. The
accompanying changes that were experienced by the participants also caused changes in their
behaviour. They could control themselves if there were minimal attacks of anxiety. In addition,
the participants experienced a new way of relating to themselves as normal persons. They
metaphorically described the experience as being a person, one who was capable of expressing
ideas without any blockages as well as expressing emotions congruent with the expression of the
twin ideas of being comfortable with oneself and enjoying that feeling.
Participants also expressed sincere appreciation because they enjoyed the sense of
being free, a sense of holding on to the self as a stable ground where emotions were free
and threat was diminished. Participants engaged themselves in finding meaning after
successfully progressing with their therapy. Armed with happiness and hope, they promised
that they could take themselves into a better future. They reported that they had clarified some
of their questions, found some new directions, and discovered a purpose with their trauma
experiences. By accepting the experiences, participants learned from the past and tried to integrate the
experiences with their everyday life struggle.
I have nothing to be ashamed of, those things are done, and I have learned essential things in life that I can use,
those events happened to me because God has something In store for me, a purpose I need to realize and
follow. (P 3)
I have learned to be strong, know my direction in life and to what my goals are. I know that I am not alone
in this abuse and because of that I can help other women who also experienced this abusive event, I can help
them. (P 1)
They realized that, by accepting what happened to them, they were being resilient. Their own
connection with their higher being helped with the experience, that there was a greater plan and a greater
purpose as to why their abuse happened to them. The participants gained a sense of control of their
emotions and developed a positive outlook on life. They also expressed that they were establishing a
connection with their self before establishing bonds again with others in their environment. A felt sense of
commonality and community was present after they realized that they had similar trauma experiences,
and that their current problems were even minor compared with the experiences of those who continued
to struggle to find stability and compared with those who were still suffering from lost contact with
reality.
Discussion
Issues of negative valence and sense of being trapped
There are certain details of trauma stimulus that, no matter how simple, can trigger related abuse
experiences and might provoke behavioral or physiological reactions (Hermann, 1992). Participants
reactions such as becoming overly sensitive towards strange persons and even unexpected gestures
from others can be identified as hyper vigilance. Others refer
to it as hyperarousal because ones sense of being threatened is activated. If anyone causes the
person harm, the participant may instantly retaliate. The experience of hyperarousal tends to be a
negative one for most victims of sexual abuse because they cannot function well in their activities
owing to this sense of emotional alarm. They sometimes resort to social isolation and withdrawal
from social functioning. Hyperarousal is a very energy-consuming affective dysregulation because
it causes the various systems of the body to work abruptly. This may sometimes be the reason why
trauma victims tend to feel tired and weary. Accompanying by the experience of hyper vigilance are
shock and intense fear (Leahy, Pretty, & Tenenbaum, 2003). The participants conscious awareness
could not process the abuse. There were also mixed feelings among the participants, described
during the sessions as anger, rage, guilt and a sense of disgust and denial, that this is something they
do not want to happen and yet it is happening. They could not accept that in front of them was the
perpetrator doing these things to satisfy his own needs and desires.
On the other hand participants use other forms of defense, and one of which is dissociating
the self from the emotionally confusing and painful state. According to Janoff-Bulman (1992),
dissociation is used to protect oneself from overwhelming painful emotions and negative
thoughts, and at the same time it minimizes awareness that the abuse is happening. The
participants automatically shut themselves off from the unaccept-able experience, moving
away, because the conscious awareness cannot process the event that is happening and it is too
much for the adolescents to accept that what is happening is real. A participant also described
feeling as if she was moving her awareness away from her body, as if dreaming and seeing her
body from afar, being sexually abused by the per-petrator. The participants affective
dysregulation was truly a burden because in a way they had had similar experiences of being
trapped.
Issues of inconsistent information processing and perception

