A GROUP THERAPY PROGRMf
FORADULT SURVIVORS OF CHILD SEXUALABUSE: AN OUTCOMESTUDY
AMANDAJ.GAULTOIS
A thes i s sub mi t t e d in partial fulfillment of the requirement for the deqree of
Ma s t e r of Education
Faculty of Education Memorial Universityof Newfoundland
March, 1993
1+1
NaHonalLibraryctcaneca BiblioUl(:q ue nationale duCanada Acquisitionsand DirectiondesacquisitionseI BibliographiCsevcesBranch des services bibliographiques
395Wellinglan Sireel 395.IlI8We\IIngIon
gA~~ ~:m0n18flO)
The author has granted an irrevocable non-excfuslvelicence allowing the Nationallibrary of
Canada
tQreproduce, loan,
distr ibute or sell copies of his/herthesis by any means and In any form or format,making this thesisavailable to Interested persons.The author retainsownership of the copyright in his/herthesis.
Neither the thesisnor substantial extracts frorn
it
may be printed or otherwise reproduced without his/her permiss ion.L'auteur a
ececrce
una licence Irrevocable et non exclusive permettant it 18 Bibliotheque nation ale du Canada de reprodulre, preter,distribuer ou vendredes copies de sa these de quelque manlere et ecue quelque forme que ce soitpour mettre des exempla lresde celte thesea
10 disposition des personnes lnteresseee.L'auteurconserve la proprietedu droit d'auteur qui protege sa these.Nlla thesenides extraIts substantiels de celle-el ne dolvent etre lmprlmas au autrement reproduits sans son autorisalion.
ISBN 0~31 5 ~a2&2{,-6
Omada
Tab le ofCo nt e nts
Lis t ot Ta bles and Fi g u r e s>
Abs t ra c t • • •
Ackno....ed geme nts
ChapterOne Introd uctio n
Sta t e mentof Si gni f ica nce St a t e me n t.of Limitations Expl an at i o n of Terms ovc rvte .... of Chap t e r s
ChapterTwo
iv
vi
Review of Curren t Lit e r atu r e 10
Child hoodSexua l Ab u s e 10
Histo rica l Context • • 11
Ef fec t s of ChildhoodSexual Abuse on Adult Survivors . . . . • . • . . . . 18 Adult Survivorsof child hoodSe xu a l Abuse Gro upTreat ment
suee er-y • • •
CurrentStudy Hy p oth e ses •
27 1J
J5
Ch a p t e r Three Ne ch cdoLo qy
Setting
Desc ri p t i onof Sample Procedure Ana Lvsisof Results Gro u p Structu re Gr oup Process . Gr ou p Program nee e uree e nt Instruments Su mm<lry
ch.rpter fou r Results
Inclexof Se1f Esteem Locus of Con tro l of Behavior Inte rnalizedShame Scal e . .
36 36 39 44
45 46 48 51 53
55 55 es
Indi v i d ua l Sco re s for ISE,LeB,and ISS 58
chapt e r five
Di sc u s sio n ofRe s u l t s Conclusion . . Recommendations
Reference s .
77 84 84
86
App e ndi x
Appe ndixA
The Group TreatmentPr oq r <'l m . . . . • . • . <)4
Appendi xB
Requ e stto Co-LeaderstoEvaluateGroup Eff e ctiv enes s . • • • . . . • • . • . • . .102
Appendix C
Requ e st toGrou p Members to Par t i cipat e in The ra py Evaluat io n • . • • •. . • • • .105 Append Lx 0
Del:loqraphicsur v ey App e nd ix E
In ter nal ized Shame Scal e Ap p e nd i xF'
• . • • • • •108
•. . . • • . 111
Loc usof Control of Behav i o r Sc al e . • • .115
iii
List ofTable san<l Figu r e s
Table 1
Index of Self-esteem(LCB) .. . . • . . . 56
Loc us of Controlof Be h a vior (LCB) . . . • . 58
'ro m e1
InternalizedShame Scale (ISS) . . • 59
Lndividua I Scoresfor ISE, LCB, and ISS . 61
Di r ec t ion of Individua 1 Score Changes
t cr-ISE, LCn, and ISS . . . .. . • . 68 r.uno ')
ISE, Exc ludingSubjects 1and)
LeB, Ex c lud ingSUbjec ts 1and) 'ronto8
70
. "
ISS, Excl ud ing Subjects1and) . , . . . , . 74
Fiqlll:e 1
Indi v i du al SubjectScoresfo r IS E, LCB,
and ISS • • . , • • . , . 6)
Iv
A.1:Istract
Athr e e phaseqr-ou ptreetee n t; proqr.."m(or wOIll""nwno wer e sexual ly abusedas childrenwas ex.:tmi ned for out come effect i vene ss . Standardized eval u a tio n que s t i o nnai r eswe re uti li zedto me a sure ch .... nqe in setr>
es t e e m, locus Ofco nt r o l, andle v el or int e r na l i z e d eheee at the end or phases Iand II. Anin ro r ma I evaluationdiscuss i onwasused todetermine subject satisfaction and conte ntat the end or phase11 1 .
Ras ul t s indicate .... sign ifico1 nt po s i t i v e cba rrqe In self-esteem, loc us of conc r-cL, and levelof lnt e rna lie ed shame aft erphas e I,and a further sig n iri cantpositive ch a nq e in self-e steemfor six of theeigh t su b j e c ts afterphas e II. All SUbjects reported feelingmore cont e n t,mor e in control of lifeexperi ences , and less shame f ul at the endof phase II I .
Ac:knovledq llmc at s
I offer special thanks "to my thesis advisor, Dr. Ro n Lehr- , for his sup po rtand encouragement from the start to the finish of this project. His acv Lce was invaluableto the completionof this project, and I thank hi m for taking theti me from his bUSy schedule to see thisthrough.
A very specialth a nk you is extendedto Denise Lawlor, who designedthe grouptherapy program, and ac t ed as co-the ra pist. Her assistancein the comple tion of thisproject is greatlyappreciated. I also tha n k her associate, Betty M<:: Kinn a , who wa s also a <::0- th e r ap i s t.
I wouldlike to thank Michelle Shapt:erfor her assistance withthe statistical analysis.
To myhu s ba nd ,Ma r i o Escobar, I say thankyoufor your love, support,andencourageme ntoverth e past two years. This project is dedicatedto my daughter, Geneva Rose, whoha sarr i ve d since the onsetof this proj ect.
vi
Ch a p te r One
In t rod uct ion
child sexua I abuse and adult survivorsof abuse aru currently veryimport a n t issues in Newfoun d land. As these topics are talked about more openl y, and as more and more adults finallydiscloseth e i r lif elong
"s e c re ts", theex t e nt of child sexual abuse isbe c o minq mo r ere a l i z e d. Unt i l recently, many of the s e reports may have been passedoff as"s t o r i e s".
\-11th thisnew opennesscomes the gripping r-eaLit y that a large nu mbe rof today's adultpopula tionhave been abused as children. Carver, Sta lke r, Stewa rtand Abraham (1983) reportedthe findingsof surveys wnLc h ind i c at ed thatbetween22 and 33%offema lesand9\ of malesin canadahave been subject.a d to sexual abuse before theage of 18.
Di sc l o s ure,however, is only the firststep towa r d s healing. Th e ne xt step is dealing withthe feelings that, for soma ny , have be e n hinde r ing full
pa rtic i p atio ninsocie ty and have lef t sc ars such as lo w self-esteem, fe elingsof gUil t, non -asse rtivenessand relati o nsh ipdiff i c u lt i e s (Be rg a rt , 19BG). Gordy (198 ) ) repor t ed thatmanyadu lt survivo rsof childhoodincest
shewo r-ked wit h experie ncedcon f lictsove r trust, diffi culti e s withcl o senessandsexualdy s f u nc ti o n s.
Intte wr o undLend , the services for helping adults deal with pro blems of former abusear e fe w, while the needser-egr e a t . Thecu r r e nt grouptherapyprogramwa s design edto help victi ms of abuse work throughsomeof their feelings , and toassist th e m through thehealing pr oc e ss. In " thre ephas eprocess, parti cipantswere qLventhe oppor tu nity to dea l,11th some of the issues nnd emo t i ons the yfound mos t hi nd e r i n gintheir adult IIves . The group therapygave theme mbe r s the oppo rt u n it y todis c l o se their own stories ,and realize they wer e notalcne in their fe e l i ng s . The membersset pers cna I qoa l s for th ems e l ve s at the outsetof therapy ses s ions.
AI th oug h thereis need for grouptherapy for both ma l eand re ma j,e incest survivors,current li t e r a t u r e sug g es ts that a hig h e r percentage of females than males a r e aousecat allag e s (Carveret• aL,, 1988). Due to thesen sit i ve natureof the issue, and sensitive feelingstowards th e sex of the abusers, it is also gene r ally agre e d tha ttherapy groups for survivorsbe compcsed of samesexmembers (Und e r h i ll , 1986 ) . Gordy
(1983) , Ga gli ,l no (1<)87) , and Fari a and Belohlavek (1<)84), among ot h e r s , havewo r k ed withgr ou p s consisting
of femal eson ly . This cu r r e n t study also foc usedon "l the r a p y group involv ingwomen survivorsofchil d hood saxua I abuse.
