QUALITATIVE A ANALYSIS OF THERAPY EFFECTIVENESS FOR MARRIED FEMALE SURVIVORS OF CHILDHOOD SEXUAL ABUSE: FROM THE COUPLE'S PERSPECTIVE by KARY S. REID, B.A.. M.A. A DISSERTATION IN MARRIAGE AND FAMILY THERAPY Submitted to the Graduate Faculty of Texas Tech University in Partial Fulfillment of the Requirements for the Degree of DOCTOR OF PHILOSOPHY Approved
August, 1993
Copyright 1993, Kary S. Reid
ACKNOWLEDGEMENTS
There are several people who deserve recognition for their effort and support towards completion of this project. Foremost, I would like to express my sincere appreciation to Dr. Richard S. Wampler, my major professor, not only for his input in this project, but for his continual support and belief in me throughout my doctoral training in marriage and family therapy. His insight, humor, and editorial rescue
from "sociologese" have helped make this document what it is today. Appreciation is also extended to all other members Dr. Karen S. Wampler, Dr. Charles
of my advisory committee:
W. Peek, III, Dr. Edward R. Anderson, and Dr. Beth Shapiro. Special recognition goes to Dr. Peek and Dr. Shapiro for agreeing to preview preliminary copies of this document. I am especially indebted to my beloved wife, research assistant, and co-therapist, Dana K. Taylor, for her undying support and enthusiasm at times when my own reserves were becoming depleted.
I would also like to express my sincere appreciation to the therapists, who must remain anonymous to protect their clients' identities, who helped in recruiting couples as participants for this study. Most of all, it has been an
honor and a privilege for me to have been allowed to share in the participating couples' past experiences. offer may deepest appreciation and gratitude.
11
To them I
TABLE OF CONTENTS
ACKNOWLEDGEMENTS ABSTRACT LIST OF TABLES CHAPTER I. INTRODUCTION Statement of the Problem Purpose and Significance of the Study . . . II. REVIEW OF THE LITERATURE Introduction Individual Therapy with Adult Survivors of Childhood Sexual Abuse Group Therapy with Adult Survivors of Childhood Sexual Abuse Marital Therapy with Adult Survivors of Childhood Sexual Abuse The Impact of Marital Therapy in General The Impact of Childhood Sexual Abuse on the Survivor's Marital Relationship The Impact of Marital Therapy With Adult Survivors III. METHODS AND PROCEDURES Rationale for Qualitative Methodology . . . Sample Subject Recruitment Subject Selection Subject Characteristics
ii vii viii
1 4 6 8 8 9 12 14 14
15
17 19 19 22 22 24 26
111
Data Collection Pre-Interview Explanation In-Depth Interviews Post-Interview Debriefing Confidentiality Data Analysis Preliminary Preparation of the Data The Final Analysis IV. RESULTS Introduction Entering Therapy Precipitating Issues Previous Attempts Summary Therapy for Sexual Abuse Issues Selection of a Therapist Building the Therapeutic Relationship Treatment Modalities Therapeutic Interventions Summary An Assessment of the Therapeutic Process Survivors Partners Summary
IV
28 28 29 31 32 33
33 34 43 43 44 44 46 48 48 49
51 58 60 63 63 64 84 87
Marital Issues Impact of Sexual Abuse on the Marital Relationship Impact of Therapy on the Marital Relationship Partner Involvement in the Recovery Process Suggestions for Improvement Summary V. DISCUSSION AND CONCLUSION Discussion Entering Therapy Therapy for Sexual Abuse Issues . . . . An Assessment of the Therapeutic Process Marital Issues Reliability and Validity Method of Data Collection Sample Participants' Responses to the Study Representativeness and Generalizability Limitations Implications Theoretical Implications Clinical Implications Research Implications Conclusion
88 90 97
101 107 113 115 115 115 117
121 124 127 128 132 133 134 135 137 137 139 142 143
REFERENCES APPENDIX A. B. C. D. E. F. RESPONSE FORM INTERVIEW GUIDES DEMOGRAPHIC SURVEYS THERAPY EFFECTIVENESS SURVEYS CONSENT FORM INTERVIEW EVALUATIONS
145
152 154 161 169 176 180
VI
ABSTRACT
Most of the studies which have examined childhood sexual abuse have focused on the impact it can have on an individual's life. Consequently, the traditional modalities
for treating adult survivors involve individual and group therapy strategies and interventions. This study is unique
in that it explores, from the couple's perspective, the effects of therapy on the system, the marital dyad. An in-depth interview was conducted with each partner of seventeen couples in which the wife was an adult survivor of childhood sexual abuse. The participants were asked to
describe past therapy experiences in which the issues of childhood sexual abuse were addressed, and then to share their perception of the effectiveness of the therapists and their therapeutic techniques. Results show that the traditional modalities of individual and group therapy were, for the most part, positive experiences which were helpful in dealing with sex abuse issues. However, the participants of this study
expressed a strong desire for more marital therapy as an integrative component of the therapeutic regimen being utilized with married adult survivors. Several issues of
particular significance to married adult survivors and their partners, and specific suggestions for improvement, as identified by the participants themselves, are discussed.
Vll
LIST OF TABLES
Frequency distribution of emergent themes and subthemes as identified by survivors Frequency distribution of emergent themes and subthemes as identified by partners Frequency distribution of survivors' responses to therapy effectiveness survey Frequency distribution of partners' responses to therapy effectiveness survey
38 41 65 67
Vlll
CHAPTER I INTRODUCTION
Although the issues surrounding sexual victimization have not always captured the attention of the popular press, the criminal justice system, and the mental health professions as they do today, interest in how these issues impact our social environment and relationships has grown over the past ten years. According to one study, as many as
4 million women in the United States report having been sexually abused as children (Kempe & Kempe, 1984). Some
estimates are that the actual rate of victimization is five to ten times greater than those reported to officials (Tsai & Wagner, 1978). One report suggests that as many as 30% of
all women in the United States have been victims of sexual abuse (Russell, 1986). The devastating effects childhood sexual abuse can have on the individual, the family, and society have forced communities to offer, and in some cases require, therapeutic services in order to address the resulting problems. According to one source (Browne & Finkelhor, 1986), approximately 40% of all victim/survivors suffer aftereffects serious enough to require therapy in adulthood. The impact of childhood sexual abuse has been identified in certain emotional and psychological symptoms. Negative self-esteem, self-contempt, shame, negative
self-worth, and distrust of others have all been identified as representing negative emotional aftereffects of sex abuse. Commonly recognized psychological effects of
childhood sexual abuse have included chronic and atypical depression and anxiety disorders, self-destructive behaviors, eating disorders, substance abuse, and sexual dysfunction (Courtois, 1988). Traditional therapeutic strategies for working with adult survivors of childhood sexual abuse have tended to center around individual and group therapy. Most therapists
have found that adult survivors tend to seek help with their problems on their own, regardless of their marital or relational status. Feinauer (1989) contends that individual
therapy may be more conducive to in-depth exploration of personal issues than any other treatment modality. Given
the personal sensitivity surrounding the issues of childhood sexual abuse, a person may choose to deal with these issues one-on-one with his/her therapist instead of with a group or spouse. The confidential nature of individual therapy
allows the client to address many of the shame-based issues which have been identified with the presenting problems of childhood sexual abuse. Once the sexual abuse issues have been appropriately identified, group therapy becomes the treatment of choice of many practitioners (e.g., Bergart, 1986; Blake-White & Kline, 1985; Deighton & McPeek, 1985; Faria & Belohavek,
1984; Forward & Buck, 1978; Goodman & Nowak-Scibelli, 1985; Herman & Schatzow, 1984; Tsai & Wagner, 1978). Many times
the treatment regimens of individual and group therapy are integrated with the client's participation in self-help and Twelve-Step support groups such as VOICES (Victims of Incest Can Emerge Survivors), ISA (Incest Survivors Anonymous), SASA (Sex Abuse Survivors Anonymous), and SAA (Sex Addicts Anonymous). As awareness and acknowledgement of childhood sexual abuse and its effect on adult survivors increase, the therapeutic community continues to seek sufficient means for meeting the resulting challenges. New modes of treatment
such as inpatient hospitalization are becoming increasingly available. The correlation between childhood sexual abuse
and substance abuse or eating disorders demands these issues be addressed simultaneously in a very intensive and structured program. Increased awareness has also brought an overwhelming demand for mental health services to provide assistance for adult survivors. As a result, experimentation with
innovative treatment modalities continues to be addressed by the academic researchers while the local therapists are doing all they can to offer some assistance to survivors. In doing so, these therapists choose modalities they are most familiar with, or can get the most information about: individual and group therapy.
The predominant use of individual and group therapy as treatment modalities for adult survivors of childhood sexual abuse is evident in the literature. However, the impact of
childhood sexual abuse on the marital system is a topic which has been addressed only sparingly in the recent literature (Bass & Davis, 1988; Blume, 1990; Courtois, 1988; Davis, 1991; Graber, 1990; Kaslow, 1987; Maltz, 1988), and has tended to focus almost completely on the sexual relationship (Maltz & Holman, 1987; Westerlund, 1992). The complicated nature of sexual abuse issues becomes compounded when addressed in the context of close, interpersonal marital relationships. The general systems
perspective of interrelational therapy suggests that changes in one part of the relational system will affect all other parts of the same system (Becvar & Becvar, 1988). To date,
no attempt has been made by the research community to examine the effectiveness of past therapeutic experiences in dealing with the issues of married adult survivors and their partners.
Statement of the Problem Most of what is known regarding the psychological and emotional impact of childhood sexual abuse, and the supposed effective treatment of such, has been learned from the documented experiences, rather than empirical studies, of therapists who work extensively with adult survivors. The
value of such information lies in the fact that, were it not for these descriptions, therapists' knowledge of the impact of childhood sexual abuse and the subsequent therapy would be even more limited. However, in the absence of
prescriptive guidelines, therapists have had to develop their own approaches and techniques for working with adult survivors, usually in a trial-and-error fashion (Courtois, 1988). With some exceptions, these approaches and
techniques have not been evaluated to determine their effectiveness in adequately treating sex abuse issues. Although they are theoretically based and appear to provide relief and recovery for the survivors in treatment, a more extensive assessment and development is needed. The therapeutic process for addressing childhood sexual abuse issues can be conceptualized as building a bridge between the past and the present. In order to fully assess
therapy effectiveness, the importance of a thorough exploration of present relational systems of adult survivors becomes obvious. The therapeutic process for childhood
sexual abuse involves treatment focused on the abuse, its aftereffects, and any resulting personality manifestations (Courtois, 1988). A primary focus of therapy is on
understanding the sex abuse experience from the survivor's perspective. When addressing issues of therapy
effectiveness for married adult survivors, the correct
protocol seems to demand inclusion of the partner's perspective and experiences.
Purpose and Significance of the Study The purpose of this study was to explore therapy effectiveness as perceived by married female adult survivors of childhood sexual abuse and their partners. With this
goal in mind, a phenomenological approach and method of qualitative analysis was selected for this study. "Qualitative methods are suited to understanding the meanings, interpretations, and subjective experiences of family members" (Daly, 1992. pp.3-4). The focus of
qualitative methods is not on the structural or demographic trends in families or couples, but rather on the processes by which families create their own realities. The purpose
of qualitative research on families or couples is to understand how they give insight into the meanings of their experiences (Daly, 1988). In order to achieve a systemic assessment of the effectiveness of different treatment modalities as experienced by married adult survivors, it is essential to obtain a clear understanding of the therapeutic process from adult survivors and their partners. To this end, this study
was designed to investigate the fundamental "real life" therapy experiences of these couples, and to determine how
effectively these experiences were integrated into their lives outside the therapist's office. It was anticipated that the results generated by this study would contribute to a better understanding of the therapeutic processes and modalities most beneficial to adult survivors who are in long-term committed relationships. Such an understanding would enhance
conceptual clarity in developing therapeutic strategies, and thus would help to bridge theory, research, and practice in determining effective and appropriate therapeutic strategies for married adult survivors of childhood sexual abuse.
CHAPTER II REVIEW OF THE LITERATURE
Introduction To date, empirical assessments of the effectiveness of diverse therapeutic interventions with adult survivors of childhood sexual abuse have received limited attention. In fact, most of the literature addressing these issues is based solely on the clinical experiences of the author(s) as the therapist. In order to more clearly ascertain the perceived effectiveness of different therapeutic modalities traditionally offered married adult survivors, several questions require further consideration: 1. What are the traditional therapeutic modalities for treating adult survivors of childhood sexual abuse? 2. How effective do survivors and partners perceive these modalities to be in dealing with the personal and relational issues of married adult survivors of childhood sexual abuse? 3. As the "experts," what suggestions would adult survivors and their partners have for others regarding the treatment of childhood sexual abuse? 4. How does childhood sexual abuse affect the marital relationship of the adult survivor? To answer these and other questions, a review of the literature addressing these issues is necessary. 8 This
discussion is based primarily on descriptive studies; as noted, empirically designed studies are rarely found in the current literature. In keeping with the scope of this
study, the current literature addressing the following topics will be reviewed: (a) the traditional modalities of individual and group therapeutic treatment of adult survivors of childhood sexual abuse; (b) the impact of marital therapy in general; (c) the impact of childhood sexual abuse on the marital relationship; and (d) marriage therapy with adult survivors of childhood sexual abuse.