The participants also experienced problems with mental processing. According to Trivino
(2000), the effects of trauma specifically from sexual abuse bring about socialcognitive
disturbance in development and cognitive performance. Mental functions such as social
sensitivity, cognitive decentering and comprehension of social activities are also affected.
These effects of sexual abuse on ones cognitive development and functioning obviously affect
the participants worldview. A change in ones worldview may be the result of the victims
diminishing sense of trust that there can be secure relationships with adults and other support
systems. The cognitive constriction may have led the person to anticipate others behavior and
social events as negative as part of personal social constructs (Trivino, 2000).
There are also instances when victims express mechanical behaviour towards the per-
petrator. Leahy et al. (2003) explained that, when victims of sexual abuse are repeatedly
rendered helpless and powerless, the more confused and the more frightened they become, and
the more they will permit the perpetrator to abuse their body.
From Hermanns (1992) point of view, participants tend to experience cognitive distor-tions and
perceptual inconsistencies because of defenses that happen at the cognitive level. This defense is
known as mental disorganization. It happens along with the dissociative experiences during the
abuse. The painful experiences that cannot be assimilated by the person may split from the ordinary
awareness. This is a kind of constriction in the cogni-tive level that allows a person to be easily
distracted and even overwhelmed by intrusive
memories of the abuse. It is also one reason why abuse victims cannot synthesize a social
situation and generate insight from it.
Issues of diminished trust and fear of disclosure

Fears regarding establishing interpersonal relations are very problematic for victims of sex-ual
abuse; there is a sense of diminished trust that needs to be repaired before entering into a
relationship. Victims of sexual abuse associate casual relationships with imagined abuse,
anticipating that the partner will have the same motives as the perpetrator. Congruent with the
cognitive disruptions, ones schema also affects information processing and likewise will affect
the behaviour of the person. It also affects in a way the way they relate to others, and the way
they trust people around them. Similar to what Gonzales-Fernando (2000) reveals in her study
on female prostitutes, men tend to be perceived as users, not to be trusted. Men are also
associated in victims view of sexual relationships with being exploitative, abusive and cruel.
Similarly, Laguisma-Sison (2000) mentions in her study that the social ineffectiveness of
abused adolescents is greatly affected by the way they perceive their environment, and that
their worldview is a very important factor in coping and adjust-ing after the abuse. In her study
on male child prostitutes, which is also similar to previous studies on sexual abuse, victims see
older male adults as people who will take advantage of them.
A problem among victims of sexual abuse is their inability to disclose the abuse and ask for
help. Somer and Szwarcberg (2001) identify four categories of variables pertinent to the
withholding or disclosure of child sexual abuse among victims of sexual abuse. First, there are
the psychological variables, if the survivor of the abuse develops intense, tenacious
attachments to abusive others. Object-relations and attachments have been used to explain the
need of the survivors to preserve the self and the attachment to the abusing caretaker. To satisfy
that need, abused children employ several defenses, including splitting, dissocia-tion and
idealization. Secondly, According to Ussher and Dewberry (1995), perpetrators of child sexual
abuse and incest use a variety of techniques to threaten, persuade and manip-ulate their
victims, so that sexual encounters are kept secret. Prominent among these is the manipulation
of the family integrity. Sexually abused children seem to be able to assess accurately the
outcome of their disclosure, which is often met with disbelief, denial or blame. Third are
sociable variables, which are reactions to child sexual abuse survivors initial revelations,
including indifference, skepticism, negative or rejecting responses and blame (Tomlin, 1991).
Issues of self-attribution
Self-blame implies a belief in personal responsibility for the abuse, and helplessness seems
based on a belief that the abuse was caused by uncontrollable external factors. Furthermore,
self-blame seems to be based on the victims belief that she was responsible for the
victimization. Self-blame for being unable to avoid victimization by an abusive individual is a
different story. Some adolescents seem to understand clearly that the abusive impulses
originated within the offender and not in response to them, but nonetheless feel angry with
themselves for failing to escape or terminate the abuse. Janoff-Bulman (1992) draws a
distinction between behavioural self-blame, which consists of attribution to a specific
behaviour or mistake, and characterological self-blame, which involves attribution to enduring
personal characteristics, which is found to be harmful for the victims of sexual abuse.
Resisting and struggling with change

The greatest challenge among the participants was to allow the images to resurface again in the
therapy session, and slowly the researcher taught them various techniques in handling these
images. For them, the images seemed to be the source of their illogical thoughts, negative
feelings and prevailing thoughts of negative self-image. Participants expressed the common
experience that they seemed to be detached from their emotions. This was the start of their
self-reflection, and they mentioned that they noticed the incongruence of their emotions only
after several therapy sessions. The dissociative effects of the trauma experience prevented the
participants from expressing their true feelings in the therapy sessions. Sometimes they wanted
to cry but could not; they were prevented from feeling essential feelings because of blocked
emotions.
Together with their sense of struggling with their emotions was their reinterpretation of
their identity as stigmatized, being abused and feeling hopeless. Participants felt hopeless
regarding their inability to find a sense of stability. In this sense, participants reflected on the
many years of struggle they had had to endure to arrive at a point where they liked and were
proud to be who they were.
Movement: from defense to openness