This stud yaimed to discoverwhe tne r th i s model of group the r apy is effe ctiveor ineffective inproducing positive changein women survivorsof sexualabuse, as measured by indices of self-est eem,shame,and locus of con t r o l. The Ind ex of Self -Esteem(Hud s o n ,19 8 2) , Int e rnaliz edShame Scale(Coo k, 1986), and Locus of Controlof Behavior (Cr a i g , Franklin , and Andrews, 19 8 6 ) we re used to evaluate whether the group thera p ywas effective.
Sta t e men t of Sign if i cance
Presently, there ar-e relatively few thera.py groups aimed specifically at wo me n survivorsof childsexua l abu s e in NeWfoundland, end fewer stil l whi ch have been evaluatedas to their effectiveness. Thisstudy is impor tant because thereis need forboth conceptualized group interventionstrategies for su rvivor s of sexual abus e , and evaluation of those strategies (Be r g art , 1986; Jehu,1987 ) .
This program was set up as a communi tybased service. The importanceof provid ing serviceat the community level was summa rizedby Gordy(1983).who
st.at ed the object ive sofcommuni tybaaed groupswas: "t o reachand helpother women in the community,toeduc...t.e .md se nsitiLze the communitytoth e ceeprexissues surrounding incest, and most impor tan t ly to helpprevent further child abuse in the future , beginningwithin thoir-attn families." (p.J 0 1) . Th e objectiveof this
qrcup was to assist women in the communi ty tound e r sta nd
and tobrp..,l:the cycle of violence byfocusing onth,-~ir own hen lLn q ,
~
The rationalefor this st udywas two-f o ld . Fir st, the group therapy provided an out l e t fora group of wome n to dis c usstheir abuse in a support ive, he l p in g cnv Lr-onmc nt;.'5 a means towardshealing. Second, the st ud y measured the effectiveness of the group. That is, it measured whe t.he r thegroup thera pywas effective in producing changeas measu redby indicesof locusof co n t r ol , self-esteem, andshame.
The ind e pend e nt variable in th i s study was the groupprocedur e. The topics for the group sessionsare.
outl i ned in appendixA.
The dependentvariableswere the fa ctor s being evn Lueted, Thosewer e the fac tors of sh a me , se lf - esteem.an d locus of contr o l , as me asuredbythe various
instruments.
sti'ltement of Limitations
The most obvious limitation in this study is the ability to qene r-eI l z e the findings to a bread population. Thesample size was small, witheight participants, and members were referredby support agencies. I twas believed to be unethical to broadly edve rtLse such a group and then s ...lect eight to ten participants from all of those who demonstrated a need for the service.
Carver et; a l , (1988) indicatedthis type of group therapy is a painful and difficult experience for many participants, and some depression during or between sessions may be expected. Gordy (1983) suggestedeach member have access to her own counselloroutside the group. This would assure her somebody withWhomto discuss individualreactions and reflectionswhich were stimulated by the group process.
However, since such in-depthcounselling wasbe y ond the mean s of the study group, it was believedthe best way to provide support between sessions was to accept referrals from support agencies who were preparedto provide individual counselling, The study group provided the group therapy support basis, while the
agencies pr o vi d ed ind i v idu a lsu pport .
Intern a l vlliidi ty mllYhave be en affec ted by the freedomof thepa r ti cipa ntsto seekin d i v idua l counse lling in addition to the therapygroup. So me of th e study resultsmay be confou nded bythis factor. To counterbalance this , a gro u p eval uat i on discus si o n wa s held duringthe last the r ap y sessio n.
Another limi tat i o n wasthegroup leaders' awa re ne s s of the goals ofth e group. The y knew, forexa mp l e , the qr-oup was designed to help women improv e their self- esteem, helpthemrealize they have cont ro l over events in the i r lives, and reduce their sens eofsha me. Since these we r e the goals of the group, th eco-leaderswere working to improve these areas, wh i ch may hav e influence dthe test results . The indices mea s ure Wh e therthey have been successful.
The studywas furtherlimited bythe una v a ila bilit y of empiricaldata for pha s e III. TheSUb j e c t s fail ed to completethe fina lquestio nnai r es. The ref ore, dat awas an a l yze d for phasesI and II only. Therewas an in f ormaleva l u at i o n disc us sion at the end of pha s e III, andthecommentsmad e bytheSUbj ects were no t ed by the co-l eaders.
Permission to reproduce theInde x of Sel f Es te em (Hudson, 1982) could notbe obtai ned fromthepubLdshe r-.
Therefore, only two of themeasureme ntquestionnaires , the InternalizedShame Scale (Cook, 1986), and the Locus of Controlof Behavior (Cr a i g , Franklin and Andrews, 1984)are reproduced in the Appendix (see Appendixes E and F).
Explanation of Terms
Foll owi ng are some of the terms referred to in thi s thesis.
Fe mi ni s t ph ilosophy.
Th e group studied was run froma feminist perspect i v e . Feminis ttherapistsassume victims of sexual abuseare innocent (Pe t e r s&Pierre-Jacques, 1988) , and holdthe adultperpetrators totally responsib le forsexualcc csinv o l v i ngchil d r e n (Wo rki ng Group on Ch il d SexualAbu s e , 1989 ). They view problems of child sexua labuse as partof societal sexual ste r eo t y pe s , and advocatewomen's rights (Peters&
Pierre-Jacques, 1988).
Ch il d sexu.,l abus e .
For the purposesof this thesis, ch ild sexual abuse is any sexua l act involving children, by an adu lt. The acts may range fr om fo nd l i ng to sexual intercourse,or the useof a child in the production of pornographic materials (Le g e r, cited in New Brunswickconference
re port,1986). Adult survi vo rs.
Su rv i vors are adul tswho are no long er experi e n c ing sexual aeuaa , or whoar e no longer su bjec t e d to abusi ve situations . The term is also used to desc:ibe adults whoha ve begunto cope with early abu se, sothattheydo not fee l theirli vesar e cont rolledby thenega t ive effects of childhood abuse .
Victims.
Victims, for the purposes of thi s th e s i s , ref e r to personswho are experi encing abuse,orwho arecurren tl y being sujectedto acucIvesituatio ns.
lW.linfl.
Healing, as it rela t e sto adult survivors, is the process of coming to gripswithchildhood abu se, acce puinqthe past,and le tt inggo of pas t emotions. It involves improvementof self-esteemand asse rtiv e ness, reduct.Lon of sens eof gui l t ,andincr easi n g pe r ceptio n ofhav i ng control overl if eex p e ri e nc e s .
~.
The inner child refe rs to the emotional pa r t ofthe personthat needs to recove r (MCClure, 19 9 0 ). for persons in rec o v e r y , it often he lpsto vtsuaitae the ir emot i o ns as a child, and the n workto nurtur e thechild during recov e r y.
Qverviewof Chapters
This chapter has hiqhliqhted th e purposes, significance, and rationale forast udyof adul t survivors of childhood sexual abus e. Cha pte rTwo cont ai nsa review of. curren t lite ratu re onthis top i c. Chap t e rThree descri bes thepop u lati on , meth od o loqy,and measur eme n t scales. Re s ult s anddiscussio nar e presented inChapterFo u r,wh il eth er.:o nc l usio n and recommendat i on s arepr e s e nt ed in Cha pt e r Five .
10 Chapter Two
Rev i e w of curren tLiterat ure
~["'y iew
The li t e ra t u r ere l a t ed to this topic includestwo main areas: child hoodsexual abuse and adultsurvi vors r)fab u s e. Firs t, the backgroundCif childsexual abuse ispr-e sentecl , fo l l o wed bya discussionaf the problem , andthesurr o unding is s u e s . Next, the topicof ad ult survivors ofchi l d hood sexual abuse is discussed, beg i nningwiththe eff e c t sof chil d h o od abuse on adults, andfollowedby discussi onof methods used to dealwith those effe cts .
Chil dho odSexua l Abuse
To unde rs ta nd the t rauma experiencedbyadult surv i vo rs of sexual abu s e ,it is firstnecessaryto unde r etand theiss ues sur rounding theabuseWh i c h occ u r r edWh e n those adultswere childre n. This unde r s t and i n ginc l u des the nature of the abuse, the dynamicsinvol ved, and the ef f ec t s the abusehadon the per s on. Adefinitionof childsexu alabUse is presented her e, fo llowedby discussion of the issues.