Individual Therapy with Adult Survivors of Childhood Sexual Abuse Individual therapy has historically been the therapeutic strategy of traditional psychotherapy. In fact,
the term "psychotherapy" has come to be identified as referring to the therapeutic treatment of one person and his/her intrapersonal problems or issues. The literature on
the effectiveness of individual therapy in dealing with diverse populations and the spectrum of presenting problems is too vast to completely review here. Instead, specific
works have been selected for review in this study because of their contribution towards the topic of treating sexual abuse survivors. According to Schwartz (1988), individual therapy is beneficial in that it: (a) provides more individual
attention, (b) may provide more confidentiality than
other modes of therapy, (c) may be used to develop trust and basic social skills for extremely withdrawn or alienated clients, and (d) may be provided in a variety of settings. Some of the limitations of individual therapy also identified by Schwartz (1988) include: (a) the therapist
may become more easily manipulated, (b) denial may be more easily maintained, (c) in regards to sexual issues, the therapeutic dyad may perpetuate the "sexual secret," (d) there may be less opportunity to practice and develop social skills, (e) there is less opportunity to learn empathy or help others, and (f) there is less therapeutic confrontation by peers. Because of the intrapersonal and interpersonal trauma that occurs during, and as a result of, childhood sexual abuse, it may be necessary for the victim to begin the therapeutic process in a one-on-one setting with an empathic therapist. Often adults who were sexually abused as
children will seek therapy during a crisis (Feinauer, 1989). According to Feinauer, the crisis situation is frequently the result of some experience that caused a resurgence of the repressed feelings associated with the initial abuse. Clients may present themselves as anxious, terrified, depressed, and suicidal. The emotional pain which surfaces
at these times may require a safe and controlled environment in which to address these issues. Confidentiality and a
sense of security allow individual therapy to be the arena 10
in which many adult survivors choose to address their problems. By providing more individual attention, individual therapy may also be conducive to in-depth exploration of personal issues. Understandably, victims of childhood They may
sexual abuse may have difficulty trusting anyone.
find it easier to trust one person (i.e., the therapist) than to trust an entire group of people. Part of the
hesitancy to trust may have to do with the question of confidentiality. Protecting one's confidentiality is much
easier if the number of people aware of the situation is kept to a minimum. Paradoxically, the necessity to maintain confidentiality may force the individual therapist into a position of perpetuating the "sexual secret." This
perpetuation of the secret by the therapist allows the client to avoid disclosure out of concern for family loyalty, trust, distrust, denial, dissociation and survivor guilt (Hays, 1987). Though individual therapy has much to offer the victim of childhood sexual abuse, continued growth and recovery can be achieved from group therapy as well. For many of the
established programs dealing with adult survivors of childhood sexual abuse, group therapy has been the treatment of choice. A review of how group therapy has been
incorporated into the treatment and therapeutic strategies 11
for adult survivors of childhood sexual abuse will be presented next.
Group Therapy with Adult Survivors of Childhood Sexual Abuse Though much may be accomplished from individual therapy with adult survivors, some of the limitations of this modality have been discussed previously. Group therapy
offers another form of treatment which can be beneficial to adult survivors. A review of the literature on the treatment of adult survivors of childhood sexual abuse reveals group therapy to be the treatment of choice indeed (Bergart, 1986; BlakeWhite & Kline, 1985; Deighton & McPeek, 1985; Faria & Belohavek, 1984; Forward & Buck, 1978; Goodman & NowakScibelli, 1985; Herman & Schatzow, 1984; Tsai & Wagner, 1978). Group therapy may take the form of professionally
led group activities and/or self-help support groups (i.e., groups utilizing a "twelve-step" format). According to Hays (1987), group therapy seems uniquely suited to address some of the issues with which adult survivors struggle. One of the major benefits of group
therapy for sexual victims is that this experience allows the client(s) to develop or reclaim interpersonal skills. Group therapy provides a safe environment which allows for the possibility of decreasing interpersonal distrust and isolation. Also, by sharing personal experiences with other 12
victims, the client may obtain validation of his or her own experience and coping skills, thus diminishing a selfperception of helplessness (Hays, 1987). The development of
new skills and supports in relation to others who have been equally victimized may lend itself toward achieving a healthy recovery. However, there are limitations to group therapy as well. According to Hays (1987):
. . . it has become increasingly clear that the very factors that make group therapy the treatment of choice are often those that make it excruciatingly difficult for incest survivors to enter such a group in the first place, (p. 145) The maintenance of silence is endemic to this population because of the guilt and shame felt by so many victims (Hays, 1987). Many incest survivors feel ashamed to
be "victims of incest," which sometimes becomes their primary way of defining themselves in adulthood (Blume, 1990). This self-labeling as "victim" has been recognized
as a level of continued re-victimization (McCarthy, 1986). By incorporating the "victim" label into the survivor's general psychological world view, the sexual abuse can become the controlling and dominating event in the survivor's life. As a result, the sexual incident can end
up controlling the victim's sexual and/or personal selfesteem. Much is at risk when a survivor enters group
therapy; therefore, he/she may resist the
13
self-disclosure and expression of personal feelings which are necessary components of this modality.
Marital Therapy with Adult Survivors of Childhood Sexual Abuse As stated earlier, the traditional approaches to dealing with the repercussions of childhood sexual abuse in adult clients usually involve individual and/or group therapy. The utilization of marital therapy as a means of
therapeutic procedure has been addressed only sparingly in the current literature. As a result, there has been no
documented attempt to empirically evaluate the effectiveness of marital therapy with adult survivors of childhood sexual abuse.
The Impact of Marital Therapy in General From a systems theory perspective, it is recognized that a therapist may conduct "marriage therapy" with an individual client in that marital issues are the therapeutic focus of the individual therapy session. However, for the
purpose of this review, the term "marriage therapy" refers to the presence of both the husband and the wife in the therapy session. In reference to spousal involvement in general marital therapy, Gurman and Kniskern (1978a) concluded from their review of several studies (Beck & Jones, 1973; Ewing, Long, & Wenzel, 1961; Freeman, Leavens, & McCulloch, 1969; Smith, 14
1967, 1969) that involvement of both spouses in treatment greatly enhances the probability of a positive therapeutic outcome. In fact, there is some evidence that "individual"
marital therapy with only one partner may be detrimental to the stability of the marital relationship. Specifically,
Gurman and Kniskern (1978b) found that when conjoint and conjoint group marital therapies are considered together, the rate of negative therapeutic outcome using these modalities is only 5.6% as compared to the negative therapeutic outcome of marital therapy with only one partner (11.6%). From their analysis of the results reported in the
current literature, Gurman and Kniskern (1978a, 1991) found that 61% of the marital cases showed signs of improvement, including those cases in which marital issues were the therapeutic focus of individual psychotherapy. When
individual psychotherapy cases are excluded from the analysis, marital case improvement increases to 65%.
The Impact of Childhood Sexual Abuse on the Survivor's Marital Relationship Current literature which directly addresses the impact childhood sexual abuse can have on the survivor's marital relationship per se is all but nonexistent. Although some
researchers have addressed the impact of childhood sexual abuse on the psychological functioning of victims, including their ability to function psychosocially (e.g., Gorcey et al., 1986; Greenwald et al., 1990; Jackson et al., 1990), 15
only Russell (1986) has reported findings regarding interpersonal aspects as they relate to the marital relationship. Russell found that a higher percentage of
victims of childhood sexual abuse were separated and/or divorced than were nonvictims. Childhood sexual abuse may have an impact on the victim's capacity for appropriate interpersonal functioning. This lowered capacity becomes pertinent to the establishment of social relationships and a subsequent marriage. Of
particular significance in interpersonal functioning is the difficulty many female adult survivors have in trusting men. Courtois (1979) found that 79% of the women subjects expressed moderate-to-severe problems in relating to men. Similarly, Gorcey, Santiago, and McCall-Perez (1986) found that 66% of their female subjects expressed feelings of anger, fear, and/or mistrust of men. In addition, Jackson
et al. (1990) discovered that persons reporting having been abused as children indicated significantly more problems in social adjustment than those who had not been abused. At this point, the repercussions of these reports of difficulty in maintaining social and interpersonal functioning, and their impact on the marital relationship can only be surmised. However, the potential for some
degree of marital dysfunction as a result of childhood sexual abuse is obvious.
16
The Impact of Marital Therapy With Adult Survivors At this time, the most detailed discussion of couples therapy with incest survivors is presented by Maltz (1988). However, in her article, Maltz focuses only on the sexual repercussions of incest. Maltz's inferences are largely
theoretical and lack any empirical substantiation beyond clinical experience. Similarly, Johnson (1989) and Nadelson
and Polonsky (1991) offer only clinically based theoretical suggestions on integrating marital and individual therapy, on how to assist in uncovering the abuse, and on how to be more sensitive to the possibility of sexual abuse in presenting couples. At the time of this writing there was no documented evidence that marital therapy was being routinely integrated into a regimen of treatment for adult survivors by therapists. Consequently, there is no documented indication
of the therapeutic effectiveness of this modality. Several of the original questions stated in the introduction of this chapter remain unanswered from a review of the literature. The questions addressing therapy
effectiveness and clients' perceptions of their therapy experiences have yet to be explored. The limited reserves
from which to pull documented information regarding the correlation between childhood sexual abuse and adult marital relationships are obviously deficient. Consequently,
17
several new questions emerge from this review of the literature for further consideration: 1. How effective has therapy been in addressing the
special issues of adult survivors and/or their partners? 2. What effect has past therapeutic experience had on
the marital relationship of the adult survivor? 3. Do the adult survivor and her partner share the
same perception regarding the effectiveness of past therapy experiences? 4. What effect has childhood sexual abuse had on the
adult survivor and her marriage?
18
CHAPTER III METHODS AND PROCEDURES
The purpose of this study was to explore and describe married couples' perceptions of the effectiveness of past therapeutic experiences in dealing with the issues surrounding the female partner's childhood sexual abuse. Focus was placed on the different therapy modalities experienced by the female survivor and her partner. In
addition, perceptions of the level of "intrasessional" and "extrasessional" therapeutic involvement in the recovery process by the survivor's partner were obtained. "Intrasessional therapeutic involvement" refers to the partner's participation in and attendance at therapy sessions; "extrasessional therapeutic involvement" refers to the partner's involvement in the sexual abuse issues outside of the therapy session itself. A qualitative methodology in the form of in-depth interviews was utilized for data collection. The interviews
were designed so that information was obtained from both partners of the relationship.
Rationale for Oualitative Methodology The term "qualitative" is derived from a phenomenological theoretical perspective which focuses on being able to understand on a personal level the motives and 19
beliefs behind people's actions (Taylor & Bogdan, 1984). The phrase "qualitative methodology" refers in the broadest sense to "research that produces descriptive data: people's own written or spoken words and observable behavior" (Taylor & Bogdan, 1984, p.5). Qualitative research is concerned with understanding a given phenomenon from the subject's own perspective. It enables "us to enter and explore the inner
world of the individual, and allow[s] us to describe individual experience in depth" (Westerlund, 1992, p.181). Given the high level of sensitivity which is an inherent component of researching childhood sexual abuse, a qualitative methodology was employed for collection of data in this study. Taylor and Bogdan (1984) discuss several
different aspects of qualitative methodology, many of which justify it as the method of choice for this particular project: 1. Qualitative research is inductive. The researcher
develops concepts, insights, and understanding from patterns in the data (i.e., the subjects' own words and behavior), rather than collecting data to assess preconceived models, hypotheses, or theories. 2. In qualitative methodology the researcher looks at settings and people holistically. That is, people and
settings are not reduced to variables, but are viewed as a whole.
