Jaycee Dugard has suffered sexual abuse, neglect and emotional manipulation to an extent hard to imagine, according to the charges in the case involving her abduction.
But therapists say the biggest challenge facing Dugard, who was found alive last week after 18 years in captivity, may be switching families.
"Her captor was her primary relationship, and the father of her two children, and at some level separation may be difficult for all of them," said Douglas Goldsmith, executive director of the Children's Center in Salt Lake City. Goldsmith added that any therapy "has to be mindful that there are three victims, not one, and that they will be entering a new life together."
About two-thirds of children who are kidnapped or abused suffer lingering mental problems, most often symptoms of post-traumatic stress and depression.
Recent studies have found that about 80 percent of victims show significant improvement in mood after three to four months of trauma-focused weekly therapy. Still, given the information available so far, experts say Dugard and her two children face an unusually complex task.
Her stepfather, Carl Probyn, says she has already expressed guilt that she bonded with the man who kidnapped her when she was 11. She and her children will have to learn to connect with and trust her first family, the one from which she was taken in 1991.
"The way I think about this case is that it is an extreme version of a phenomenon that is really not that uncommon: a child engaged in an abusive relationship when young and, not knowing any better, coming to accept it as their life, adapting as best they can," said Lucy Berliner, director of the trauma program at Harborview Medical Center in Seattle. "Certainly every case is different, but we now have some proven interventions we can use."
Therapists say Dugard's transition to a new life is likely to take some time, probably years. Elisabeth Fritzl, the Austrian woman held in a dungeon by her father for 24 years, has reportedly undergone extensive therapy and still struggles mentally, 16 months after she was freed.
And Shawn Hornbeck, abducted in Missouri at age 11 in 2002 and held captive for four years, told reporters nearly two years after being freed that he was still learning to cope with the emotional effects.
By contrast, Elizabeth Smart, the young woman in Utah who was kidnapped at age 14 in 2002 and held for nine months, is now reportedly doing well, a student at Brigham Young University. When she was reunited with her family, she told CNN last week, "we just spent time as a family, which was like — it was the best thing I could have done."
The main challenge in all such cases, experts say, is breaking the bond with the captor and abuser.
Once victims have shaken the influence of a perpetrator and re-established trust with loved ones, they can better learn through therapy how to ease the impact of their ordeal, said John A. Fairbank, a professor of psychiatry and biobehavioral sciences at Duke and co-director of the UCLA-Duke University National Center for Child Traumatic Stress.
The most rigorously tested therapy is called trauma-focused cognitive behavioral therapy. In weekly sessions over three to four months, people learn how to examine and refute suspect assumptions about their ordeal. One of the most common of these is "I can't trust anyone anymore." Another is "It's my fault I didn't resist more."