Thedefinition of child sexual abuse,as prese n ted
11 by Re v . PaulLeger (1986 ). chairmancr a conferenceon thePr eve nti o n of ch ild Abu se, is accepted forth e purpos es of thisthesis . Hede fine sch ild sexual abu s e as "t he exploitat ion of a child for these x u a l gr a tifica tio n ofan adult. It mayranqefromexhib ition and fondlingto inte rc our s e or useof ach ild in the product i on of po r no g r aph ic materials" {p,6). As suc h, ch ild sexua l ab useis dis tinct from otherformsof abu s e,nam ely, nonacc i denta l ph y sical injury ,phys i c,11 neglectandemotionalabus e . Je hu andca a en (1983)uaeu the term "s ex ua lvi cti mi z at ion" torefer to expl oLtIve se xualexperiencesbetween juven il es and olderporso ns. Th e s e expe ri en c e sare expl o itive "beca useofthe juv enile'sage, lac k of sexual sophistic ation or rel ati c ns hlp to the ol der person"(p. 2). Inc est, acco rdi ng to Gagliano (1987), is sexualabuse"whenth e se x ualacts occur between pe oplesoclosely relatedthat th e yare for bidden bylaw tomarry and ... ince st ge n e ral l y OCCc1rsbe t ween a chi l d andanadultwho isin a pos iti o n of trust andau t hori t y "(p, 105).
Histori caIcontex t.
Kissner (1 989) pointed out thehelping profes s i on s ha v eon l y been awar-e ofchildsexua labus e as a probl em for abo u t fift e en years. Prior to this, although child se x u al abuse exi s ted , the magnit udeof the problem wa s
12 den i ed forma ny years (Deightons McPee k, 1985). Rush (1980) asse r cec sexual abuseofchi l d r en hasalways existed, but was notalwaysviewed asa probl emby members of s oc iety, AccordingtoWat c he l (1989), child sexual abusecame to be viewed asa pr oblemby society when laws against it we r edeve l oped in theseventies . Since th e n, although therehas been adramatic in c r ea s e in the reporting of sexualabuse,Ba dgl ey (1984) co ncl u d e d thereha s l",t been a sha r p increase in the e ceuei inc idenceof sexual offences in recentyea r s . Mctlilronand Morgan (1982) gave credit to th e cons cio usness -raisinggroups ofth e sixti esfor allowing women to share previously unspo ke n re a lit i e s. During that t ime, wamen beganto realizeth e y we renot alone with theirpr o bl e ms and began toput the situation into perspective . The Indianand Inu i t Nurses of Canada, in a con s u l t a tionon Child SexualAbu s e (1987), wrote:
"Only re c ent ly have the victims- -ma nyof the m now .:\dults- -begunto speakof thei r expe rie n ce, and to search for solutions that address th e comp lex and Lnterr-ete ted nap'll c:.of victims, abu sers , an dth e i r fa mili e s "(p. q.
F~""IIY,after many year s of de nial , chil d sex u al abus eha s been acknowledgedby memb ersof societyas not only e x LatLr-q,tOot as being a probl e m. Th i s is the
13 firs t step in dealing with the pr o blem, as it ope nsthe way for discussion of the issu e s, anddeve lop me ntof plan s ot action . It is not enough to mer e l y ac kn o wl edg e theproblem. ~sKr e i d l er and Eng la n d (1990) so i' pt ly sta t e:
There aregroupsof wome nWhoarema k ingcourageous effor ts to turnthe ir livesaro un dandface th e cons eq u enc e s of in c e s t on th eiradu l t de vel o p me n t . They desperat elywant to be healed and arewi ll i ng to risk themse l ves in an at t e mp t to bewhole.
They ..• face aresurgenceof pa i nan d grie f th,l t hasof t e nbe e n buried or denied fo r yea rs. They want to be better mothers; the y wan t to be ableto lo v e ; they wantto be able to fee li they wan t to be free of destructivelif e s t y le s. {p , 41)
Ext e n t of the pr o b l e m.
Es t i ma t e s on the extent of chil dhoodsexualabuse in Canada are varied. The Commit te e on Sexu alOf f enses Against Ch il d ren and Youths, heade d byBad gl e y (198 '1) . repor tedone in five females and one in te n malesas th e mos t wid e l y cite d ratesof ch ild hoodsexu a l abus e. Th at is , 20% of fema le s and 10% of males hav ebe e norwil l be se xuall y as s a u lte d inCanada befo re the ybe c o me adul ts. In certainr..opulations, the inci de nc ema y be eve n
14 higher. Carver et a1. {l988),citi ng several researchers and health pra ctitione rs, r-epcr ted that44\
of il groupof female drug abusers and 43%ofa payc n Lctr-ic inpatientgroup had bee n victimsof chiIdhood abuse.
Badgley(1984)attributedthe problemof gaining accurat.eesti mates of abuse to the underreportingof incidents. He wr-cte , "knownch i l d sexua labuse is a tract Ion of its true occurrence" (p.113). He atrr tbu reersome of thisunderreporting to healthcar e andsocia l workerswho believe the evidence is inad e qua te toreport, the incide n tshave stopp ed,or the unity of thefamily is mor e important.
The re is als oa lar g e proportionof sexual abuse whichne v er comestothe attentionof workers in the fi e l d becaus et.hevict. imsremain e a iene• Runtz and Co rne 's (1 9 B5)analysi s ofearlier data found only 6% of women Wh o ind i cated they were sexuallyabused as chi ldren had reportedtheas sa u l t to the police, and 83%
remaine d silen t whe n the perpetra torwas known to them.
Thus, the extent of the prob le mwas not only denied In the past, but alsore ma ine d hiddenbecause of th e scarc ity of reports to police and ot he r authority figures. Many of thecurr e nt estimates arebased on reports of adults who are willing to disclose th e y have
15 been abused inthe past. The abovestatisticssuggest tha t as the to p i c gains widespr eadrecognition, morean d moresurvi vor s ar e wi ll i n g todisclos e theirown experiences. However, once thoseexper ie nc e s are disclosed,the survivors need assi sta nceto deal with there etir.t eeof the experiences. Kre idlerand England (1990) recognized the ne edfo r serviceswhentheystate d
"the lastde c a de has seen an explosion inne e d for program s , but onl y afrac t i o n of victi msar e recei ving services" {p . )6j.
Dy n amic s of sexua l abuse.
Altho ugh there ar e malevi c tims of sexualabu se , the ma j ority of vi ct i ms arefemale, and the majority of offe nd e rsare male fami l y members(Hal liday, 19 8 6 ). As well, mostat: the vic t ims are le s s than eightyears ol d at the ti me of the initia tion (Summi t , 1983). Run tzand Corne (198 5 ) report e d up to90% of ch i ldsexu alabuse perpet rators to be mal e, while 90\of th e vict ims a r-e female. Also, abo ut 80 %of the perpet r at ors ar e fathers and step-fathersin positi onsof auth or ity ove rchild r en (Halli day , 198 6). Hallidayfoundon l y8.5%of the pe r pe t r a tors to be strange rsto the vic t im.
Furthermore, ch il d sexua l abuse occur s in allrac e s, inco megroups, eth n icgroups and re ligions (Pete rs £, Pierre -Jacques, 198a ).
16 These st a t is" Lcs suggest more sexua l abuse of chi Ldr-en occurs in the homeby per s on skno....n to th e victim than by strangers. Theper petra to rsare cve rwha Iminq Iy inpos it i ons of powe r andautho rityove r the victims, and no singlegroup isfree from this type of viole nc e.
Runtz and Corne (1985) suggestedsinc emos t incest victimsareyoung girls, and mostof f enders are fathe r figures or other family member s, co erc i on isus e d more often eno n physicalforce to getthevict ims to comply.
Ha Lliday (1986) e xp l a lned how expl oitat ionof the chi ld'slove, tru s t and innocencear eof t en eno ug hto ge t them to keep the secre t.
There are various reasonswhy childre nre main silentabout theabuse. These inc lude their fe e lingsof guilt and shame (Rush, 1983, inBa ss&Thornt o n, 1983) , low self-worth , helplessness, fea r of re j ection and disbelief by others, and fear of repri s al by th e offender(Badgley, 1984). These feel ings , mi x e dwith feelingsof lov e for the perpe tra t i ng fa mi l yme mber , cause much confusion for the ch ild. The resulting confusion oft e n keeps the child co mpla ce n t and una bl e to report.
Initialeffectsof child sexu a l ab u se.
The initial eff ec tsof sexual abus e includ ethe
17 fee l i ngs thech ildhad at the time of th e abu se, andthe reac t i on s whi c h occur withi n two ye a r softhe terminatio n of theabuse . Accord i ng to Rus h (198J), childre ngain se l f-esteem and conf ide nc e frombeing valued by adultswhom they tru st . When they are sexuallyexplo i ted,the reactions th eynee d fromtr u st ed adultsto promotea positive identi tydo not occur. I f they areunsupported in their rightsto expres s themselves, including expressionof ang erand ind i g na t i o n , they experience feel ingsof ins ignificance and shame. rather tha n feelingsof hi gh self-este em and confidence.
Browneand FLnkeLh o r (1986) list ed other initial etfects of child sexual abuse. Thesein c l ude fear, expeeas tcne of anger and hostili ty, guilt,shame, depression, sle epand eating distu r bance s , and adolescent preg nan cy.