20
3. Qualitative researchers maintain sensitivity to their effects on their subjects. In in-depth interviewing,
for example, they model their interviews after a normal conversation, rather than a formal question and answer exchange. 4. Qualitative researchers try to understand people from their own frame of reference. Central to this
methodology is being able to experience reality as others experience it; to be able to empathize and identify with the subjects in order to understand how they see things. 5. For the qualitative researcher, all perspectives are valuable. The purpose is not to obtain "truth" or
"morality," but rather to gain a detailed understanding of the subjects' perspectives. The versatility of qualitative methods allows them to be considered as the methods of choice for examining the diversity of family forms and experiences (Daly, 1992). When studying families, most survey researchers identify the individual as the unit of analysis and focus on that individual's characteristics, attitudes or behaviors. In
contrast, qualitative research is capable of accommodating multiple perspectives and can better deal with familial or marital relationships as units of analysis. The results of
such methods are richer accounts and closer approximations of lived family experiences (Handel, 1989).
21
Given the limited sample sizes inherent in clinical studies, sophisticated quantitative analysis of collected data from clinical populations would often suffer from weak reliability and validity. Qualitative research, on the
other hand, is in some respects more practical when researching clinical populations, especially those projects which specify adult survivors of childhood sexual abuse as the target population. Due to the stigma and shame
associated with sexual abuse, this population is somewhat "invisible," making it difficult to sample systematically or randomly. Therefore, a qualitative methodology is ideally
suited to better capture the rich experiences of a sizelimited, yet important, sample.
Sample Subject Recruitment The participating couples were recruited with the assistance of local therapists who work with adult survivors of childhood sexual abuse. These therapists agreed to
assist in presenting the opportunity to participate in this study to past and present clients who were married. A
letter from the therapist supporting the research project was mailed or delivered by the therapist directly to prospective participating couples, accompanied by a brief introductory letter from the researcher. At this point, the
researcher had no knowledge as to who received the 22
invitation to participate in the study.
The couples were
supplied with a self-addressed, postage-paid envelope and a response form (Appendix A) indicating their willingness to participate in the study. The couples were then asked to
return their responses to their respective therapist's office. A total of 53 explanatory letters and response
forms were either mailed or hand-delivered by seven therapists. Those respondents who consented to being
contacted regarding the study were contacted via telephone by the researcher, at which time a more detailed explanation of the project was provided, and an interview was scheduled if possible. tasks: 1. It allowed the respondents to ask questions about The telephone interview accomplished two
the study, and to make a more informed decision about participation. 2. It allowed the researcher a second opportunity to
determine whether or not the respondents met the selection criteria. As an incentive to participate in the study, participants were offered a free dinner-for-two at their choice of two restaurants located in the city in which the study was conducted. Upon completing the scheduled in-depth
interviews (Appendix B), the couple was presented a voucher for a dinner-for-two at the restaurant of their choice.
23
Subject Selection Given the focus of this study, it was necessary to be purposefully selective in establishing participant criteria. Specific factors were deemed necessary to exist before a couple could be considered as potential project participants. First, the wife must have received within the
past three years, or be receiving at the time of the study, some form of therapeutic assistance which included individual, marital, and/or group therapy for childhood sexual abuse issues. The three-year limit was chosen with
the recognition that much of the data to be collected would be based on a retrospective account of past experiences. Placing a three-year limit on such recall decreased problems with accuracy and thoroughness which might emerge with a longer recall period. Secondly, the survivor had to be married to the same person throughout the targeted interval of therapy. An
essential portion of this study was the additional input of the survivor's partner. It was determined, therefore, that
the inclusion of partners who had become relationally involved with a survivor after her completion of therapy would not provide the perspective necessary for the goals of this study. Finally, only married heterosexual couples were considered. It was not within the scope of this study to
examine the effect of sexual orientation on the relationship 24
issues of sexual abuse survivors.
It is, however, an area
that warrants further investigation.
The Couples The final sample for this study included 17 married couples who met the selection criteria. Of the 53
invitations to participate which were mailed or delivered, a total of 23 responses (43%) were returned. Two of these
respondents indicated no interest at all in participating, one willing respondent canceled the scheduled interview after further deliberation, and one apparently willing couple was never contacted successfully by the researcher despite several attempts to do so. In addition, one couple
had not been married long enough to be able to offer adequate partner input. Upon learning of the intent to
audio-tape the interview, another couple chose not to participate out of concern for confidentiality and anonymity because of the partner's professional status in the community. Finally, the researcher learned from two
recruiting therapists of the desire of three female adult survivors to participate in the study; however, their respective partners were unwilling to participate.
25
Subject Characteristics The Couples All of the couples participating in this study lived within a 120-mile radius of the city in which the data were collected. This city, with a population of almost 200,000
inhabitants, is located in the Southwest portion of the United States, and is recognized for its conservative political and religious attitudes. The participating
couples had been married an average of 11.8 years, ranging from 1 to 43 years. Their average combined annual income
for the year prior to the study was between $30,000 and $40,000. The majority of the couples could be described as
being Anglo, Protestant, and college-educated.
The Survivors The mean age of the survivors was 34 years old (ranging from 24 to 61 years). Fourteen were self-described as being
Anglo, one was Hispanic, one was African-American, and one described herself as being American Indian. Thirteen of the
survivors had some college experience with 7 of them receiving at least a bachelor's degree. survivors were in their first marriage. Thirteen of the They averaged 2.7 The
years in therapy for childhood sexual abuse issues.
sexual abuse itself was likely to have begun around the age of 6 (ranging from 1 to 13 years old), and lasted, on the average, for 8 years, ending at about 14 years of age 26
(ranging from 7 to 22 years of age). The most frequent number of perpetrators identified by the survivors was 3, and in 64.7% (n=ll) of the cases, the abuse was incestuous (i.e., involving members of the immediate family). The most
commonly identified perpetrators were fathers, brothers, and grandfathers. Four of the survivors reported having been
sexually abused by immediate family members as well as persons outside the family. Of the 17 survivors in this
study, somewhat more than half (56.3%, n=9) had not told anyone about the abuse during the time of occurrence.
The Partners The average age of the survivors' partners was 38 years old (ranging from 26 to 65 years). Fourteen were Anglo, one
was Hispanic, one was African-American, and one described himself to be of Amerasian descent. Thirteen of the 17
partners had some college experience: 2 had finished bachelor's degrees; 3 had master's degrees; and 3 others had doctoral degrees. marriage. Ten of the partners were in their first
Eleven of the 17 partners stated they had
participated in some form of therapy; 8 had received individual therapy for their own issues. Only one of the
partners was aware of being a victim of childhood sexual abuse; he was also an adjudicated perpetrator of sexual abuse of children himself. Five other partners reported
being victims of physical abuse from their family-of-origin. 27
Thirteen of the partners did not know that their wives were survivors of childhood sexual abuse until after they were married.
Data Collection In-depth interviewing was the primary method of data collection for this study. The interview process is In addition to the
addressed later in this section.
information collected from the interviews, demographic and descriptive data regarding the couples were collected from survey-type questionnaires and information sheets (Appendices C & D) which each participant completed immediately after his/her interview.
Pre-Interview Explanation Prior to beginning the interview itself, the researcher and his assistant met with each couple to explain in detail the purpose of the study and the interview process. point addressed in the Consent Form (Appendix E) was explained verbally before the participants were asked to sign. Emphasis was placed on the couple's right to rescind Each
their consent to participate at any time up to the moment the final document was presented to the researcher's dissertation committee for approval. In addition, the
issues of confidentiality and anonymity were discussed in detail, and a review of the selection process was offered to 28
explain how the couple had been identified as potential participants. Each participant signed the consent form
prior to the interview which allowed for audio-taping of the interview for future transcription by a hired legal transcriptionist. All participants were asked and consented
to allow the researcher or his assistant to contact them for clarification or additional information.
In-Depth Interviews In-depth qualitative interviewing has been defined as "face-to-face encounters between the researcher and informants directed toward understanding informants' perspectives on their lives, experiences, or situations as expressed in their own words" (Taylor & Bogdan, 1984, p.77). Rather than being a formal question-and-answer exchange, the in-depth interview is modeled after a conversation between equals. One of the most important steps in preparing for indepth interviewing is learning what questions to ask. After
identifying several questions to include in the interviews, the researcher and his assistant conducted pilot interviews with two couples (which were subsequently included in the final sample) known to fit the selection criteria. After
each interview, the content of the questions asked and the format in which the interview was conducted were discussed in detail with the pilot couples. 29 Information gained from
these pilot interviews was taken into consideration during final restructuring and organization of the interview guidelines. The in-depth interviews (Appendix B) of the participating couples took place in the private therapy offices of the researcher away from the university campus. The architectural design of these offices allowed for simultaneous interviewing of the partners while maintaining complete confidentiality. Completion of each in-depth The
interview required an average of about 1.5 hours.
questions presented in the interview guides were used for direction, and were not necessarily asked verbatim. The interviews were designed to obtain information regarding perceptions of the effectiveness of past therapeutic experiences and therapists in dealing with the issues surrounding the female partner's childhood sexual abuse. In addition, each participant was asked to describe
the level of involvement of the survivor's partner in therapy and the healing process outside of therapy. That
is, both the partner and the survivor were asked to describe the partner's involvement. There were two kinds of in-depth
interviews: one for the identified female adult survivor of childhood sexual abuse, and another, parallel form in which the questions were directed to her partner. Based upon input from the pilot interviews, the survivors were interviewed by the researcher's female 30
assistant while the researcher interviewed the partners. Preliminary interviews indicated that an appropriate level of comfort for the participants was not possible when the interviewer was of the other gender. was that, The initial concern
given the sensitive nature of sexual abuse
issues, to do otherwise would increase the possibility of obtaining "stress infected" information. A sexual issue by
nature, childhood sexual abuse becomes a gender issue as well. An interview evaluation (Appendix F), which was
mailed to all participants after completion of all interviews, indicated that the original concern was indeed justified. Eight of the thirteen survivor respondents felt
it was important that their interviewer was female (i.e., they chose "4" or "5" on the response scale). Given the
nature of childhood sexual abuse issues, and out of respect for and sensitivity toward the interviewees, using samegender interviewers would seem justified had only 1 of the respondents indicated the importance in doing so.
Post-Interview Debriefing Immediately following the interviews, demographic questionnaires were completed. Then, the researcher and his During this time,
assistant met with the couple briefly.
any questions the participants may have expressed regarding the research project were answered. It was also at this
time that the couple chose the restaurant for their 31
complimentary dinner.
A voucher for the restaurant of Those couples
choice was then presented to the couple.
expressing interest in the final outcome of the study supplied addresses to which a final copy of the document could be mailed.
Confidentiality The protocol for any study involving human subjects demands that care be taken to insure as complete a state of confidentiality and participant anonymity as allowed by the confines of the project. With this in mind, a plan for
confidentiality of the data and anonymity of the participants in this study was carefully constructed. contacting the potential participants' through their personal therapists (see Sample Recruitment), only those persons willing to participate or explore the possibility of participating were contacted directly by the researcher. In addition, the participating couples were informed that references by name to any person would be omitted by the transcriptionist, and this precaution was followed. Once the researcher completed his review of the tapes, all tapes were erased to eliminate another risk to disclosure of their participation in the project. By
32
Data Analysis Basically, there were two stages involved in the analysis of data from qualitative inquiry: (a) the
preliminary preparation of the data, and (b) the final analysis. Before the actual interpretation of the data
began, the data were checked for accuracy and completeness. Once the interviewer's recording of the responses had been checked for clarity, more detailed coding of the transcribed interviews allowed for a complete final analysis of the data.
Preliminary Preparation of the Data Two protocols of data preparation were utilized prior to any attempt at interpretation of the results of the indepth interviews. First, the interview guides (Appendix B)
were used as a resource to review the audio-taped interviews to ensure that all pertinent information had been obtained and clearly recorded. Although the ability to articulate
their thoughts varied from subject to subject, all of the interviews were deemed sufficiently complete, and none were discarded as being an unworthy resource of information. Once the interviews had been determined to have been satisfactorily completed, the tapes were turned over to the transcriptionist. Secondly, the completed transcripts of the first five couples were checked for accuracy using the tapes for 33
comparison.
Then, a preliminary test was conducted to
identify emerging themes using randomly selected transcripts of four couples. The researcher, the researcher's
assistant, and the researcher's major advisor each read copies of the selected transcripts, making note of any emerging themes they could identify independently. A
subsequent comparison of the emergent themes indicated good agreement between the readers.