Consistent with the work of Hermann (1992), all of the female adolescents in this study spoke
about the painstaking process of moving from having a stigmatized identity, char-acterized by
feelings of self-loathing, shame and invisibility, at the outset of therapy, to a more positive,
integrated and visible sense of self by the end of the treatment process. Participants started to
feel safe after several sessions of cognitive restructuring, psychoe-ducation and stress
inoculation training. Although there was still a sense of trauma, the researcher observed the
slow transformation of their identity from being a victim, the stigmatized self, to being a
survivor, one who needs help. Congruent with the findings of Courtois (1999) among sexually
abused survivors, within the context of the therapeutic relationship and with the support of
significant others in their life, they began to separate themselves from the abuse and were
slowly able to dismantle the false self that had been formed around the time of the abuse.
Control of emotions and finding stability

Healing among the participants involved the process of regaining control over their bodies and
their feelings, and developing an increasing ability to handle their reactions towards trauma.
Participants gained much from the therapy sessions and, as evidence, they experienced a
decrease in trauma symptoms and also regained composure. Participants remarks show
positive responses based on how they experienced changes. It was an experience they also had
with the therapy sessions, where they felt safe, and where they were able to challenge their
illogical thoughts and manage their emotions well through simulations, role-playing and
imagined relaxation. These findings are congruent with Monahon (1993), who stated that
victims of trauma need a safe release of feelings, the recovery of a sense of mastery and
control in life, and restoration of a sense of trust in themselves and in the future.
The process of self-renewal

Participants described having experienced a sense of incongruence between how they were feeling
on the inside and what others perceived from their outward appearance. This expe-rience co-
occurred with their experience of dissociation. However, it was also observed that the greater sense
of visibility and connection that participants experienced was not evident in their assertions about
their current self-perception. An important dimension of healing trauma is the process of rebuilding
the home, which is the self, or the process of finding the self again. The first step is finding a safe
place, which can be a shelter, or the psychological safe place within the self where the participant
starts to put the pieces of experiences of trauma and information back together. Healing is possible
because, despite the destruction and damage to the physical body, the emotional self remains.
Merging of public and private selves

Participants reflected on the important step of starting to feel a greater sense of visibility,
congruence and connection, being able to place their own individual experience of incest and
or sexual abuse into a larger social context. Participants explained how their ability to put the
abuse into a broader social perspective enabled them to start sharing and connect-ing with
others, allowing for the first time their inner self to be seen and known. Sharing more of
themselves with others, in turn, contributed to what the participants in this study described as a
merging of their public and private selves.
One important dimension of healing is the repair of broken relationships. Even if the
relationship with the presumed perpetrators is difficult to repair immediately, an important step in
healing is connecting with people. In the study of Wright, Crawford, and Sebastian (2007a),
survivors mentioned that their relationships with others had improved because of their abuse
experiences. Some women reported that their interpersonal skills and sensi-tivity had increased.
Other women noted that they had become more accepting and less judgmental of others. Still others
mentioned helping and supporting other people.
Finding meaning from the experience

One crucial dimension of survivors recovery is finding a way to make sense of what
happened to them in the past, and to find some kind of meaning for the abuse in their current
lives. If children do not rationalize the abuse, they resort to denying their feelings and
pretending to be unaffected (Wright, Crawford, & Sebastian, 2007b). A gradually more
sophisticated and accurate understanding of the world is a necessary part of adaptation.
Cognitively, generating meaning involves using various frameworks of understanding
religious and spiritual growth, psychological adjustment, appreciation of lifes purpose or other
to make sense of events and experiences.
Conclusion
Participants experienced the effects of trauma in various dimensions of their personality. It
delimited their expression of feelings, educational activities and other cognitive-related
activities, social functioning, capacity for growth and achievement of a sense of well being.
The experience of trauma in sexual abuse allowed the participants to assume a damaged self-
identity (which in this study was referred to as being the victim). This was the result of the
dynamics of mental inconsistencies, issues of negative valence, learned hopelessness, negative
attribution and social ineptness.
Table 1. Experience of sexual abuse superordinate themes and