Often, the effec tsof th echild hoodabuse do no t become apparen t untilthechild bec omes an ado l e s c e n t . Powersand Jaklitsch(1989) re por ted anumbe r of psycho logicaland behavioural effectscommonto adolescentswho were maltrea ted. Th ese includeguil t , depression, low self-es teem, los s of er u ee ,anxi ety , de ni al of the abuse,pro bl e mswith establishi ng intimacy, feelingsof fu t ur e l e ssness , famil y di s t o rt i o n ,
18 se xualactingout, aggress ion , probl emsof control, see ingthemselves asvi c t i ms , and suic ide.
Not every child who hasbeenabused displa ys all of thesenegativeeffects, but many ex peri ence seve ra lof them. I':ostash (1987) interviewedte enage girlsacross Canada, and found manywho haveex pe ri e nc e d a combi na tion of the above effec ts.
~ctsof ':hilcthood Sexual Abuse on Adult Sur v ivo rs [-1any victims of childhoodsexua labuse experience negative effects well into adulthood. Gil (1988) explainedho w, as children, victims ofsexu a l abuse developedcoping mechanisms tohe l p the mdea l withthe situatio n. These methodsof coping allowedthe childto surv ivethe sexual abuse by enabling the m to det ach themselves from the painof th e expe r iences . As adults, however, the abilityto detach emo tio nal l y or psychologica lly interferes with buil di ngadult rela tions hips, an d theadu l t sur vi v o rex p e r-Ience s difficultiesas a result. Tomlin (19 91) notedthe l1i g l',e s t leve lof discomfort for wome nsurvivors can be round in the are as c r new dating and new parenting.
Clinical workershave ofte nfou nd ad ultsur v i vo r s of chil-moo dabusetoseekpr o f e s si on a l hel p for problemsotherthan the abu se. The s e present ing
19 probl e msinclude sexualdys fun ct ions , depress io n , mari t aldifficulties,sub sta nce (alc o ho l or oth e r drug) abuse, diffic ulti esestablis hi ng relation ships ,and nervous prob l ems (Bergart, 1986; Eva n s, 1987 ;Hal lid ay, 19 8 6; Parker &Parker, 1991). Unti l rec e ntl y , ma ny clinicians did not make the connect i o n s between child hoodsexua l ab us e and thepresentingpro bl e ms as adults. As a consequence, theprese n t i n g prob l e ms were of te n tr e a t ed in is o l a ti o n, wit h littlesucce s s.
Gelinas(1983) pointedto thisunawar eness, as she became aware of the problems unde rlying her clients' presenting problems.
Be s i de s the above presentingproblem s for which past victims seekthe r a py , clin ic i ans have also identifiedan array of long termeffects attributed to chil d hoodsexual abuse. These may be clas s i f ied as ernotiona 1, physic a L, behavioural and inter p ersona1. The fo l l owi ng sections gi ve a bri e f ove r vie wof these effe cts . Methodsfordeal ingwi t h th e s eef fect s ar e discuss ed followi ng the secti o ns out li n ing th e various effects.
Emotional effec ts.
Cole and Ba r n e y (1987) lis t adu l t depres si on asone ofthe most common emo t i o nal eff ectsof childhood sexu al abuse. Depression and gu iltwerethetwomai n
'0
thera pe ut i ctar-qets in thei r workwith adultsurvivors of sexualab use . Al e xan d e r,Neimeyer andFo l l e t t e (199 1)wereableto re d u ce dep r ess i on and distres swit h womensurvivo r s in grou pwork. Browneand Finkelhor (1986 ) tar g e te d lowsel f-este e m, fear,and anxietyas the r apeu ticgoa lsfor adult survivorsthey worked with.
Is s ue s with touch, bodyeheme , an d fear of intimacyan d abando nment;werenote dby Evans (1987 )as effects of bound a ry vio la tions infa milies. The Vict oria Women's Se xual As s a ul t Centre co mmit tee (1987 )added powe rLee anes s , rcneitne e s , sad ne s s , shame, anger, and loss of trust as otheremotiona l effect s ofchildho o d sexua l abuse. Nightmare s , memo r y blocks, and the crea ti o nof mul t ip le pers onali t i e s werenotedby Gil (1983) and McClur e (1990 ) as resultsof childhoo dsexual ac u se •
As Steige r and zenxc (1990 ) pointedout, incest doesnot how esp ecifi c , pr e di c t ab l e consequences ,but it oc c u r s fre qu e nt l yin the bac kgro undsof psychiatrica lly distu rbed wome n . Sau nd e r s , Vi l l e n p on t e a u x , Lipovsk yand Kil p at ri ck (19 92) also st Ud ied the backgroundsof women whowere exp e r i enci ngme n t a l dis o r de r s. The y found molesta t io nvictims to be ov e r r e p r e s e nt e din adults ex p eri en ci ngcomp uLsiva di sor d e r and social phobia.
21 Physical effects.
Jehu andGazan (1 9 8 J )hav e done research onthe physi caleff ects of childhoodsexual abuseonadult surv ivors. Their findings indicatedwomenwho were sexuallyabused as children experience problems in sexualadjustment, impa i r e d sexual motivatio n,sexual phobias,and sexual di s s a t i s f a c t i onas adults . The Vic t or i a Wo men'sSexual Assault CentreCommittee (19 86) also reportedpain during int ercour s e andrecurring med LceL pr o blemsasphysical effectsof childhoodac c ce• SaundersetaL (1992) found an overrepresentation of adult sexual abuse surv i vo r s among women who axp e rience se xual disorders. Most of the physicale rtect;sof sexualabusetend tobe manifested in sexualproblems , and mus t be dealtwithas part of the treatme ntfor ch ild ho odabu s e , rather than in isolation.
Behav ioural eff e c t s.
Dani ca (198 8) relatedher personal accountsof pr oblemsin parenting,substance abuse, and suicide attemptsas being assoc iatedwithearly sexual abuse.
Beitchman, Hood, oecese e , and Akman (19 9 1) noted se xual promiscuity, suicidal thoughts, and an incre asedrisk for revict i mizationare more commonamong victimsof se xu a l abus e . Powe r s and Jaklitsch (1989) highlighte d aggressi onand pr ost i t ution as behavioural effects of
22 abuse which need tobede a l t wit h, whi l e Gi l (1988) poi nted to the connections of chil d hoodabuse wi th eatingdi s ord e r s , self-mutilation , andpros t i t ut ion.
The behavioural effectsof childhoodsexualabuseare
V<1rI e d , a n d d i f f e rw i t h Ln-t Lv I du e L s,
Treatmentfor behavioura l ef f e ctsof childhood c buee,such as eatingdisorde rs, self- mutilatio n, and prostitutio ncannot be effectiveunlessrel ated tothe underlying problem - -thatof thechildhoodse xua l abuse.
Interpersonal effects.
Jehu, Gazan,and Klassen (1984) haveid e nt i f i e d severaleffects of childhoodabuse whic hcan be classified as interpersonal problems. These Inctuc;e problemswith intimacy, avoida nceof close relationships , and the tendency to becomeinv o l v e d in transientr-eLa't LonahLpe and inre l atio n sh i p s inwh i c h the partner is abusive. Alexa nderet a1. (1991) also noted theef f e c t on re lationshi ps . The y at tri bu t ed childsexualabuseas interfering wi t h the est a blishme nt of supportive re la tio ns hi ps. The ef fe cton
interpersonalrelationsh ipswas also noted by Carson , Gertz, Donaldsonand Wonderlich (1990 ). The yfound the curren t famiiyrelationships of femal e survivors to be dise ngag ing, controlling, con fl ictua l , and lacki ng in organization and emotionalex pres si veness .
Many of the in t erperso naleff ectsof child h ood abuse are among th os e which, inthepas t ,we r e often not seenas being connected to ch Ljdhoc dabu s e. Effecti v e treatment, howe ver , must depend upon theac c u r a t e dete ctionand treatmen t of sexu alabu se.
As evidencedby the above discussion, theeff e c t s of childhood sexual abuseare many and varied, and they differ with individuals. The severityof th e ef fectsof childhood abuse differswith differe n t pe rs o n a li t i e s, but therealso seem tobe other fa cto r s which playa ro l e in the severity of the effects. According to Beitchman et a1. (1991), the mos t ha r mf ul teetor's of childhood sexual abuse in terms of long -las tingeffects on the childare: 1) the fr eque ncyand duratio nof the abuse; 2) abuse invo lvingpenet ra'ti.on, force , or violence; and, J) a close l:e1at ionshipto the perpetrato r. Edwa r d s andAlexander (1992)also noted the existence of parentalconflictand patG rna1 domina nce compound the effectsof chilJhood sex ua l acc sa .
Adul t Survivors of Childhood Sexu a l Abuse Methods to deal with the errecnsof ch ildhood sexualabuse differ with in dividualpractit io ne rs,and vary according toth e severityof thepresen ting
effects. Healing may be accomplished in different ways, altho ugh someele mentsappear to be common. The foll o wi n g fac torsare essential to any treatment program of child sexual abuse: 1) th e survivorsmust be believed;2}the survivorsne e d to be assured theywere not at fault;an d , 3) the survivors need tokn o w they are not alone (The WorkingGroup onchi ldSexual Abuse, 198 9).