The Final Analysis In qualitative studies, the researcher gradually makes sense out of what is being studied by combining insight and intuition through what Lofland (1976) calls "intimate familiarity" with the data. A content analysis of the
transcripts produced from the audio-taped interviews was the method of data analysis used in this study. Drawing heavily from the works of Gilgun, Daly, and Handel (1992), Taylor and Bogdan (1984), and Strauss and Corbin (1990), the following protocol was employed for data analysis: 1. Reading and rereading the data. This was
accomplished by both the primary researcher and his assistant rereading all the transcripts of the participating couples. 2. Recording themes, hunches, interpretations, and ideas as they occur. Any important ideas and/or thoughts 34
that resulted from review of the transcripts were documented for evaluative consideration. 3. Recording themes and patterns which emerged from vocabulary, recurring activities, and expressed feelings. The procedure referred to by Strauss and Corbin (1990) as "open coding" was employed in analyzing these themes and patterns. These authors define open coding as being "the
process of breaking down, examining, comparing, conceptualizing, and categorizing data" (Strauss & Corbin, 1990, p.61). A total of 34 transcripts (survivors=17, partners=17) of participating couples were analyzed. transcripts averaged 33 pages in length. The individual In an effort to
obtain inter-rater reliability, the researcher and his assistant independently reviewed all of the transcripts, recording what appeared to be prominent themes. A comparison was then made between each reviewer's record of themes. The transcripts were then read again to obtain a
collaborative interpretation of the few themes which were originally identified by only one of the reviewers. themes that were identified by both reviewers working independently and that could be supported by the data were then categorized under the main headings discussed in Chapter IV. Emerging themes were divided and categorized as belonging to either survivors or partners. 35 Only the topics The
which were identified or addressed by the majority (9 or more survivors or partners) of the participants were considered to be emerging themes. Given the limited sample
size of this study, it was arbitrarily determined by the researcher that an issue should be recognized, at the least, by a majority of the participants in order to be considered an emerging theme. Therefore, nine participants identifying
the issue as being significant was set as a prerequisite for the issue to be worthy of consideration as a theme. themes can be identified by referring to the first subheadings listed under each of the main areas discussed in Chapter IV. For example, under the main area "Entering These
Therapy," the themes which emerged included "Precipitating Issues" and "Previous Attempts." On occasion, an issue was referred to by fewer than nine survivors or partners, but was considered by the researcher to have contributory value within the scope of this study. In those cases, these subthemes were included
in the discussion, and were clearly documented as not representing the majority of the sample. An issue having
contributory value is defined here as an issue that was not identified directly by a majority of the participants, but, nonetheless, was subjectively determined by the researcher to have therapeutic and theoretical value in discussing therapy effectiveness for adult survivors of childhood sexual abuse. By following the analytical protocol 36
described above, a thorough, qualitative description of therapy effectiveness as perceived by married adult survivors of childhood sexual abuse and their partners was obtained. Table 1 and Table 2 show a frequency
distributions of the emergent themes and subthemes as identified by the survivors and partners respectively.
37
Table 1:
Frequency distribution of emergent themes and subthemes as identified by survivors.
YEARS IN THERAPY FOR ABUSE
EMERGENT THEMES AND SUBTHEMES Precipitating Issues Depression Substance abuse* Suicidal tendencies* Relationship problems Previous Attempts Marital therapy Self-help groups More than one therapist Selection of the Therapist Professional reputation Fee amount
1-2
3-6
TOTAL
5 2 2 5 5 3 8 6 7 9 8 5 7 4 6 4
5 6 4 6 7 6 8 4 4 7 6 4 6 1 3 3
10 8 6 11 12 9 16 10 11 16 14 9 13 5 9 7
Building a Therapeutic Relationship Trust and safety Compassion and acceptance Professional demeanor Gender of therapist Survivor status of therapist* Accessibility of therapist Boundary maintenance* Treatment Modalities for Sex Abuse Individual therapy Group therapy Marital therapy* Therapeutic Interventions for Sex Abuse Journaling Bibliotherapy Inner child work Guided imagery Experiential role-play Hypnosis* Networking
9 6 1
8 8 1
17 14 2
8 7 7 6 5 1 5
7 8 6 4 4 0 7
15 15 13 10 9 1 12
38
Table 1:
Continued YEARS IN THERAPY FOR ABUSE
EMERGENT THEMES AND SUBTHEMES Positive Aspects of Individual Therapy Self-disclosure Freedom from blame Reasons for past behavior Relating past to the present Sense of self Boundary construction Hope for the future Negative Aspects of Individual Therapy Emotional expenditure Focus on self Therapist's sense of timing Intentional exclusion of partner Resistance to change Positive Aspects of Group Therapy Identification with others Supportive network Receiving vicarious therapy Assimilation of positive attributes Negative Aspects of Group Therapy Concerns for confidentiality Lack of identification* Absence of group focus* Negative Aspects of Therapy in General Financial costs Shame and guilt Impact of Sex Abuse on Marriage Sexual intimacy Communication Transference of anger Physical intimacy Inconsistent behavior Partners' reactions 39
1-2
3-6
TOTAL
9 8 6 6 7 5 3
8 7 8 6 4 4 6
17 15 14 12 11 9 9
8 6 6 4 5
7 7 5 6 4
15 13 11 10 9
6 5 6 4
8 7 4 5
14 12 10 9
5 2 1
4 4 5
9 6 6
7 6
7 3
14 9
6 7 5 7 3 5
7 5 4 8 6 5
13 12 9 15 9 10
Table 1: Continued YEARS IN THERAPY FOR ABUSE 1-2 3-6 TOTAL
EMERGENT THEMES AND SUBTHEMES Impact of Therapy on Marital Relationship Enhanced communication Directives of therapist Partner conflict with therapeutic process Unsolicited change Partner's Involvement in Recovery Process Involvement essential Intrusive/ disrespectful* Suggestions for Improvement Psychoeducation Partner/therapist relationship Marital/sex therapy Family therapy/Parenting skills Empathy for partner's needs
6 5
3 5
9 10
9 1 9 6 9 5 4
8 4 8 5 8 7 6
17 5 17 11 17 12 10
*A subtheme or topic raised by less than 9 of the 17 survivors, but considered important in understanding the processes of therapy.
40
Table 2:
Frequency distribution of emergent themes and subthemes as identified by partners. YEARS WIFE IN THERAPY FOR ABUSE
EMERGENT THEMES AND SUBTHEMES Positive Aspects of Survivor's Individual Therapy Self-disclosure Freedom from blame Reasons for past behavior Relating past to the present Sense of self Boundary construction Hope for the future Negative Aspects of Survivor's Individual Therapy Emotional expenditure Focus on self Therapist's sense of timing Intentional exclusion of partner Resistance to change Positive Aspects of Survivor's Group Therapy Identification with others Supportive network Assimilation of positive attributes Negative Aspects of Survivor's Group Therapy Concerns for confidentiality** Lack of identification** Absence of group focus Negative Aspects of Therapy in General Financial costs Shame and guilt** Impact of Sex Abuse on Marriage Sexual intimacy Communication Transference of anger Physical intimacy Inconsistent behavior Partners' reactions 41
1-2
3-6
TOTAL
8 5
7 4
15 9
6 4
6 6
12 10 11
6 5
7 7
13 12
5 1
2 5
7 6
8 5
7 2
15 7
8 7 8 8 5
8 7 7 7 6
16 14 15 15 11
Table 2: Continued
YEARS WIFE IN THERAPY FOR ABUSE 1-2 3-6 TOTAL
EMERGENT THEMES AND SUBTHEMES Impact of Therapy on Marital Relationship Enhanced communication** Directives of therapist Partner conflict with therapeutic process Unsolicited change Partner's Involvement in Recovery Process Involvement essential Intrusive/ disrespectful Suggestions for Improvement Psychoeducation Partner/therapist relationship Marital/sex therapy Family therapy/Parenting skills Empathy for partner's needs
1 5
3 4
4 9
8
12
8
8
16
8 5 8 5 7
8 4 8 5 6
16 9 16 10 13
*A subtheme or topic raised by less than 9 of the 17 * partners, but considered important in understanding the processes of therapy.
42
CHAPTER IV RESULTS
Introduction Over 1,000 pages of transcription resulted from the audio-taped interviews with the participating couples in this study. A thorough content analysis of these
transcripts revealed several major themes regarding therapy effectiveness for married female survivors which will be discussed and illustrated in this chapter. Each of these
themes will be supported by excerpts of quotes from the survivors and/or the partners. However, to include every
quote which relates to a particular theme is neither preferable nor necessary. Therefore, the quotes presented
were chosen to be representative of the statements of those participants who addressed the specific theme being discussed. Data collected during this project revealed a shared therapeutic process among the female adult survivors of this study and their partners. A detailed outline and discussion For the
of this process will be the focus of this chapter.
purpose of conceptual clarity, the results of this study will be presented under the headings of four major areas of the therapeutic process: entering therapy, therapy for sexual abuse issues, assessment of the therapeutic experience, and marital issues. 43 Each of these areas is
potentially a factor in determining how effective the participants perceived the therapeutic process to have been for them. Therefore, in order to clearly understand this
perception, it is necessary to learn, first, what issues precipitated the survivor seeking therapy initially; second, what specific treatment and intervention modalities did the survivor experience; third, what the survivor's and/or her partner's assessment is of these past therapeutic experiences; and finally, what impact all of these issues had on their marital relationship.
Entering Therapy Precipitating Issues The tendency for adult survivors to present themselves for therapeutic assistance with issues that are not overtly related to their past sexual abuse has been well documented (Butler, 1978; Ellenson, 1986; Gelinas, 1983; Summit, 1983). The female adult survivors of this study had a variety of reasons for their decisions to seek therapy. For the
majority of these women (n=16), the initial reasons for seeking therapy were not immediately attributed to the residual effects of childhood sexual abuse. Issues
surrounding acute and chronic depression, alcohol and drug abuse, suicidal thoughts or attempts, and past or current relationship dysfunctions were each reported to be
44
precipitating issues for which these women originally sought therapeutic assistance. SURVIVOR #9: My parents had taken me to a psychiatrist because I just fell apart one summer. . . . I'd been away, I'd gone to school and then I'd come home for the summer. And I fell apart that summer, . . . I think just that it was exhaustion. I don't know what it was. SURVIVOR #13: . . . I was even denying the fact that I had had the affair because I had separated myself from the whole situation. It was just like, . . . that's my body doing that, but, I had nothing to do with it. He [husband] said, "Well you need help." And so that was when we went into therapy. In sixteen of these cases, sexual abuse was not identified as the underlying issue during the initial therapy. For some, once the suspicion of sexual abuse
issues surfaced, the survivor was referred to another therapist, or in several cases, actually discouraged from addressing the abuse issues at the time. Partners and
survivors both reported a reluctance on the part of some therapists to deal with issues of sexual abuse. SURVIVOR #4: When we were in marital therapy and this [the issue of sexual abuse] all surfaced, he [the therapist] said, "Oh no, let's not open that can of worms yet." He said, "Let's work on the marriage and then we'll go to that." Although the original presenting issue was not sexual abuse for most of the survivors, some sought assistance when they began experiencing nightmares, flashbacks and/or other indications of possible sexual abuse. SURVIVOR #5: The memories started coming back stronger and more frequently about the abuse, and my coping mechanisms weren't working anymore. What I used to do before to push the memories down, or just to make the memories stop . . . it just wasn't working. And it's 45
like everything kept coming back stronger, and stronger and more often, the memories, and the crying, and the anger. SURVIVOR #15: I would get a flash here and a flash there. . . . Every once in awhile I could see the curtains or the bedspread . . . or smell a certain smell. For many of them, suspected childhood sexual abuse brought meaning for the first time to past behavioral and relational difficulties. Therapy was their way of gaining answers to
these and other unanswered questions. SURVIVOR #14: I promised myself that I was gonna get an answer to my problem. I was gonna try to find an answer. I was looking at what's making me feel sad, what was the grass roots of my problem. . . . I knew myself that something was wrong. After going through therapy, I realized that it [the childhood sexual abuse] was controlling every aspect of ray life. SURVIVOR #15: I began to see how my [patterns] go back to all my major men in my life. My father and his narcissism . . . my sex abuse came from my father's narcissism. He wanted sex release and he used me. One of my boyfriends that I was just crazy about, was totally narcissistic in that he didn't want to be emotionally involved with anybody in particular so he would keep several women. . . . My first husband wanted to have fun, and he wanted to drink, and he wanted to do drugs, at my cost. . . . It's [therapy] been educational in that I really want to blame somebody else for my unhappiness. . . . It's been educational in the aspect of watching someone be so co-dependent. I've learned that well.
