Authors’ Note: We would like to acknowledge and thank Dr. Steven Gold for his personal assistance in the writing of this article.

Childhood sexual abuse survivors frequently present with ruptures in attachment, myriad mental health stressors, as well as histories of subsequent victimization in adulthood (e.g., Marx, Heidt, & Gold, 2005). The Contextual Model of trauma posits that survivors of CSA largely have an ineffective family of origin; this maladaptive family environment, in conjunction with the effects of the trauma(s), may result in the formation of insecure attachments and deficient skills acquisition (Gold, 2000). These deficits contribute to gaps in functional capacities across several domains, including emotional, interpersonal, and instrumental competence. Consequently, avoidance of new opportunities may present, restricting the survivor’s functional capacity, and thereby increasing vulnerability to victimization and often revictimization, as well as impaired adjustment in adulthood (Gold, 2000).

Early familial experiences shape the way CSA survivors develop and perceive themselves, the world, and others. According to Loevinger (1976), early learning and experiences contribute to the formation of the ego. Loevinger’s stage theory of ego development includes nine stages encapsulated within three tiers (i.e., Pre-Conventional, Conventional, Post-Conventional).

Within each stage, the individual exhibits additional capacities for mediating interactions with others and enhancing self-awareness. The developmental process occurs with a sequence of stages of increasing complexity, each requiring the completion of a specific task to progress to subsequent stages (Loevinger, 1976). Therefore, akin to self-perception, ego development may constitute the formation of various personality types.

Previous research has examined the relationship between ego development and mental health stressors. For example, lower levels of ego development have been associated with externalizing and internalizing behaviors (Krettenauer, Ullrich, Hofmann, & Edelstein, 2003). Behavioral problems and limited self-control may be associated with the Pre-Conventional stages, specifically, the Impulsive stage (Loevinger, 1976).

For instance, individuals at the Pre-Conventional levels may present with more impulsive, guarded, and opportunistic behaviors. These behaviors may result from experienced mistrust between the survivor and caregiver due to unreliable, inconsistent, or abusive interactions, resulting in feelings of betrayal and insecurity.

Survivors at the Conventional levels, in contrast, have been successful at establishing trust, and as a result develop a capacity to strongly identify with their close family members and peers. In fact, survivors at this level may conform to family and community expectations and reject those who think or act differently. Enriching learning experiences and exposure to various individual and cultural differences may further enhance the progression of ego development, subsequently increasing feelings of autonomy and individuality.

Based on theory, survivors may be less likely to advance to the highest tier (i.e., Post-Conventional stages), which is characterized by an increase in the tolerance of self and other and an ability to cope with inner conflict. At this level, survivors are able to form health relationships, develop an aptitude for corrective learning, and have an increased complexity/intricacy in the formation of their ego.

Ego development represents a normal course of development, with the majority of adults (80%, as found in Pfaffenberger, 2005) falling within the Conventional stages, while 10% of the population never progress beyond the Pre-Conventional stages. This indicates that approximately 90% of adults never reach Post-Conventional levels, leading to the question of what may prevent one’s ego from developing beyond this level?

Dyl (2002) has suggested that problems during childhood may be to blame for the inhibition of ego development. Given the integral role of learning and early experiences in ego development, survivors of CSA may be more likely to experience arrests in the developmental process. For instance, survivors of intrafamilial CSA experience greater betrayal trauma (Freyd, 1994), thereby negatively impacting attachment formation. The experienced mistrust in those exposed to trauma may inhibit progression from the Pre-Conventional to the Conventional tier of development.

The Contextual Model of Trauma Treatment

The Contextual Model of trauma (Gold, 2000) stresses the importance of forming a safe and trustworthy collaborative relationship, encouraging client-guided conceptualization, and teaching therapist-guided skills to be utilized for activities of daily living and affect regulation.

Collaborative relationship

For many CSA survivors, the relationship with their therapist may be their first exposure to a safe, functional, and healthy interpersonal relationship. Moreover, the development of rapport and the use of a collaborative relationship may positively impact attachment by decreasing clients’ perceived need for approval (due to increased empowerment and confidence in their own understanding of their difficulties) and increasing their comfort level with closeness and intimacy.

Therapists can foster a strong working alliance by:

Building trust through consistent empathic validation and active listening. In being authentic with the client, the therapist is not only modeling genuineness, but is also communicating warmth and human connectedness. Creating and maintaining boundaries. A collaborative relationship with adaptive and appropriate boundaries can manifest by limiting between session contacts or through the balance of confrontation with empathy. The former maintains the therapist’s boundaries, while the latter seeks to maintain the client’s psychological boundaries.

Client-guided conceptualization

A client-guided conceptualization empowers clients by reaffirming that they are the experts of their own experiences and encourages them to explore and provide rationale for their beliefs. In this way, clients cultivate their own conceptualization of their presenting difficulties based on continuously revised hypotheses of their past experiences. Providing clients the space to describe themselves and their beliefs in therapy may allow for further ego development by enhancing their ability to develop understanding of themselves and others.

Therapists can foster a client-guided conceptualization by:

Following the survivor’s pace. The purpose of a client-guided conceptualization is to foster a sense of identity and autonomy in the individual. By letting the client guide the session, as well as their conceptualization of themselves, their history, and their trauma, it creates a sense of empowerment. Recognizing the expert in the room. As therapists, we may be experts on techniques, modalities, theories, and concepts. But it is the client who is the real expert in the room. Recognizing and taking a “one down” approach, allows for the client’s understanding of their own ego.

Therapist-guided skills transmission

Lastly, the transmission of therapist-guided practical skills may be exceptionally important. By teaching skills that have never previously been learned, CSA survivors learn adaptive ways of coping with distress and affect regulation. Skills acquisition may increase feelings of competency, distress tolerance, and focus in the survivors, thereby decreasing the presence of trauma-related symptoms (Gold, 2000).

Teaching grounding and distress tolerance skills. Clients who are not grounded in the present are unable to take away the full effects of the therapy. Further, without proper safety and stabilization, subsequent trauma work may leave the client ill prepared to cope with rising intensity of affect. Teaching skills related to grounding and distress tolerance allow for the client to build more adaptive ways of coping with stressors, and to appropriately manage their affect. Challenging “stuck points” (that is, cognitive distortions). A wide range of therapeutic techniques are available to accomplish this task, such as Socratic questioning, but essentially they are designed to capture the same concept: working towards the development of critical judgment, problem-solving, and cognitive flexibility.

Conclusion

In essence, the theory of ego development captures some of the difficulties CSA survivors present with in therapy. Arrested developments in ego development, failure to acquire affect regulation and interpersonal skills, and insecure attachments are not a surprising result of inconsistent, neglectful, and abusive home and family environments. Utilizing a Contextual Model of both conceptualization and treatment may help clients reach their full potential and psychological well-being.