Ways of deeLl nq with the abuse may include reading and writing (Ba ss&0Thornton, 1983 ; Danica, 1988;
xcse r cn&0Mo r gan, 19 82 ) . individual therapy (Co l e &0 Ba r ne y, 19 6 7 ), grou p therapy led by a professional
(Alex a nd er et aL,., 19 91; Peters&0Pierre-Jacques, 198 8 ), concu r r en t indi vid ual and grouptherapy(Alexander et al. , 19 91; Carv e r et aI. , 1988 ; Tayl o r, 1989), and self- helpor con s ciousness ra i si n g groups (Kissner, 1989;
Underhi l l , 1986). Eachof thesemethods present advantages and limitlltions, and ar e discussed in followi ng secti ons.
The extent of ch i ld ho o d sexual abuse and the negativeeff e c t s both inchildhoodand adulthood have promptedcommunitygroups to request treatment for clients (Rogers , 1988; Watchtel, 1989; The working Gro up onCh i l dge xue I Abuse, 19 8 9 ) . Nortar (cited in New Brunswick Con feren ce report, 1986) alsostresses the
25 need for a community response to fill the needs of prevention,identification, assessment, and treatment services fo rchil dsexual abuse Victims. The s e four elements are esse ntialto eliminating the problemof childhoodse xu a l abuse.
The above authors stressthe nec essityof services beingavailable at the ccmraunLtylevel,with access for all whowish to ava i l of them. Isolated clin icsand programs will not fu lf il thisneed; nor canthey address the need forpubl Lcawareness and prevention. Kreidler and Engla nd (19 90), pointing to the need for services , noted onlya fractionof victims receive treatment.
Cli e n t s of therapistsrepresenta fr ac t i o n of adult sur v i vo r s who need the service. Byoffering service at the communi tylevel, throughcommu n i t y organizations, a wide r range of adult surv ivorswi l lbe able to availof the service.
Ind ivid ual'ISGroupTh e.r..2RY
The questionof whetherto useindividualor group therapy isapoint of disagreementamong therapists.
Some womenhave had pastne g a t i ve expe rie nces in Lnd Lv i.duaI therapy due to non-recog nitio nof the effects of childhoodsexual abuse (Pe t e r s &Pierre-Jacques, 1988). In those cases ,the women weretreated [orthe
as presentingproblems rathertha n th e und erl yingabu se , and treatment was neither ef f e c tive nor be neficial.
Howev er , individual therapy ca nbe afirst step inthe treatment process, and is preferablein somecases.
Severetr a uma andself-destructive beh av iou r requi re intensiveindividualtherapy, and cannot beadequa t e ly deal twith in a groupse t t i ng (Ber gart, 1986; Cole &
Barney, 198 7).
Grouptherapy has sever aladvantage s over individualtherapy forthe treatme n t of ad ultsurvi vors of sexual abuse. G:'ouptherapy servesto reduc e the members' feelingsofiso l ati o n , createsa strongsens e of mut ualityandac c e pt a nc e, emph a s i ze s empowerment; of members, and in cre a s e s feelings of adequacy and self- esteem (Knig ht, 19 9 0). Kreidlerand England (1990) summarized the advantagesof group therapywhe n they wrote:
Groupcounselingis well suitedto meet many of th e needs of inc es t survivors. Victims can usethe group experi enceas a me a n s ofex a min i n g fe el i ngs, l ecr-n i.nq to trust, and estab lish i ng hea lthy relationships. A group canprovidevictims with the opportunity to deal with thedestructive behaviorsthatoftenplague them. (pp . J6~37)
27 Because ofthe uniqu e advantag esofbo th indi v i d ual and group therapy, severalclin icians suggest a co mbina t ionofthe two. Indiv.;.dualtherapy canbe used as the fiststep towardshealing, fol lowed bygroup therapy (Berg a rt , 1986) , or ca n be concur rentwith group therapy (Alexander et al. , 1991;Ca r v e r et al., 1988;
Taylor , 19 8 9). Cole and Barney (198 7) requiredgroup parti c ipants tobe in concurrent ind i v i d ua l therapy so tha t the y cou lddealwith is s ue s wh i c h emerg edduring th e grou p ses s i ons , but wh i ch were not ede qu atieIy addr essed duringthat time. Co ncurre n t ind i vidual and gro u p therapyal soallowed therapiststo deal with emo t i o ns which emergedbetwee ngroup sessions. This is re i t erat e d byAlexan d e r et a1.,who found short term the ra py witho u t concur ren t ind ividual th era p y to be Ins u r r Ic ren e,
Group Trea t me n t
A decision to pro videgrouptreatment, with or without individu a l therapy, pres entsis s ue s concerning whichtherap e ut i c iss ue sto target, Which type ofgroup to run, and whichphil osop hicalapproach to take. This sec t io n reviews someof thecurr ent thought.
Therapeut i c issues.
Given the largenumber of lo ng term effects,and
28
the fact that not everysurvivor experiences the same effects, a de c i si on ~asto be made astowhich issues sho u l d be focussed on inthe group. One wa y tona r r ow th e focus is to havegroupmembersset goalsat the beginningof t reet ce nt;,byask.ing what they expect to gain from the groupexperi ence. The therapistsmay then ,"odify the group tre a t me nt process, to ensuretha t the dif f e r e n t ne e d s are me t . Coal setting has beenusedby seve r al cl inicia ns , includLnq Alexa nderet a1. (1991 ), Apo li nsky and Wilson(1991), an d Kre i dl er et er. (19 9 0 ).
Alt houghsurvivorsexper i e nce va riedeffe c t s fro m the pastabuse , someeffec tsappear to be morecommon. Ang er, los s of trust . lowself -esteem, di f f i CUl ty exp e ri e nc i ng fe eli ngs. difficultieswithinte r pe rsonal rela. tions h i ps, guil t,and shame appear tobe ve r y common araonq survivcrs. Hence, therapists oftendesigna the r apy programar ou nda li s t of commonissues,While be i ng preparedto dea l wit hothe r issues as they are pr e s ent e d by participants . Apoli nskyand Wllcoson (199 1 ), forexample,targetedang er, trust, self-esteem, int erpe r s o na l rereeten s nt pe , quil t, and empowermen t as therap euticissues . Kreidl e r and Engl an d (1990) dealt wit h issue s of healing, des t r uc t i ve tho ughts , feelings and beha v i ou r s , andcontr o l ofac t ionsand rea ctions . It wouldbe unnecessar y to deal wit hallofthe po ss i b l e
29 neg a t ive effec tsof past abus e, as indiv i du al s do not exper ienc e every ne g a tive effe ct.
Self-helpysther apygro up s.
Th e r e aretwo basictypes ot grou ps: th ose Whic h are ledby oneor t....oprofes sionals, referred tohere as therapygroups,and th ose wit ho u t II group lea d er (Tamara ck wHount ain , 1984). These latter group smaybe termed se lf- help, mutual aid,or cons ciousne ss-r ais i ng gro ups . The members mee t and disc us s the irprobl ems in self-h elpgroups , but ther e is no designat e dle a de r .
Howeve r , as Co leand Bar n e y (19 87 ) ex p l ai ne d , group wor kwithsexual abusesurvivorsca nbe tra umatic for thepa r ticipa nts, as membe rs talkot theirown expe rie ncesand the impact ontheir lives. Themembe rs may exper i en c e over-vheImLnqanxi etyasthe ylist e nto othe r s and bring forwardtheir ownpa Ln fuI memo ri e s. especi allythose ...nc hadnot previously discl o s e d the abuse (Alexander et eL,, 1991 ).
AsCo leand Bar ney po inte d out , the val ueof using thera pist le dgrou ps isthat therap ists canuse in terve nt ions to assistgro up membersto cope withnew anxi e t i es, while resolving pasttrauma andworkingon long lasting ef fec ts. Other cli nicia ns who hav eused spe c i f i c in terven tions in therapygroupsinclude Alexa nder et a1. (199 1). ApolinskYandwtrc c s cn (199 1),
effect..::: of the abus e (Gagliano , 1987). Feminist th era p i st. s are basicallyclient ceneec e a . They also advocate women 's ri g h t s , and see the pro b l e ms of child sexual abuseina larger context, aspart of societal stereotypes (Peters&Pier re ~ Jacques ,1988).
The family centeredapproach assumesch il d re nha ve the right to notbe assaulted, and focusesattent i o n on the family as a system (Badgley , 19 8 4 ) . Familyoriented th e r a p i st s see sexual abuseas an over a l l fami ly problem. According to Peters andPierr e-Jacques (198 8 ) , fa mil y therapists"t r e a t the family as a whole system, and the victimas part of the problem. Of tenfamily therapists want to treat the whole familytog e the r, as well as offering individual the ra py " (p. 17). Family the r a p i s t s insist that contactwit hthe famil yis essential tore s o l ve issues with fa mily member s
(Deighton &McPeek, 1985).