Previous Attempts Early therapeutic experiences of the participating couples in this study included most treatment modalities. The traditional modalities of individual and group therapy tended to be the most prevalent. 46 Of this sample, 14
survivors indicated their participation in group therapy and all 17 had received individual therapy. The interviews with
the couples revealed that almost all of the survivors had been in therapy with more than one therapist and in more than one modality. One survivor reported receiving over 13
years of therapy under the direction of 11 different therapists. Past therapy experiences of the survivors
included individual, group, and marital therapy; some had more of one modality than others, most had not been in marital therapy for survivor issues. Eleven of the partners
had also experienced some form of therapy, eight of them in the form of individual therapy for their own issues; however, therapy was usually more limited compared to that of their wives. An assessment of the different modalities
and therapists' style will be discussed in a later section of this chapter. In addition to therapy per se, nine of the survivors and seven of the partners had also attended self-help support groups of different types. Among these were
Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Adult Children of Alcoholics (ACOA), Co-Dependents Anonymous (CODA), Overeaters Anonymous (OA), and Al-Anon. Two of the
partners had also sought help from a men's issues group. SURVIVOR #1: It's always amazing the trail survivors take to find the right place. It's an incredible story of persistence and knowing that there needs to be something more, and the continued search for where to find that spot. . . . There will be a point when it is time for me to move on . . . when I've outgrown my 47
therapist. . . . I think it's probably gonna be an "in and out" process, so there will be different times in my life where I need to do something about the problem and I'll have to go back [to therapy].
Summary The interviews with the couples revealed a commonly shared view that their therapeutic experiences regarding the survivor's childhood sexual abuse had been a continuing process. For the majority of the couples, this process
began when they sought help for personal or relational issues which were not initially identified as being the residual effects of past sexual abuse. From their
retrospective perception, each new therapist, modality, and/or self-help group was seen as a step toward the inevitable: an acknowledgement of the sexual abuse and the powerful, but diffused, effect it had on their relationships, both past and present. Survivors indicated a growing awareness that therapy may be a lifelong process that progressed from one stage to the next. Each new stage was determined by the time and Reported patterns
place in which therapy was to reconvene.
of the therapeutic process illustrated a progression through the stages of recovery.
Therapy for Sexual Abuse Issues Once the sexual abuse issues surfaced, the survivors and partners were compelled to address them directly. 48 The
therapeutic process continued with the selection of a therapist, building a therapeutic relationship, negotiating treatment modalities, and involvement in different tasks and interventions. Each of these stages in the process were
recognized by each member of the couple as having significant meaning and impact on their personal and relational experiences.
Selection of a Therapist One of the most commonly reported factors in selecting a therapist was the therapist's professional reputation. In
some cases, having already been involved to some degree with the therapeutic community, the survivors and/or their partners knew of the therapist's reputation directly. Others sought the advice of a trusted friend or agency. SURVIVOR #13: I was dealing with a lot of things internally that I wasn't talking to anyone about. I was seeking a person to handle it for me. . . . And I had gone to my employer's wife. She had been in counseling for other issues and I just told her what was going on in my life and that I needed help. I didn't know where to turn. And she called several people and found a therapist for me to go to and offered to go with me. SURVIVOR #2: She [therapist] had a recognized reputation throughout the community as the one to go to if you have an issue of sexual abuse in your childhood. I think also the fact that she had her Ph.D. [influenced my choice]. There seemed to be an overwhelming desire for specialized help and guidance once addressing sexual abuse issues had become unavoidable. 49
Another significant factor in determining where the couples turned for help was the cost of such help. Private
practitioners' fees ranged from $60.00 to $120.00 per hour, a financial burden many couples could not bear. If an
agency or clinic is funded from sources other than client fees alone, they can charge less for their services, their fees usually being based on a "sliding scale" format. However, their staff may or may not have the same professional reputation as other therapists in private practice. Not only did concern for the financial cost of
therapy determine the therapist of choice for some, it continued to be an issue of concern throughout the therapeutic process. At times, couples were financially
restricted from continuing therapy at the level they and their therapist preferred. SURVIVOR #8: We [survivor and therapist] were doing individual [therapy] once a week, and then I started group once a week. For a while, I'd bumped up to twice a week in individual when things were especially difficult, but decided I couldn't afford it so we went back to once a week. On several occasions, financial difficulty precipitated a change in the survivor's choice of therapist to one who charged less for services rendered. SURVIVOR #2: The reason I stopped seeing [Therapist #1] was the insurance sometimes wouldn't pay half, they'd only pay one-fourth, and I felt bad about that. So, [Therapist #1] recommended I call [therapy agency], and that's when I started going to [Therapist #2]. I probably always felt [Therapist #2] just didn't measure up to [Therapist #l's] skills, but I kept going to [Therapist #2] because I couldn't afford [Therapist #1]. 50
In addition, partners reported feeling somewhat frustrated at having to put their own issues "on hold" due to inadequate financial means. INTERVIEWER: So what prompted you to seek therapy? PARTNER #8: I really screwed testing done. If I have some work on them." was there with insightful, it but both of us went because I wanted to know if I was up. . . . i wanted some psychological And I told [therapist], "i want to know problems. And if I do, then I want to . . . And so until our money ran out, I [therapist] once a week. And that was was good. I would like to have gone on, in therapy was killing us [financially].
Building the Therapeutic Relationship The characteristics of the therapist, the therapist's level of accessibility and availability, and boundary maintenance via observing confidentiality and showing respect were all reported to be essential components to building a strong therapeutic relationship.
Therapist Characteristics Therapist characteristics that were identified by survivors as being significant included: (a) the ability to establish an atmosphere of trust and safety, (b) the conveyance of compassion and acceptance toward the client, and (c) displaying a professional demeanor. For some of the
survivors, the therapist's gender and personal survivorship status were also identified as important factors in building the therapeutic relationship.
51
Trust and safety.
Trust has been identified as one of
the most prevalent issues presented by adult survivors of childhood sexual abuse (Bass & Davis, 1988; Blume, 1990; Graber, 1991; McCarthy, 1986; Maltz & Holman, 1987; Westerlund, 1992). The experience of childhood sexual abuse Because of the
compromises a person's ability to trust.
immense emotional cost survivors have paid in the past, they have learned that they cannot afford to trust blindly. They
have found it difficult, if not impossible, to trust anyone, and an unfamiliar therapist is no different. SURVIVOR #1: Safety and precaution were really a big deal to me. Her [therapist] whole physical environment was real comfortable . . . it felt right. She worked in an old, wood-framed house. She had a door at the back that you could go out and a door that you could come in, in the front, so you never ran into her next patient. SURVIVOR #5: We'd talk a little bit about what happened to me. I'd watch her [therapist] reaction and I didn't see a negative reaction or a negative expression, a scowl, or shock, or something to tell me that I was unacceptable. Her [therapist] body language was very, very accepting . . . that let me know I could trust her. SURVIVOR #9: I went to her [therapist] for sexual abuse, but I just think it's vital that even though that's what I went to see her for, we needed several sessions of just barely touching on that. I needed for us to get to know each other and deal with everyday, ordinary things until that bond of trust was there. Compassion and acceptance. Another important
characteristic noted by the interviewees included the therapist's ability to provide acceptance and compassion. Comfort with the therapist undoubtedly relates to the survivor's sense of trust and acceptance. 52 According to the
survivors and their partners, it was absolutely essential that the survivors felt comfortable with the therapist. Compassion was described as the therapist's ability to offer a nonjudgmental and empathetically nurturing atmosphere in which to address the clients' sex abuse issues. SURVIVOR #12: Knowing I was in the right place boiled down to her [therapist] accepting me. She was right there. . . . she let me know she was really hearing me and she was really feeling what I was feeling. SURVIVOR #17: I knew I was in the right place because she [therapist] wasn't invasive. She did not start rattling off a bunch of questions. . . . She was like, "What's going on? Tell me whatever you are comfortable sharing. I'm here for you. I can handle anything you say. It will be okay." I felt protected. SURVIVOR #8: She [therapist] was compassionate, like when she would say, "That must have really been hard for you. I can see that has really hurt you." Comments like that, instead of asking me a question, gave credence to what I was feeling rather than just mirroring back what I had said. Professional demeanor. Another characteristic found to
be of importance to the study participants was the therapist's sense of professionalism. Therapeutic
professionalism was recognized in the therapist's attire, demeanor, office, and structure and style of treatment. SURVIVOR #2: Somehow she [therapist] communicated with me that she had the goods, the training, the background, and the experience. . . . She could handle whatever might be inside me that might come out. Whatever my problem was, it wasn't gonna throw her. . . I just felt like [therapist] was comfortable with herself. She dressed professionally in hose and heels and suits, but she was comfortable. If you're comfortable with who you are and with your capabilities, that will be conveyed to your clients. And if you're not, that is what will be conveyed.
53
Gender of therapist.
The gender of the therapist is
another factor that both survivors and partners described as being very important in building a therapeutic relationship. While many of the survivors interviewed had experienced therapy with both male and female therapists, the majority (n=13) expressed a strong preference for working with a female. The reason for this preference was reported to be a
reaction to the gender of the perpetrator(s). All 17 survivors had been sexually abused by a male or males, with three having experienced like abuse by one or more females. SURVIVOR #3: I'd never see a male. I don't trust men. I don't like men in general. I feel that men try to take away from women instead of being part of them. All men's brains are run by private parts. To have a male therapist . . . I wouldn't even want to talk to him. I'd feel like he was getting something out of it. SURVIVOR #17: So I went to see this man, and it was just uncomfortable because it was a man. He kept on coming back around and asking, "So what happened? What did he do then?" I didn't want him to be that invasive. It almost felt as if he was getting something out of it . . . like he was a voyeur or something. Survivor status of therapist. Finally, when asked
directly, 5 of the 17 survivors stated it would be very important for their therapist to be a survivor herself/himself. SURVIVOR #12: A therapist needs to have actually experienced sexual abuse and have gone through their own treatment and healing process. You get some therapists, and I've talked to a couple of them in treatment, and they haven't been through it [sexual abuse] and they look at you like, "What are you talking about? Explain this to me. I don't understand it." . . . They just don't connect. 54
In contrast, only 2 of the 17 partners thought that it was necessary for the therapist of survivors to also be a survivor. Those survivors who knew their therapist was also a survivor expressed comfort in knowing they were working with someone who could more completely understand their situation. This awareness provided hope and confidence to
the survivor as she identified her therapist to be a role model who had effectively resolved childhood sexual abuse issues. However, there was no expressed feeling of
therapeutic sacrifice for those survivors who were unaware of their therapist's survivor status. SURVIVOR #5: I don't think it really makes a difference if the therapist is a survivor because I don't think [therapist] was a survivor. It really didn't make any difference to me. All I knew is that I needed some help. I needed somebody to help me figure this out and get past it. And she had the tools, she had the knowledge, and that's what I wanted.
Accessibility and Availability of the Therapist Accessibility and availability of the therapist were also found to be significant components of building a therapeutic relationship. Survivors expressed a sincere
appreciation for those therapists who were readily accessible in the time of crisis. SURVIVOR #15: I always felt confident that if I really needed [therapist], which I never did, but if I needed [therapist] at two o'clock in the morning, I felt like I could have gotten ahold of her. So I felt like she was always there for me. 55
SURVIVOR #7: I was told that if I needed an extended session for one day, that could be arranged. If one session was particularly bad, and, by the time I left his [therapist's] office I wasn't pulled back together yet, he would say, "If you need me again tomorrow, I'm here." The therapist's willingness to remain accessible outside the therapy session is perhaps another indication that the therapist can be trusted. Dealing with issues of
abandonment and rejection are often key elements of a survivor's recovery process. A therapist who is readily
accessible during times of crisis may diminish a survivor's sense of abandonment, perhaps increasing her/his level of trust in the therapist. SURVIVOR #7: I have his [therapist] home phone number. I can call whenever I need to. It's been real hard for me to say that what I am going through is tough enough or bad enough to go ahead and call. In fact, I think I've only called him twice. But to know that I could has made the big difference. Just knowing I could call gives me a safety net.
Boundary Maintenance Boundary issues are paramount for survivors of childhood sexual abuse. For the participants of this study,
boundary issues were addressed in terms of confidentiality and respect for the survivor. In the therapist-survivor
relationship, boundaries were maintained by allowing the survivor to move at her own pace and reinforcing the survivor's sense of autonomy. SURVIVOR #9: [Therapist] allowed me to go back and forth in dealing with my sex abuse issues. She just hung in there with me. Looking back, that would have 56
driven me crazy. This person comes in one week and says, "Yes, this happened" and the next week, "No, it didn't." She was just with me wherever I was, reaffirming me, and knowing when to push those buttons and when not to. She knew when I came in and I was in a really bad place, and she would be there with me and not push. She just allowed me to be where I was. SURVIVOR #8: She [therapist] remembers things that I've talked about before in the past. She's got a lot of clients and I spend just an hour a week with her. But when she can remember things from months ago, she differentiates me from anyone else she sees. SURVIVOR #11: She [therapist] made me feel like I had things to give that are of worth. She was seeing me in the role of a contributor and not just a victim. A strong therapeutic relationship with the survivor appeared to result from allowing her control of the therapy process by deciding what and when information was to be shared with her partner. Ironically, the boundary
established around the therapist/survivor relationship, bound by strict adherence to ethics of confidentiality, was also felt by some of the partners as being very alienating. This was especially true when the partners perceived the therapist to be actively discouraging the survivor from sharing parts of her therapeutic process with her partner. INTERVIEWER: Do you think that [your wife's] therapy ever got in the way of your relationship with her? PARTNER #8: Sometimes. Yeah, because I was always left out. There's never been a marital component. They [wife and therapist] talked about our relationship. If she [wife] doesn't mention it, I have no idea of what's going on. And so that was one of the reasons I think I resisted somewhat, quite a bit in fact at times, to the idea of her going to a therapist that wasn't helping us. PARTNER #6: When her counselor said I couldn't be there [in session] that made me mad. Why can't I be 57
there? I'm her husband. And when the counselor said not to tell me anything or not to talk to me, that didn't help. And especially when her counselor said, "You should leave your husband and your children and go to a halfway house," boy that really set me off.