their source.
Superordinate themes Subthemes

Affect dysregulation Hypervigilance
Experience of shock and fear

Sense of sadness
Hatred and anger
Feeling of numbness
Cognitive and perceptual distortions Mental block
Escape and denial
Negative worldview
Sense of betrayal and mistrust Negative view of men and intimacy
Disruption of felt security
Fear of disclosure
Self-degradation Self-blame
Sense of shame
Negative self-image
Asia Pacific Journal of Counselling and Psychotherapy 167
R.J.S. San Diego
Table 2. Healing process superordinate themes and source.
Superordinate themes Subthemes Arising from
Initial resistance towards Not motivated, feels irritated when

therapy attending the session,
uncooperative, tardiness
Re-experiencing trauma Physiological manifestations of
effects anxiety, unexplainable recurrence of
symptoms, paranoia
Struggling with emotions Experiences the pain of trauma again,
inability to express true emotions,
painful remembrance of abuse
experience
Openness to healing Experiences the pain of trauma again,
inability to express true emotions,
painful remembrance of abuse
experience
Therapeutic changes
Establishing a sense Moderation of illogical thinking,
of control realization of positive effects,
stabilization of emotions,
identification of safe place
Sense of self-renewal Starting to connect with the self,
moving and connecting with the
emotions, feeling congruent
Meaning making Trying to make sense of the abuse
experience, finding spiritual purpose
and connection
Social reconnection Openness to people, learning to trust
others, sense of commonality,
helping others, taking responsibility
The healing process is not linear. The process itself takes time and depends on the participants readiness and
capacity to integrate traumatic experiences and to process the events. The process requires multilevel work among
participants; it is a spiral moving pro-cess, which takes the participant therapeutically from dealing with the blocked
trauma experience to integrating the trauma experience.
In addition, it is directional and progressive. The stigmatized self moves from being a victim until it reaches a
certain point where an individual realizes that a survivor self is capable of directing the path to healing and self-
improvement, wherein achieving a renewed self from the process, accepting the self, experiencing peace from within,
emergence of public and private selves and maintaining security within can be fulfilled.
Trauma healing is a learning experience. The participants mentioned that they grew stronger, and more prepared
to face the future. They were now putting things into a new perspective after reclaiming the self and empowering it. A
learning experience where participants can see growth from within also improves the way they see the world.
Limitations of the study

Significant themes were extracted from the experiences of sexually abused female ado-lescents. Data used could
possibly be tainted with biases that should be taken into consideration. The rich information revealed in this study was used to
generalize only
Asia Pacific Journal of Counselling and Psychotherapy 169
to the phenomena of sexual abuse and its trauma effects, while no attempt was made to generalize to the
entire population of cases of sexually abused victims. The results pre-sented may appear to be consistent
based on the analysis made with other sexual abuse literature. Given the positive outcome of the study,
more studies should be made to inform counsellors and psychologists about the healing and recovery of
victims. Future research endeavours would include looking at the gender and cultural differences in the
healing themes and stages, and also identifying psychological constructs and socio-cultural factors that
positively influence recovery from the trauma of abuse and exploitation.

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Asia Pacific Journal of Counselling

Healing the invisible wounds of

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Healing the invisible wounds of trauma: a qualitative analysis

Counseling and Educational Psychology Department, De La Salle University, Manila, Philippines

Background and aim

ISSN 2150-7686 print/ISSN 2150-7708 online

152 R.J.S. San Diego

The studies of both Laguisma-Sison (2000) and Gonzales-Fernando (2000) showed

The trauma of sexual assault

Cognitive and perceptual distortions

depression brought about by the illogicality of their thoughts.

Sense of betrayal and mistrust

The experience of healing

Initial resistance towards therapy

Re-experiencing of trauma effects

Struggling with negative emotions

Issues of inconsistent information processing and perception

Issues of diminished trust and fear of disclosure

Resisting and struggling with change

Movement: from defense to openness

Control of emotions and finding stability

The process of self-renewal

Merging of public and private selves

Finding meaning from the experience

Table 1. Experience of sexual abuse superordinate themes and

Superordinate themes Subthemes

Experience of shock and fear

Hatred and anger

Cognitive and perceptual distortions Mental block

Escape and denial

Disruption of felt security

Table 2. Healing process superordinate themes and source.

Superordinate themes Subthemes Arising from

Initial resistance towards Not motivated, feels irritated when

Limitations of the study

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