Some feministandclientce n tere d the ra p istsreact negatively towards the familysyste ms approac h to therapybecauseof the inclusionof both the perpe t r a t o r and the victim or survivo r in the same grou p. Th ey see thi s as harmfulto the survivo rs in dealing with the i r problems, and feelth e familyap p roa c hig noresthe dy na mic s involved in male powe roverwomen anrlchi ldre n (Rush, 198 0 ) . Badgley (1984) co n c lu de dtha t the child
' 0
Carv e r et; a1. (19881 . Knig h t (1990 ). and Kr e i d l e r et e k, (19 9 0 ).
Kiss ne r (1988) sugge s t ed mutu a l aid groups ca n be
,10 adjunct to individual and group therap ypr ogra ms . He
vect.e, "wheresufficient finan ci a l and pop ulation reaourccs ex i st , the recanbe littledou b t thi sty p eof in t.eg ra te d appro a ch of fersthe bestform of intervent i on for child r e nandadul t sur viv o r s ofse xua l abuse" (p•
"u). Otherssuggestedmut ua l aid as a foll ow-upto therapy group s , or as on-goinggroup support (Berqart, 19 8 6: Gor dy , 19B3).
Client centeredand feministoppro a c h ys fa mil Y syst ems appr o a c h tothe rapy.
Among th era p i sts whout ilize ther apygroups , there isso me disagreement about orie nt a tLon. Cl i e ntce n t e red therapy assumes the client is innoce ntin th e sexu a l abuse relationship, holds theadu l t offende r totall y re s po nsi b l e for any abusewhich oc c ur s, and focuses serviceson thevict im (Bad gle y , 198 4) . Accor ding to Badgley. thi s app roa chusuallycoord inatestreatment betwee nesse nt i a l medica l and child prote cti on services, so the chil dre c e i ve s maximum be ne f i t s without havingto repeat thest o r y toseve r a l differentagencies. Clie nt centered group therapy foc u s e s on groupsof survivors to he l p them alleviate thegu ilt, shame, and other negative
32 centeredapproach "pr ov i de s moresho r t - ter mbenef i tsfor sexually abused childre n " (p . 63 5) over the fa mi l y center edapproach. Thesebe ne!its incl ude:
More promptly urrd e r t.a ke n init ia l as s essme nts.
Morevictims rec e ivin g medi c al ex ami nat ions.
Broader andmoreexte nsive consu Lua t.Lonwith otherdiscipli nesin rela t i o n to assessingthe child's need s ••..
A slight l yhigh erproportionof vict ims being counselled ,and ove ra l l , themore freque n t provisionofa broader range of counse l l i ng .1nd treatment services for vict i msandmenb er-r- of their families. (p.636)
Gagliano (19 87) used a combinat io nof the two approac hes in work ingsuccessf u llywith abused adojascent s . Her clientsreceivedthe benefits of group workwithothersur-vLvor-s in a suppor tive the r apy gr ou p . Incas e s where the fatherswanted to Chang e , they at t e nd e d individual andgro upthe r apy for pe:·pe trator s . Familyth er a p ywas th~fin al phaseof tr e at me nt.
Deightonand Mc Pee k (1985) also us ed therapygroups with adult surv ivors, and durin gthe lastphases of treatme nt, incorpor a ted gro upsess i on s for membe rsand their malepa r t ne r s asa way ofdealingwi t h some of the
J3 interpersona l issues .
fromthe above literatur e , itappea r sclient centered treatment isthe mostappropriate firststepi11 tre a tin g the childvic t im. Fami ly centered ther a py wit h the family of originmaybe bene ficial tothe ch ild ,as a last step, i fthe perpetrator acce pts re spons i b i l ity for th e abuseand wantsto change. For tho ad ult survivo r,however, feminis t counse lli ng appears to be mor-eap p r opr i a t e . Family co unsell i ng , when us e d wi t h adults, often involvesthe adultpa rtn e r and chil d ren ratherthan family of origin (Deighton &-McPee k , 1985), andseems to be rtore effective afte r clien t cente red or feministindividualand groupcoun se l ling.
~
Thereis evtdenccof a wides p rea d problemof childhood sexual abus e , the effec tsof wh ic h causeno t onlychild hoodtrauma, but alsolong la s t ing negative effects well into adulthood. Ack now ledq me n t; of childhoo dsexualabuse as a proble mopensthe way to the provision of treatmentand preve ntio nprograms. This newopennessalso en c o urag e s thos e who have been abus ed as children to di s clos ethe ir lo ng heldsec r ets, andto see kassista nce .
The ttiO..:"tm en t programs forsur v ivo rs of sexual
34 abuse include individua l couns e lling .grou pcounselling, .lnd longtenll self -helpgroup s. Croupcouns e lling appearsto be especiallyeffective, because of the abilitytoreduc e fe elings of iso lation, wh ileprovi d in g peerac ce ptance andsuppo r t . Ital so appe ars a gr ea t numbe r of today's ad u ltpopula ti oncouldbene fit from surv i vo r's therap y groups.
cu rr e n t St udy
Inlight of theabove litera ture , thecur r ent stud y in vo l v e da therapy group for adu l t survivorsof child sexu al abu s e. The gr ou p was eva l u at e d for ou tcome eff ec t iveness in the areasof self -esteem, lo c us of control of behav i orI andred uc t i onof shame.
Thecur r en tstud y groupinco r p orated the following factors :
1. The stud ygr o u p wa s ma d eavailable to cl i en ts ofseveral communityagencie s.
2. Individualtherapyconcur ren t wit hgrou p thera py wa s us e dtodeal wi themotionswhichemerge d duringor be t we e nse s s ions that coul dnot beadequatel y addressedby thegroup .
J. Thegro upwa s led by the rap i st sbecauseof the adva ntaqa s of us ingtherapeu ti c inte r v e nti o ns.
4. Thegr o up wascond uct e d by two female
J5 therapist s.
S. Theco-leader s werepr e pa r e dtodeal wit ha numb e rof therapeuticissuesco mmo n to ad u l t survi vors, wh ile ind i v id u a l group members set theirown goals.
6. Theco -leader s use d afeminis t co u n s e l li ng approa ch.
~
The qu est i o ns studied co nc e r ne d theeffectsof invo l vement in a group for sexual abuse survivors on the pa r t ici pa nt s ' self-esteem, sense of shame, and per ce ption of contro l ove r eve nts inth e ir lives. An attem pt was mad e tomeasure whe therinv olvement in group ther apy hadaposi t ive effect on these traits.
The hyp o thesesstu d ie d were as follows : 1. Invol v e ment in this thera py group will improve the
part i c ipants' sense of self-esteem. 2. Involv eme nt inth i s gro u p will lessen the
pa rt i c ip antst sense of shame ove r past abuse.
J. Involvement in thisgr ou p will increase the participants' abilityto perceive eventsas being und e r their personalcontroL
4. Involvement in thisgro u p for a longerperiod(36 weeks ) wil l produce gr e a t e r change than short term invol vement (12 we e ks ).
J6 Chap te rThre Q
Meth odology
The present re searc h utili zedagr oup unde r goi ng therapy for past sexual abuse. Thegrou ptherapy sessions were run in three phases, with athre e to four week break between each phase. Thetir-eet.me n t;pro g r am
101 ....: designed byone of the co-therapists , based on currentlit e r a t u r e as well as inp utfromSUbj e c ts invo l ve d ina trial group, tobe discusse dbelow.
setting
All three phases of therapy took place in a room suitable to accommodate a large group,whichwas ce ntrallylocatedwithin the cityof St. John's, Newfoun d la nd, Canada. The group th erapywa s made available to clients of community centres, fncLu d Lnq The Womt:ln'sCentre and Patrick House- -ashelter for homeless women, as wellaspr i va te counsell ors.
Descriptio nof Sample
The group was comprised of eig htSUbjectswho had bee nsexuallyacusecas ch i ld re noradoles c e nt s. The ages rangedfrom 20 to 48 wi t h a mea nageof 27, and
J7 included six employedsUbjee t.sandeve students. All eucj eet.s had worked at least ayea r at some ti me . There were foursingle, two divorced and twocommon-law relationship subjects , Oneof the divorcedsubjectswas also livingil"la ccneon-uav relationship. Th r e e subjeceewere living with par ent s, two livedalone ,two lived with a boyfriend, and one livedwithboth parents and a spouse. All except oneof the sUbjectsgrew up in St. John'5 . There were four universitygraduates, two technichal college graduates, and twouni v er s i t y students. It is interesting to note tha t all eubjects had post-secondaryeducation . AllsUbjects had previous therapy, and wereeither- in concurrent individual therapy, or had a counsellor available. It is likely thattheir therapists encouraged the sucjec t. s to seek group therapy.
Subject l was 26 years old, single, auni v e r s i t y graduate, worki ng, and liv i ngwith her parents. SUbject 2 was 27 years old, sing le,a col legegraduate, working, and livingalone . She grew upina mediumsized town.
Subject Jwas 48 years old, divorced, living in a common-lawrelationship,a unive rsi tygraduate, an d working. She had one child. Subjec t 4 wa s JJ years old, divorced,a univers i tygradu a te , worki ng, and li v in g alone. Subject5 was 38 yearsold , living in a
38 common-law relationship, a university graduate, and working. Subject 6 was 19 years old, single,a univers ityst ude nt, and livingwithher parents. SUbj ec t 7WdS 21 ye a r s old, single, a collegegraduate, wo rk Lnq, and liv in g withher parents. SUbject a was 22 yearsold, married , a university student,and li vin g withsp ouseand parents .