Treatment Modalities A general description of the treatment modalities experienced by the survivors and partners of this study will be presented here. A more detailed discussion of the
positive and negative aspects of each modality is included in the section of this chapter entitled "An Assessment of the Therapeutic Process."
Survivors Information gained from the interviews in this study revealed that all of the survivors had received individual therapy, and 14 had participated in group therapy. In
addition to these traditional modes, three of the survivors had experienced inpatient treatment for sex abuse and seven had received treatment for drug/alcohol addictions, eating disorders, and/or suicide attempts. The treatment process tended to follow a pattern which was shared by all of the survivors: they started in individual therapy and progressed toward group therapy with a transitional period of modality overlap. The period of
modality overlap varied from person to person, and was usually directed by the therapist. 58 For some, both
individual and group therapy continued, and survivors articulated different functions for the two modalities. SURVIVOR #2: In individual therapy I was working more on what was going on right now in my life: issues that were coming up, buttons that were being punched because of what had happened . . . because of a movie I saw on TV, or because of what one of my kids had said to me yesterday morning. We were working on how I was working on my life and my relationships. . . . My first experience in group took me a while to catch on to the value of telling some story over and over again. . . . Every week we had a member who wasn't there last week so we'd tell our story again . . . it was for us as much as or more than it was for the new group member. It was so that we could tell our story and get used to telling the secret. Letting the family secret out. In addition to individual and group therapy, three of the survivors had also experienced inpatient treatment specifically for sexual abuse issues. Seven of the 17
survivors had received some form of inpatient treatment for other related issues. Chemical dependency, eating disorder,
depression, and suicidal tendencies were all identified as presenting symptoms. Four of the seven had been unaware of
their past abuse at the time they were admitted for inpatient treatment.
Partners As noted earlier, eleven of the partners in this sample had received some form of therapy also. Their therapeutic
experiences, however, were not as varied nor as extensive as those of their wives. Eight of the partners had received Those partners who
individual therapy for their own issues.
59
had experienced abusive pasts and dysfunctional familial environments found therapy to be personally beneficial. Group therapy and/or self-help support groups were other therapeutic modalities experienced by the survivors' partners. Two of the partners had attended a group Another
specifically designed for partners of survivors.
partner reported attending a group which addressed men's issues in general. Seven of the partners reported they had
attended other self-help groups such as AA, NA, ACOA, AlAnon, and CODA in an attempt to deal with some of their personal issues.
Couples and Marital Therapy Twelve (71%) of the participating couples had received some marital therapy during their relationship. However,
only two of the couples reported that the marital therapy directly addressed the effects that sexual abuse issues were having on their marriage. Instead, marital therapy tended communication
to focus on other relationship issues:
skills, financial concerns, and parenting difficulties.
Therapeutic Interventions Therapeutic interventions are defined here as the planned tasks, assignments, or requests given by the therapist with the intention of producing change in the existing system. Several different interventions were found 60
to be common among the participating therapists and couples of this study. These included: (a) journaling (maintaining
a written record of feelings, thoughts and/or behaviors); (b) bibliotherapy (books and articles the therapist assigns the client to read); (c) inner child work (an intrapersonal reacquaintance with one's "real self" [Whitfield, 1987] often initiated through guided imagery); (d) guided imagery (a form of mild trance induction which utilizes relaxation and imagination techniques to offer new perspectives of the presenting issues); (e) experiential role-play and Gestalt therapy (a model which focuses on the immediatewhat people say, how they say it, what happens when it is said, how it corresponds with what they are doing, and what they are attempting to achieve [Kempler, 1982]); (f) hypnosis (formal trance induction utilized to access or enhance the client's memories); and (g) networking (expanding a person's source of social contact with other survivors, usually initiated through group therapy). Specifically, journaling was identified most often by the survivors, followed by bibliotherapy, networking, and experiential role-play and Gestalt therapy. The books most
often referenced by survivors and partners included The Courage to Heal (Bass & Davis, 1988), Secret Survivors (Blume, 1990), and Ghosts in the Bedroom (Graber, 1990). One survivor referred to The Courage to Heal as "The Carriage to Hell." 61
The effectiveness of inner child work received mixed reviews from both survivors and partners. PARTNER #1: In some of the therapy I've been doing myself, in dealing with the inner child, . . . I've begun to see it as a relationship issue of . . . different personalities within us. SURVIVOR #1: Everybody is trying to force this inner child shit on people. It is difficult for me, it is scary for me, it is unbalancing for me, and I don't like it. . . , A lot of people do think that it's the quickest way to get in touch. It may be a quick way, but it drags me back into shit that I don't want to be sitting in the middle of all the time. The interventions of guided imagery and hypnosis were referred to the least of all, perhaps because of the lack of utilization by therapists in this study's geographical area. In fact, one survivor recounted a hypnosis session in which an outside hypnotist was brought in as a co-therapist to induce the trance. The effectiveness of this intervention
per se was not addressed by the survivor in her interview. The interventions experienced by the participants in this study were among those commonly utilized by therapists working with other adult survivors. The therapeutic value
of each intervention undoubtedly depended upon the individual client and where she/he was in the recovery process. A more detailed, subjective assessment of the
therapy experienced by the participants of this study, including specific interventions, will be presented in another section of this chapter.
62
Summary The therapeutic process for addressing sexual abuse issues directly begins with the selection of a therapist, and continues with building a therapeutic relationship. The
therapist's reputation is an extremely important factor in the selection process. However, a sustained therapeutic
relationship depends upon more than the therapist's reputation. Such therapist characteristics as apparent
trustworthiness, gender, an ability to provide emotional comfort and warmth, and professionalism were all identified as essential components of the therapeutic relationship. The therapist's degree of accessibility and the manner in which relational boundaries are constructed and maintained were also found to be important factors in the survivors' recovery process. The treatment modalities and interventions reported by the participating couples and utilized by the therapists interviewed for this study were all similar to the traditional interventions and modalities discussed in earlier chapters. An overall assessment of the therapeutic
process experienced by these couples will be presented next.
Ap Assessment of the Therapeutic Process SURVIVOR #15: I felt like there was a very, very dark place inside of me, and it was like a vault. And the stuff that was locked up in that vault couldn't come out and I was gonna die. But that's what therapy did. It started letting the stuff out of the vault, and it 63
was scary and uncomfortable . . . but incredibly, incredibly valuable. Any exploration of therapy effectiveness should include a subjective assessment by the client of the therapy experience. This project involving adult survivors of This study is
childhood sexual abuse is no different.
unique, however, in that information on the effectiveness of therapy for sex abuse issues was obtained not only from the survivors, but also from their partners. Table 3 and Table
4 show frequency distributions of the therapy effectiveness survey (Appendix D) as indicated by the survivors and partners respectively.
Survivors Positive Aspects of Individual Therapy All of the survivors interviewed for this study were able to describe numerous positive aspects of their individual therapy. They unanimously expressed their
sentiments that individual therapy was an absolutely essential component of their recovery process. SURVIVOR #4: It's been a long, long road but I had to do it, I had go through it, there was no way to turn back. Without therapy, I wouldn't be a survivor. I probably wouldn't be alive today. SURVIVOR #5: The way I look at it, my therapy, and the process I went through, I had no choice. I had to do it. I had to go through therapy. As hard as it was, as painful as it was, I had to do it, because I really had no choice. The alternative would be to die.
64
Table 3: Frequency distribution of survivors' responses to therapy effectiveness survey. LOW 1 Individual therapy satisfaction Group therapy satisfaction Marital therapy satisfaction Satisfaction with partner's support in therapy Satisfaction with partner's support out of therapy Female therapist importance Survivor-therapist importance Overall effectiveness of therapist Therapist's effectiveness in helping partner Marital satisfaction when sex abuse therapy began Relationship satisfaction when sex abuse therapy began Satisfaction with partner when sex abuse therapy began 0 11 0 0 2 4 HIGH 5 BLANK
11
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Table 3: Continued LOW 1 Marital satisfaction today Relationship satisfaction today Satisfaction with partner today 0 0 1 0 2 3 3 2 1 2 8 4 HIGH 5 BLANK 8
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Table 4: Frequency distribution of partners' responses to therapy effectiveness survey. LOW 1 Individual therapy satisfaction Group therapy satisfaction Marital therapy satisfaction Satisfaction with partner's support in therapy Satisfaction with partner's support out of therapy Female therapist importance Survivor-therapist importance Overall effectiveness of therapist Therapist's effectiveness in helping partner Marital satisfaction when sex abuse therapy began Relationship satisfaction when sex abuse therapy began Satisfaction with partner when sex abuse therapy began 10 5 0 0 0 0 HIGH 5 BLANK
67
Table 4: Continued LOW 1 Marital satisfaction today Relationship satisfaction today Satisfaction with partner today 1 2 0 2 1 2 1 8 4 HIGH 5 BLANK
68
Any dissatisfaction expressed in the context of individual therapy was focused on the therapist at that time, not the modality. Of the 17 survivors, 64.7% (n=ll) reported being
"Very Satisfied" with their individual therapy. The most frequently expressed positive aspects of individual therapy included: (a) providing safety,
security, and a sense of privacy for self-disclosure with one trusted individual; (b) feeling freed from blame and responsibility for the abuse; (c) discovering reasons for unexplained past behaviors; (d) relating the past sexual abuse to present behavior patterns; (e) developing a stronger sense of self; (f) learning to construct more stable personal and relational boundaries resulting in improved decision-making skills; and (g) providing a sense of hope for the future. Self-disclosure. The most commonly expressed benefit
of individual therapy was having a safe place in which to reveal and address the secrets of childhood sexual abuse. The experience of working one-on-one with a therapist who provided a private and secure environment was conducive to progressive recovery. SURVIVOR #3: Individual therapy gave me a safe and secure place, a one-on-one place, to work on my sole, individual stuff. SURVIVOR #4: The good part about being in individual therapy was that I could talk to her [therapist] and tell one person ray story. I could tell her, just one person, everything. I was able to tell her all my deepest, darkest secrets. 69
SURVIVOR #8: Individual therapy provided a place where I felt I was understood for the first time in ray life. The biggest thing in therapy is just sitting down with someone who wants to hear what I have to say and feel completely understood. I can take an hour and just talk about myself. That's something I'm not accustomed to asking for. At first it was very uncorafortable, that focus on me. Yet it grew into something that I was really feeling good about. Freedom from blame. By sharing the secret of their
past sexual abuse, survivors allowed the therapist an opportunity to emphasize their innocence in and powerlessness over the events which had occurred. In the
presence of someone who would not judge or blame the survivor herself, the survivor came to realize that the abuse was not her fault. Consequently, she learned how to
place the blame where it belongedon the perpetrator(s). SURVIVOR #14: She [therapist] showed me I was not to blame. "You were a child. You were not at fault." Each tirae I had to tell things of my past, she'd say again, "You were not to blame. You couldn't make adult decisions. You couldn't defend yourself. You were not to blame." I needed to hear that I wasn't to blame because I blamed myself. I needed to hear that over, and over, and over again. SURVIVOR #3: For once I had somebody that didn't judge me, that didn't think I was at fault, that didn't think I was dirty, and not only that, but acted like she cared about me. The first thing she did was tell me, "This isn't your fault." She drilled that in to where I began to believe that maybe it wasn't. SURVIVOR #4: The very first quality I can remeraber about [therapist] is that she didn't blame me for it. Everyone else around me did, including myself. I felt so guilty, like it was all my fault. She took it off of me. She'd say, "Let's think about this reasonably, like you're another person. How would you feel if you saw another child being done the same way?"
70
Reasons for past behaviors.
Finding some reason for
past unexplained behavior and thereby realizing that they were not "just crazy," was also a positive result of being in individual therapy for sexual abuse issues. Unexplained
feelings of fear, anxiety, depression, and sadness were identified by the survivors as being unrecognized symptoms of childhood sexual abuse. Past dysfunctional relationships
and earlier instances of compulsive/addictive behaviors began to be seen as the product of the sexual abuse. SURVIVOR #10: For the longest tirae I didn't understand why I was afraid, why, at tiraes, ray skin would crawl. And when we first gotraarried,a thunderstorra would happen and I would just shake in bed. I would just shake and cry. . . . Later I realized that it was raining when I was raped. SURVIVOR #9: It was after the third overdose. I was really scared. But I convinced everyone that I was going to be okay, but it was just a facade. The inside feeling was strong enough that I thought, "I'ra going to die. Soraehow I r going to kill rayself. Either I will 'a develop cancer, or I will kill rayself in a car wreck." . . . It's sort of like I just woke up that day and said, "Oh gee, I was sexually abused." Something just clicked. My life began to just fall into focus. Relating past to present. In addition to being able to
explain past behaviors, it was also helpful for the survivors to see how their sexual abuse was impacting their present lives. By examining the residual effects of their
traumatic pasts, the survivors began to recognize how current behavioral and emotional states could be explained. SURVIVOR #7: The most helpful thing that [therapist] did with me was to ask me what had been going on for the last week. He would then ask me, "So, how does this relate to [your childhood sexual abuse]?" He'd 71
kinda relate what's going on with me now to what was going on then, and helped me see how they fit together. SURVIVOR #17: In individual therapy I really began to see how the emotional impact of all that stuff [sexual abuse] was catching up with me. On the outside I was real tough, real raacho. Everybody thought I was brave, tough, and strong. As a child I had created that iraage for protection, but as an adult I realized I was crumbling. Sense of self. Repeated self-disclosure, freedora frora
blarae and responsibility, and the understanding of past and present behaviors allowed the survivors to develop a stronger sense of self. These women articulated feelings of
worthiness, self-acceptance, and autonomy as a result of their therapy experience. SURVIVOR #14: Whenever my abuser abused me, I felt like that was all I was worthy of, that was the way life was gonna be. I was to be abused. . . . In therapy, ray whole life began to change. I saw myself as a person, a person capable of love. Before, I was a nobody. But now I was becoming somebody. I was feeling it and believing it. And I was glad that I was rae, and I loved rae. SURVIVOR #7: I was always so corapliant and willing to please, and so desirous of everybody being happy, that I always did for others and seldora was it done for me at all. I thought I had to be nice to everybody. At that time, others were more iraportant. Now it's finally getting to a point where it's easier for me to say, "I am just as important. I would like to do this for you, but I need to do this for me first." Boundary construction. Another benefit of therapy for
the adult survivors of this study was learning how to construct and maintain stable personal and relational boundaries. Boundary violation has been recognized as a
common and significant issue for adult survivors (e.g., Bass & Davis, 1988; Blume, 1990; Courtois, 1988; Westerlund, 72
1992).
The ability to redefine the parameters around
interpersonal relationships is a significant step in the survivor's recovery process and her sense of increasing self-esteem. Survivors reported an added component of
boundary construction and maintenance was learning to generate options, raake decisions, and trust in their ability to do so. SURVIVOR #14: I never could raak6 decisions before, and [therapist] knew that. I had told her how I was afraid to make decisions, how I was afraid to venture. She let me know that, whatever I felt like, whatever satisfied me, I could do. I was the one in main control of me. That was something new I had to adopt. SURVIVOR #13: I needed to deal with the fact that every time a man did soraething nice to rae I thought I had to pay hira back by [having sex]. In ray past, this guy just happened to be there, and happened to listen to my problems, and I ended up having an affair with him. . . . I realized that all had to do with ray abuse, and that I didn't have to do it any raore. SURVIVOR #8: [Therapist] is teaching rae to trust rayself because I always look at soraeone and go, "What do you want from me?" Hope for the future. In spite of the painful and
sometimes tedious process of therapy, survivors were able to gain a new sense of hope for the future. They were able to
recognize that life had becomeraoreraanageable,the past did not have complete control over the present, and a new future could be constructed. SURVIVOR #7: When you get stuck in a rut like abuse, you just really don't see a future. It's just all gonna be the same over, and over, and over again. And in therapy, I began to see a new way that kinda gave rae hope, that I could go from this point to that point. I began to believe that there is a future. And that was 73
the most beneficial part of therapy, because up to that point I never actually saw a future. I had hope. SURVIVOR #15: [Therapist] would tell rae that God would never allow rae to deal with [ a sexual abuse] until I ry was capable of it, and I could be assured that it wasn't gonna kill rae. She assured rae that I would not even be to this point if I wasn't in a safe environment. Something was unfolding . . . and I began to believe that by going through this I could have a new future.
Positive Aspects of Group Therapy For most of the survivors, group therapy was also a positive experience. In the survey used to collect
additional inforraation for this study (Appendix D), survivors were asked to respond to the question "How satisfied are you with the Group Therapy you received?" by circling their choice on a 5-point Likert scale. Of the 14
respondents, six chose "Dissatisfied" and eight chose "Satisfied," indicating a split in satisfaction with group therapy. The benefits of group therapy as a major treatment modality for working with adult survivors have been well documented (Bergart, 1986; Blake-White & Kline, 1985; Deighton & McPeek, 1985; Faria & Belohavek, 1984; Forward & Buck, 1978; Goodman & Nowak-Scibelli, 1985; Herman & Schatzow, 1984; Tsai & Wagner, 1978). The survivors of this
study indicated that the most beneficial aspects of group therapy included: (a) identifying with other survivors; (b)
developing a supportive network; (c) receiving vicarious 74
therapy through assisting other group members with their issues; and (d) assimilating other members' positive attributes into a stronger sense of self. Identifving with other survivors. Being in the company
of others who had experienced similar abusive behavior was reported to be very validating and self-assuring. Several
of the survivors reported feeling relieved to learn that they were not the only ones who had experienced the trauma of childhood sexual abuse. SURVIVOR #4: It was wonderful to be able to tell a group of twelve my deepest, darkest secrets and all the guilt and everything be out there, and to have those twelve look at it and tell rae, "Look, you were only five." They were really validating for rae because they had been there, too. SURVIVOR #5: Growing up I always felt so alone, feeling like I had nobody to share [ a sexual abuse] ry with, and that was hurting rae so rauch. And then coraing into the group and hearing other people's stories, and just identifying with what they were feeling . . . I began to feel like I kinda belonged with soraebody. It's nothing to be glad about, but at least we had each other. Developing a supportive network. In addition to
identifying with other groupraerabersas survivors of childhood sexual abuse, the woraen of this study found it beneficial to establish a strong supportive network araong each other. Feeling free to raake contact outside of therapy
in tiraes of need was conducive to increasing their sense of support and safety, thereby expanding the survivors' ability to trust in others. SURVIVOR #12: We know we need each other, and we're there so we can hold each other up when soraebody [else] 75
can't do it. I know if I'm having a bad day, and I just don't think I can do it anymore, all I have to do is call them, and they're going to be there, holding rae up and helping rae through it. It's like the faraily I don't have. SURVIVOR #8: I have serious social issues. I'm nervous all the time. But here I was in a situation that it was okay that I was nervous, and people wouldn't go, "God, she's weird." I think mostly with group I needed friends, people to talk to, people to call and say, "I'm really hurting," or "I'm having a great day," or whatever. Receiving vicarious therapy. Survivors also reported
their own therapeutic experience was enhanced by observing the process at work in other group members. By assisting
otherraerabersin addressing their issues, each survivor vicariously addressed her own. Having the benefit of
multiple perspectives expanded the survivor's worldview of her own past and present experiences. SURVIVOR #2: One of the things that was most helpful about group [therapy] was when there was a structure by which, if the woman next to you was doing her anger work, then you could plug in and be involved with your own. So, basically, one person did the work but everybody was feeling it. Your therapist would come back and notice what effect that had on you, what your reaction and response was, and pull you [into the process] that way. SURVIVOR #3: Group lets you see that you're feeling the same things other people are feeling. . . . It gives you ten points of view on your particular themespan rather than a one-on-one [point of view]. You get all these different angles to fit into your whole picture. Assimilating positive attributes. A growing respect
for other survivors of the group and learning to identify strengths within each meraber challenged the survivors to take a personal inventory. The assirailation of such 76
qualities allowed the woraen to acknowledge the presence of like attributes within theraselves. SURVIVOR #5: . . . looking at thera [groupraerabers]and seeing things that I adraired and appreciated, learning from them a lot of things, learning frora thera a lot of coping skills. I adraired their strengths. Then seeing that same strength inrayselfthat I had never seen before was a lotta help. SURVIVOR #3: You interact with people [group raerabers], and you see this one person and you see how they've been affected [by the sexual abuse]. But, yet, you also realize they've all survived it and they've corae a long way, and they are living . . . and so are you.
Negative Aspects of Individual Therapy There were times when individual therapy was not necessarily a positive experience, paradoxically adding to the survivor's stress. Although the prevailing opinion
regarding the effectiveness of individual therapy was extremely favorable, each survivor acknowledged some negative components as well. The most frequently referenced (a) the
negative aspects of individual therapy included:
emotional expenditure required; (b) the exhaustive focus on self; (c) the adherence to the therapist's sense of timing; (d) the intentional exclusion of the partner in the therapeutic process; and (e) the resistance by the partner to changes in the survivor and to their relational systera. Emotional expenditure. The pain and fear of exploring
their abusive past pushed some of the survivors to their emotional limits, thereby making it difficult to persevere. Having to relive their trauraatic past via therapeutic 77
technique proved to be exhausting for some.
The realization
that the process of therapy would require more tirae than originally anticipated taxed the survivors' eraotional reserves. SURVIVOR #1: It is a struggle to keeprayselfin therapy. These are very difficult and painful issues to address and to call your own. . . . If I had a dirae for every tirae I quit therapy . . . SURVIVOR #7: I don't understand! Here I have been in therapy for over four years, why do I feel like I r 'a still in the beginning? I'm just dealing with this over and over and over again. SURVIVOR #11: Okay, you have done this for three years now and it's getting to be a broken record and I'm tired of it. You know, a lot of money has gone toward this and I haven't worked it through to any extent. . . . It's really hard to juggle all the individual needs, family needs, finances, time, and try to find a balance that is going to work. Focus on self. A necessary component of dealing with
childhood sexual abuse issues as an adult survivor involves introspective focus. The woraen involved in this study
frequently indicated that their deterraination to deal with their past experiences forced thera to concentrate on their personal issues, raany tiraes to the exclusion of others. This self-absorption seemed to be essential, yet costly to themselves and those around thera. SURVIVOR #15: The pro is that once you get through [therapy] you get where you're going. But the con to it is, that once you get it into your head, and you start down that path, you don't care who you step on or whatever it takes. It doesn't raatter because you're going . . .I'm gonna be a happy person because nothing and nobody is going to stop me.
78
SURVIVOR #4: Whenever you first realize that you've been abused that becomes your whole world. You eat, sleep, and drink it. That's the way you do it. PARTNER #11: There's that trap that they talk about in the book [Ghosts In The Bedroom] that you get pulled into her issues so much because that's the focus. Her whole life is around her issues and herself, and I got pulled into that. Therapist's sense of timing. One of the negative
components of individual therapy surfaced when the survivors perceived the therapist to be operating from a predetermined plan of timing. At times the participants felt forced to This
address certain issues without adequate preparation. often resulted in the survivors feeling confused and distrustful of the therapist.
SURVIVOR #9: Her [therapist] time table was too fast. She is good at zeroing in and hitting the target. I guess for some people sometiraes that can be good. For rae it wasn't. In that one session we had together, she had me reliving an experience that I wasn't ready to relive. She just led me into that. It just went too fast. SURVIVOR #7: When I did therapy with [therapist], I felt pushed. I did feel pressured. It was like, "I need to do this, and I need to do it now." Intentional exclusion of the partner. Survivors also
expressed feelings of frustration when they were prevented, by their therapist, from incorporating their partner into the therapeutic process. The purpose of this inclusion was
to assist the partner in understanding more clearly his wife's sexual abuse issues. The survivors felt a need to
enlist the help of the therapist in explaining these issues to their partners. 79
SURVIVOR #6: I would talk to her [therapist] and I would ask her if [partner] could be a part of [therapy] so that he could understand. She told me that she would rather not. She did not want him involved. . . . I wasn't supposed to tell him anything. SURVIVOR #3: I wanted him to go to therapy. I wanted to bring things out in the open so there weren't any secrets. That way, there would be no blackmail, so he couldn't say, "You liked it!" He needed to be educated about incest and its effects. Resistance to change. Ironically, the behavioral and
attitudinal changes that can result frora effective therapy may be difficult for the existing systera to assirailate. redefining personal boundaries and relational roles, the survivors found that they experienced resistance frora iraraediate or extended farailyraeraberswho were atterapting to raaintain the status quo. SURVIVOR #3: We fought all the time . . . he hated my therapy. The therapy seemed to be making the marriage even worse because I was changing and he wasn't. It was clear enough to see that what my therapist wants for me and what my husband wants from me are two different things. PARTNER #12: She started acquiring boundaries in areas that we didn't have before. I didn't respect her boundaries as far as sexually. It did affect our relationship when she started learning some of those things. I was used to having things the way we had them. Then all of a sudden there was a change. PARTNER #13: . . . she began to get her strength and assert herself more as an individual. I saw that as a potential threat. By
Negative Aspects of Group Therapy Survivors reported numerically fewer negative aspects of group therapy than they did individual therapy. 80 Three
factors which were reported to adversely affect the group therapy experience were: (a) concerns for confidentiality;
(b) the inability to identify with other group members; and (c) the absence of group focus. Concerns for confidentiality. It was not uncoraraon for
the survivors to experience uncertainty upon their initial introduction to a new group. By joining a group, each
member was publicly announcing her status as an adult survivor of childhood sexual abuse. Concerns for However, for
confidentiality usually dissipated with time. others, these concerns continued to linger.