~
The group se s sions were co-ledby twofemale the r a p is t s. Boththera p istswere engaged in pri v a t e pra cticeinthecomm un i t y , and had mastersdegreesin Soci al Work . One of the therapists had additional trai ni ng inhypnoth e r a p y.
Fema l e therap i sts were us e dbe c a us eof the se n s i t ive nature of theissues being discussed , and becaus eof sensit iv e feelings towards the gender of the abusers . Although usinga maletnerap istmayha v e been beneficial as a ro l e model, it was felt thiswa s outweighed bythe benefits of using female therapists in the proces s of recallingtraumatic mamories .
The advantagesof using two therapists included sharingof responsibi lityandadded gain forthe members from the combinedinput of two ther apis ts. La wl or (199 2 )no t e dthe importance of co- l eadershipfor groups
39 fo r adult sur vivors inallowi ngth e r ap i s t s to dea l wit h the i rownanx i e ties so they donatinter fe re wit hthe runningofth e group .
The study grou pwas ru n in thr e e peri od s of 12 wee ks each , fo ra to ta l of 36we e ks. A trial group was run previous tothe st.udygr o up, buthadadro pout rate of 80\. The trial groupstart ed withten me mbers,an d had dropp ed to fourby th e end oftwe l v e wee ks. 'rnree ofth e SUbjects who dropped outhadnothad extens ive individual therapy, and foundit very difficult to de a l withtheirmemoriesin agroupsituat i o n . On",SUbject had notpr e v ious l y disclosed,·butwas encouraged to go by her sister, who was also.:l gro upmember. Bot h sistersdroppedout. One SUb jec t had not reso l ved an alcoholaddiction,and dro ppedou t tode al wit h that issue first. Two othersUbjec ts dro ppe doutwitho u t giving re a s o n.
The highdropou t rate of thetrialgroup was not su r pr isi ng, as otherre s e a r c hersals o expe rie nc ed h Lqh drop o ut ra t e s in similargroup s. xtasne r (1988) at t ri buted the dropou t rat e tothe high anx ie ty brought on byaffe ct - l a den memo rie s. Da t a fr omthe trialgroup was us edto furth e rdev e lo p the currentth r ee phase
40 treatment plan, byhavingsUbj ectsgive input as to what theirneeds were , and ho wth o s e needs could best be met.
There were no dropouts inthe study group until phase III, when three SUbjectsmoved out of town for work or famil yrelated re a s on s . All three subjects ind ic a t ed theywo uld have con t i nue d in therapy ha d they been able to remainin theci t y. Onedifference between the trial groupand the studygr oup is that for the tri a l group, individ ual commu n ity therapistssuggested group wo r ktotheir cli e nt s. Afterthe trialgrou p sta rt e d, wordspr-ead in the communityaboutgroup therapy.Clie nts con t a c t e d the groupleadersthemselves and went ona wa i tinq li s t for thene xt group. When the wait11st gr e w to eight women. the cu r r en t study group was started _ The fact thatSUbjects in the studygroup requested groupworkthemselves is one factorwhLc his different fromthe trIe I qr oup, This inte res t seems to have madea difference betweendroppingout and remaining in therapy for the complet io nof the three phases.
Other differences between the trial and study gr oupswere: a) all subjects hadbeenin individual therapypr e v io us to joiningthestu dygroup; and, b) SUbjectsin the study group wererequiredto have no p rcb I ems withsubstance abuse. Sub jects were
41 interviewed by the co-the rapis ts pre v i ousto th estart ot thestudygroupto assesswhet hertheywere re a d y for group....orkby meeting the above conditions. The necessityof screening clientsfor suitability for gro up wo r kwa s pointed ou t by Cole and Barney (1987 ),and Apolinsky and Wilcoson (1991) . They suggeste dwomen Who we recur rentsu bstance abu s e r s . who were go i ng through a curre ntcrisi s, or who coul d not speak about the ab usiveexperienc e s receive indi v id ua l th erapy be f o r e mov i ngto gro up therapy.
The co-therapists inv ited the gro u p membe r s to parti ci pateinthe evaluationstud yby compl e ting questionnaires (see Appe nd i xC). One ofth e questi o nna i r e swasa demoqraphlcsurvey(see Appe ndix 0). Th e oth e r s we r e the Index of Self-esteem (Hud s on . 19 8 2 ) . the InternalizedShameScale (Cook , 1986 ), and the Locus of Contro l of Behavior (Craig et a1. ,1984) (see Ap p e ndixe s E and F). Th e se ins t r umen tswere chos e n to measu rechange as a resu lt ofgroup workwithsexual abus e surv i vor s .
Sinc e many of the long-termeff e ctsofchild ho od abuse have a ne g a ti v e impact on thesur v iv o r 's se1f- esteem, a me a sure of setr-esueemduring and af te r therapywasdeemedap pro p r i ate . Sha me, and a feelingof no t hav i ngcontro love r events in life were majo r
42 therapeuti ctargetsfor the study group. A measure of these tra itswa s included inthe assessment.
De pressi o n , tho u g h not me a s u r e din itselfI is reflected inone' s sense of se l f - es t e e m and sense of gui lt . Beca us ei twas imposs i bletomeasureal l thet raits whi c h wer e ta rget ed dur ingtherapy, these threema jor onesvare chose n to measure, whi l e an evaluatio nof the othertraitswas inf or ma llycarried out through di s c u s s i o n during the last therapy session.
The co -the ra pis t s expla i ne d to groupme mbe r s that part i c ipat i o nin theeva l uationstudywa s optional. Th e y were no t requi r ed tocompletethequ e s t i onna i r e s , andtheycould s till re ma i nin the group should they decide no t topart i c ipate. Allmember sag ree d to parti cipate in theeval ua t i o nst ud y.
ThestUdy groupmetone eveninga weekfo r two hour s ,and contin ue d forthree 12week periods , for a totalof 36 sess ions. The literaturesuggests that lon g er groups aremor e be nef i cia l to survivors of sexual abu s e. Gordy(19C 3) , for example, found eig htsessions to be teoshort a ti me to deal withall of the issues, wher easae eqart; (1986) found it necessary toleng t he n groupti me tosixmo n t hs. De i ghton and McPeek (198 5) found gro u p s toaverageaboutthirtysessions, wh i l e Kreid le r and England (19 90) rana three pha s egr ou p
wh ich ext e nd ed over56 sessions. Th es e clinicians found the intensivegroupworknee d ed fo r surv i vors of sexu al abusereq u i r ed between26to 56 week s . Th e traditio nal group of ei ght to 12 weeks inleng t his not suffici e nt to deal withall the is s ue s invol vedwi thsexual abuse survivors.
The first sessionof phase I and the last sessio n of each of the three phasesof the study group were reserved for pre-and post-testing. Testingat the end of each phase allow ed theeva l uator to dete rmine whether a lo n ger period ofth e r a py was more ef f ec t i ve in producing ch anq e in thesubjects. Bymeasuring cha nqe over time, ind i v i dua l subjects'pr ogress coul dbe monitored. This gave a moreaccur atepicture than just measu ring before and after th e rap y . Th e impor tan ce of measuring over ti me was pointed outby Anton (1978), who ca u t i oned cause and effect Would be difficult to determine withju s t one te st before and after the group therapy. 't'he re z or-e,gradual chang e as the . apy pro g res se d could be more rea d ilyatt r i bu t e d tothe group the r a py, and is amor e reli ablein dicator than justone post-tes t.
Each SUb jectwas inst ructed tomake up a numbe r to useon all questionnaires . This en sur ed confid ent i a lity of partic i pants, whil e allowi ngpr e - andpost-test
44 comparisons to be made.
Unfortunately, datacouldnot be collec t edat the endof the last sessionbecause the evaluation discussionwent on until quite late intheevening. The SUbjectswe re giventhequestionnairestoco mp let e at home, but they failedto return them. As timewe nt on, it wa s realizedthat comple tingthe m l a te wo uldrender the resu lts in v a li d, as otherfactors wo ul d probably have infl uencedthere s u l t s. An atte mptwas madeto do a follow-up su r ve y ten monthsaf te r thegroupended, but mo st of the SUbjects hadmoved out of the provinceand could not be contact ed. Thus, s uender-d Laedevaluation isavai l ab l e fo r phasesI and II only. De s p i t e this, a tr end can besee nover ti me, andthis is furt her discus s e d in chapter 4.
Analysisof Resu lts
xee surement; data was analyzedusingapai r ed samples,t-test. Tracey(1983) pointed to th e necessity of usingstatistica l te s t stoana l yz edat a , stating that associat iona l designsdonot al lowaconc l u s i o n of cause and er re ct. Th e informal , subjective eva lu a tio nwas utilized togathe r other eva luat ivein fo rma t ion whi c h could not otherwi sebe tested. Barnsl ey , El l isand Jacobson (1<)86 ) pointed out the ne ed to incl ude
45 descriptive and subjective informati on in evaluation, tr a d i t i o n a l evaluation,th eycontend, does not take into accoun t the innovativestructuresof women'sqr cups ,
Other issues besidesguil t, shame , and seir-est.eem dealt withduring the course ofthe r a p y are difficu lt to measure using a sne nuarc Laec questionnaire. For example, much of the first phase ofthe r a p y focused on reduction of isolation and identificatio nwith others in the group. For some subjects, thiswas the first time they had ever experienced a true senseof belonging.
Althoughthene w sense of belon gingwouldha v e an effect on self-esteem, it in itself coul dnot be measured.
Thus, asking the SUbjectshew they felt after the therapy as compared to before they startedth era py ...ould give a truer pictureof the impact of the th e r a pe ut i c intervention.
Group Structure
The group ...as loosely structured so that there...as minimumemphasis on the agenda of the the r a pis t sand maximum focus on the needs of the subjects. Subjects had an opportunityto set personal goals at the beginni ng of gro up work, and flexibil ity wasmain tained wi th i n the group sess ionsto allo... subject s to ta l k abouttheirown issues.
Each of the three therapyph a s e s focused on ma j o r
46 is sueswhLcn seem to beco mmo n among adul tsurvivors.
'ropLcs and Inc e rven t Lone wereint r od uc e d byth e thera pist s ,thoug hsub j ectswer eableto di' I::USS other issues whe nthe need arose. The therapistsused interventionssuc has getting in touch with feelings, iou rn al wr-Ltinq , ta k ing car e of the inner child, r eLexet Lo n , hypn otherapy vi s u a li z a tio ns , cognitive restruc t uri ng, and use of photographstoemphasize the Innocen c e of en I Idhood ,
Us e of in t e rven t i o n s is supportedin the literature on grou p work withsu rvivors. Fariaand Belohlavek (19 84), for exa mpl e, used jo u r na l writing, reading mater Lals, and ccqnitive restructuring, while Bergart (198 6) use drol e pla y , empt y-cha i r techn i q ue s , and gui d ed fantasie s . Theinterventionsare used to assist the SUb jectsto effectivelyget in touch with feelings, cne 11enge pr e viou s beliefs, reorganize thoughts, and takecontrolov e r their lives.
Gro up Pro ces s
The fir s t sessionof phase I was used to setgoals, talk generally about some of the issues of childsexual ab u s e , allow the SUbjectsto getto knoweach other, and beginto e s.t.abLiah trust. Sessions2 to11 in each phasewere"wo r k i ng sessions", th Q ses sions in which the
47
therapeuticwork to o k place. SUbjects talked about their own ex pe r i enc e s andgave eac hothe r support. The process of healing in this framework is describedaptly by Lawlor (19 9 2 ) :
The sharing of one'sstoriesand experiencesof being a victimof sexual abuse is a verydiffic ult process . As each membersha r es herstoryof pain and aor row members begin to acceptthat th e yar e not responsi blefo r the abuseandhad l i t tleor no po·....er-as a chi ldtostopit. Becauseof th e id e n t i f i c a t i o nwi t h one another 'spai n an d sorrow , members begin to let go of guilt and shame. (p . 248)
The therapistsbegan to prepare the SUbjectsfor terminationof each phase by session10. In th e terminationst a g e, the issue of loss was dea l twith, and the enount; of time between each phasewas agre e d upon . In the thirdphase, termination in c l ud e d pl a ns for the fut ure. Some c r the SUbjectsexpressed a desire to form asupport group . Ho we v e r , two of the subj ectswere going through personal difficulties, and fel t the y needed to continuein individualthe r a py inste a d. Th ree subjectsleft the provi nc e befo r ethe end of phaseIII , and were not availab le for a suppor tgroup. The re ma in i ng three sUbjec tsdecided no t to form a formal
48 suppo rtgroup, but do maintain con tact,and occasionally qet;together fo rco f f e e or lunc h.
The three basicstages
or
groupproc ess- - introduction .~Iork.ingstage, andte r mi nation- -we r e identifiedbyother researchersas well (Gazda, 19 8 3 ; Gordy, 1983; and Napier and Ger s he nf eld, 19 8 7 ) . Berg ar t (1986) noted the te r min at i on stage in her groups often led to the deve l o pme nt of self-h elpsupport groups.The Gr o up prog ram
The groupthe r a p y pro gramwasdesignedto deal with a limitednumber of issu e s tha t are commo nto adult sur vi vo r s of sex ua l abuse. Memberswere also give n the oppo rt u ni t y towork on their own is s u e s . Noattemptwas made to deal wi t h all of the possible errect;e of childhood abu seas a group. Rathe r, the SUbjects id en t if i ed t.he Lr needsatthebeginn ingofqroup t her-apy, and fr-c m that, an agend a wases ta blis hed.
Id en tif i e d issues included isol at io n, body image, learningto feel feelings, trust , anger, rage, de p r e s s i o n , shame, and learni ng to ta ke con trol of events in their lives.
Commo n is s ue sde al t wit hin th e th r ee phase s include trust, safety, and lettinggo. The first two sessionsof each phasedeal twith issuesof trus t and
sa f ety. In phase I,trust wa s established, boundaries se t , and issues of con f i den tialitywerediscussed . Trus t and safetyhad tobe re-establish.d inthe init i al se s si on s of ph a s e s IIand III , becau s eotthe separati on from thegroup. Lettinggowa s dealt withduri ng the last two ses s io n s of each phase , to prepa resubjects for the break, and for th e eventualending of gr o up support.
Journa l ....ri ti ngwa s a majorfocus in all th re e phases . Subjec t swer e encouragedto write duringthe week, as thou g htsand feeli ngs sur faced. Home work , or sp e c ific journalwritingwas oftenassigned, whe reby SUb j e c t s were req u fred to writ e on a particula r topic dur ing the we e k. This....as sharedanddiscussedduring the foll ow in g session.
Phase I was meant toassistthe SUbjec t s to bond wi t hthegroup, todeal wit h issues of isol ation , trust, and lIIistrus t. and to get in touch withbas i c feelings.
Duringphase I, SUbjec t s began to write abo u t an d sh a r e their ownexpe r iences and is su e s. They wereas k e d to reca ll incid entsfl'om their child hoo ds,and tovrtee abo u t theexperiencesas if they werethe child. This was difficultfor some subjects, who could not ge t in touchwith the feelings theyha dexpe rie ncedas achild. Thosesub jects wrote in the third perso ninstead , from an adu lt pe r s pect i ve. Thi s was acce p table in phase I.
50 By phase II, allsubjecthad learned to writefrom a child'sperspective.
Phase II consisted mainly ofre c a ll of abuse incidents, and getting in touchwith feelings. SUbjects used journal writingto get in touchwith and validate theirfeeli ngsof shame, guilt, rage , ange r , dep ress i on, suicide, and sexua lity. Eachsess i o n foc u s s e d onone feeli ng. SUbjects shared thei r jour n a lwritingsduring the sessions. Two sessions eachwer eneeded for the issues of anger and shame,asth e re was a lot of di s c us s i o n on these issues. Thisphaseassisted SUbjects to get in touch with feelings ,and to dea l with many of theis s ue s which we re ha mpe ri ngthemasadults.
Inphase III, SUbjects weregiventheopportunity to work on their ownissues. The ycould do more work on whichever feeling still needed to be dealtwithfrom phase II, or work on different feelings. Thi swas done through hypnotherapy. The thera p i st had th e SUbjects go back intime, throughrelaxatio nand sugg estion , but did not specifyWh i c h feelingto focus on. Hypno t h era p y was
c arried outeve r y second week, withdebrie f ing aft e r the
hypnot herapy, and discussion of the exp e r i enceduring the following session. One of the the r a p i sts was certified in hypnotherapy.
Three types of hypnot herap ywe reused: a) a
51 breathingmeditation; b) a basic induction ; and , c) he a ling the inner child script. Abasic brea t hinq meditation ....as done at the beginningof eachsessio n.
The basic induction was used to assist subject.s intoa deep relaxation, using sun ene r gyas guided imag e ry.
This inductionwa s used threetimes, in sessions1, J, and 5. The time to ac h i e v e deep relaxat i o nwa s red u ced from 20minutesin session 1, to10minutes insession 5. Thehealing the inner child scr iptwas us e d every second session,st,),rtili~with session2. The complete therapy scriptsar e detailed by La wl o r (in pres s). An outl1ne of the sessionsis inclUdedin AppendixA. In phase II I , subjects learnedto take careof the inner child, integra te the inner child with the adult, andlet go of the past.
Specifics of phases I and II of the groupprogram have been detailed by Lawlor (1992, in pre s s ). An outline of the three phas esof the groupprogram is inclUded in AppendixA.
Me a s u re men t Instruments
To measure whether th e qro upthe rapywas effec t ive in producing positive changein thesubjec ts, three measur emen t in s t r u me nts were used. The rndex of Self Esteem (HUdson, 1982), theInte rnaliz e dShameScale