SURVIVOR #1: I hate group! I'd never do it on my own. It has trust issues, it has fear issues, it has confidentiality issues, and by God, I'll choose when I want to tell somebody [my story]. Lack of identification. The survivor's inability to
identify with the other groupraerabersliraited the benefits she received from this modality. The feeling of "not
fitting in" often influenced the survivor's perception of group therapy effectiveness. SURVIVOR #7: There were all these others that had been there for a while. And I just felt I had absolutely nothing in common with them. I couldn't even see the point. SURVIVOR #17: The only thing about that group, it was a first level group and I had already had a lot of stuff exposed, so it wasn't that beneficial. The women were not aware of some of their own stuff, or would get off [track] talking about co-dependency. Absence of group focus. Sorae survivors expressed
frustration with the group's inability toraaintaina sense 81
of therapeutic direction.
Consequently, the benefits these
woraen gained frora their group experience were significantly dirainished. SURVIVOR #8: We'd just corae in and sit down, and whoever had an issue with the kids, or with Dad, or with work, or anything, would talk. But we weren't really concentrating on specific issues. It felt like we weren't moving in any particular direction. SURVIVOR #4: For a long time we'd go in and everyone would talk, but as far as giving us a topic to talk about, or relating it to sexual abuse, we really didn't do that. That was frustrating for me. She [therapist] didn't give us an area or a direction to go.
Negative Aspects of Therapy in General Financial costs. In addition to the eraotional costs,
therapy of both types increased the financial burden for several of the survivors. Asraentionedbefore, the lack of
financial support forced some to seek help elsewhere, or to suspend therapy altogether. This became particularly
significant when the survivors began to realize that dealing with childhood sexual abuse issues was not a temporary ordeal. The realization that the results of their past
trauma would be with them for the rest of their lives felt overwhelming to some survivors. SURVIVOR #17: Somebody, somewhere, has got to effectively address the financial cost of therapy. . . . It's a necessity that few can afford. And to do what you need to do, the expense will go on for a long, long time. Sharae and guilt. Finally, the stigraa of being in
therapy produced negative feelings of sharae and guilt for 82
some survivors.
At times, the sharae and guilt felt by the
survivor was exacerbated by the reaction of other faraily raerabers, particularly the survivor's partner. SURVIVOR #3: . . . He's [partner] asharaed of me being an incest survivor. Anytime I would tell anybody he would just die. He hated it, he didn't want to tell anybody. SURVIVOR #16: . . . He [partner] thinks that this is all for crazy people or soraething. . . . He doesn't understand why it's not over in a week. He's never had soraething that was drawn out, that just goes on and on. The need for therapeutic assistance is soraetiraes viewed as an indication of failure by clients with any issue. Given
the relationship between shame, guilt, and childhood sexual abuse, the stigraa of being in therapy raay cause a survivor to react with overwhelraingly negative feelings.
Inpatient Treatraent Perceptions of the benefits gained frora this experience differed widely. INTERVIEWER: You mentioned that you were hospitalized for a while. Was that an inpatient program where you were able to work on some of these issues in the hospital? SURVIVOR #8: Yeah, but I don't think it was a very good program. I don't think I got very good treatment at all. . . . I think there were not enough therapists for the number of people that were in the hospital. It was really detrimental to me. SURVIVOR #12: [Not responding to interviewer question above.] Treatment helped. Treatraent was the best part. . . . I think the best thing that happened in treatraent for rae was being so safe and knowing that I was accepted there. And there was other people there that had been through it [sexual abuse] that I could talk to. In treatment I wasn't any different [from the 83
other patients], l think that was a big part of it, was just the acceptance.
Partners Positive Aspects Several of the positive aspects of the survivors' therapy were mirrored by their partners. The most commonly
addressed benefit of individual therapy for the survivors was that therapy offered a place for the survivor to talk about the sex abuse. PARTNER #4: I think that [wife] receiving individual [therapy] from [therapist] was, helpful was to go ahead and talk about the getting it out, and really kind of putting her now. the the most situation, it behind
INTERVIEWER: What do you think was most helpful about the individual [therapy your wife received]? PARTNER #12: I guess finally just having a safe place to go and talk about it. . . . 1 see that as the biggest part. Just finally being able to talk about it. Partners, at times, expressed some relief at learning that unexplained behaviors demonstrated by the survivors could be, in part, the result of their abusive past. Merely
knowing that a reason existed for the behaviors was less confusing, and in sorae cases, easier to deal with. PARTNER #16: . . . It was just like she flat out didn't care. And there wasn't a reason except that's how she was and she wasn't gonna change the way she was for rae. And that really bothered rae because I just felt like we would grow closer together the longer we were together and it wasn't happening. At least I understand [now] a little more of why she's like she is. 84
PARTNER #13: . . .as long as I have a cause in my mind for [wife's behavior] I can deal with it. But if the problem weren't identified, it would be much harder. The partners tended to have a slightly higher opinion of the survivors' group experience than did the survivors themselves. Over 60% responded on the 5-point Likert scale
regarding their wives group therapy as being highly satisfactory by circling "4" or "5." Group therapy was recognized by the partners as providing an opportunity for the survivors to identify with other survivors, thereby reducing feelings of alienation. PARTNER #11: Group therapy, I think, was reassuring [in] that so many people had the same issues. INTERVIEWER: What do you think [your wife] got out of the group experience that was helpful? PARTNER #12: The knowledge of knowing that there are other people like her. . . . And having a safe place where she can go talk to other people who can relate to her . . . to actually be able to talk to somebody, and they know the feelings you're going through.
Negative Aspects While acknowledging crucial benefits of the survivors' therapy experiences, the negative aspects were more frequently the focus of their partners. The most prevailing
negative aspect of the survivors' therapy involved the partners feeling alienated frora the therapeutic process. The partners reported feeling, at tiraes, as if this alienation was at the blatant instigation of the therapist.
85
PARTNER #6: I wanted to be there, to sit and listen. But raost of the therapists said, "No, because he'd interfere or be an influence." Whereas, all I wanted to do was learn. . . . I felt rejected because I couldn't be there. PARTNER #7: That's the sad part. I've been kept in the dark. The therapy is not shared with the spouse . . . the therapist isn't inclined to help [the survivor] share, either. This is not an issue that's dealt with well. And I have had some of the therapists that are supposed to be the experts in town and, no, they don't [help the survivor share with her spouse]. PARTNER #11: . . . [Therapist] did not want me in there. She said there was so much [ that a wife] had ry to work on, that she wanted her to focus on her issues. Another result of the survivors' therapy experience with which the partners reported dissatisfaction involved the interaction between partners and survivors which took place iraraediately following a therapy session. Reportedly,
raany times the survivors returned home in eraotionally charged states of anger which were focused on their perpetrator(s), but were directed at the partner. INTERVIEWER: Was there ever a time when you thought that her therapy was doing [your wife] more harm than good? PARTNER #16: Well, when she would come in and be so upset. I didn't know why she was so upset because she just would always come in and, . . . it just brought back so rauch memory and stuff. It was just hard for her that day but then, like the next day, she was . . . she would be better about it. . . . She really didn't want much at all to do with rae on those days. PARTNER #2: . . . yeah, she would corae home from therapy angry. . . . The thing we're doing is, we're making sure that her anger is identified in trying to figure out who she's angry at. The partners' dissatisfaction with their wives' group therapy included the lack of confidentiality among group 86
members, and the survivor's lack of identification with the other group raerabers. PARTNER #3: . . . one day child welfare [carae] to our door and said they were gonna take our kids. . . . And it scared the hell out of me. So I got to asking questions, I mean, you have to do something really bad to get them to take the kids. Anyway, come to find out, one of the girls in her therapy [group] had misread something [wife] had said, and she'd reported that a lot of mine and [wife's] loveraaking had been in front of the kids. It wasn't true. And that throwed rae against group therapy. And then she [wife] started up another group therapy, which I didn't really want her to, 'cause I was scared. PARTNER #17: [Wife] didn't relate real well to a lot of the woraen that were in her group. . . . One of her coraraents to me were a lot of the women in that group were really heavy into denial and miniraizing the effects of the abuse. And [wife] was a lot further along than that, a lot raore aware. . . . She didn't really quite fit [the group]. Once the therapeutic process towards recovery began, it seeraed to the partners that the entire focus of life had becorae the survivor's sex abuse issues. Partners expressed
negative feelings of irapatience with the process, wanting to "get this behind us." PARTNER #1: . . . there are many points where I get frustrated with, well . . , it's time for this to be over, isn't it? I mean, we have both been in therapy so long and she's specifically been dealing with this issue. PARTNER #3: You know, there's not really a day passes that it's not brought up.
Summary Frora this discussion of the positive and negative aspects of therapy, it can be concluded that the therapeutic 87
process for these survivors and their partners was rewarding and, at times, very painful. However, the survivors and
partners were unanimous in their position that therapy was essential for recovery frora the trauraa of childhood sexual abuse. The participants were able to articulate very clearly the benefits they received frora their therapeutic experiences. In addition, they were also very explicit in
their descriptions of how the process of therapy in general, and for adult survivors in particular, can be eraotionally, relationally, and financially draining.
Marital Issues The couples in this study had beenraarriedan average of 11.8 years (range = 1 to 43). The currentraarriagewas the first for 13 of the survivors and 10 of the partners. The participants were asked to coraplete a survey (Appendix D) which included a question regarding their raarital relationship. Couples were asked to respond by circling the
appropriate number on a 5-point Likert-type scale (l="Not Satisfied," 5="Very Satisfied") to the question, "At the tirae you/your wife began therapy for sex abuse issues, how satisfied were you with your raarriage?" As a group, the participants' average response was 2.4 (survivors = 2.5, partners = 2 . 3 ) . In responding to a sirailar question
referring to their current satisfaction level, the 88
participants' responses averaged 3.8 (survivors = 4.0, partners = 3.5). One of the systeraic consequences of childhood sexual abuse for raarried survivors is that his/her issues becorae the couple's issues. The non-abused partner becoraes a Consequently, the
secondary victira of the original abuse.
complexities of interrelational dynamics become exponentially difficult. SURVIVOR #11: A lot of our concerns were not only getting rid of the past or dealing with the past, but also how was this affecting our marriage. . . . One of the things we have realized is that, as a result of this [sexual abuse], it has had an irapact on hira [partner] and on us. It's justraaddening,you know. SURVIVOR #8: Because ray own personal issues are so entangled in the marriage, it's really difficult to not doraaritaltherapy, even when I am doing individual [therapy]. A unique aspect of this study is that it gathered information on childhood sexual abuse from within the marital systera. Both survivors and partners were in
unaniraous agreement on the benefits of individual therapy for the survivor. However, they also unanimously agreed
that marital issues for survivor couples were not being adequately addressed by the therapeutic comraunity. An
assessraent by survivors and partners of this study regarding the therapeutic techniques traditionally applied to the treatment of childhood sexual abuse, and the irapact it can have on the raarital relationship, identified specific issues which they believed lacked sufficient attention. 89
^^^.^l^^^s.
The raajor
theraes which emerged from the in-depth interviews in regards to marital issues can be categorized within four specific topics: (a) the irapact of sexual abuse on the marital
relationship; (b) the impact of therapy on the marital relationship; (c) partner involvement in the therapeutic process; and (d) specific suggestions for iraproveraent,
Irapact of Sexual Abuse on the Marital Relationship The irapact of childhood sexual abuse on the marital relationship of adult survivors is an issue that is seldom addressed systemically in the traditionalraodalitiesof individual and group therapy. Two conclusions raay be drawn
frora a review of the literature on childhood sexual abuse, and frora the discussion presented thus far in this docuraent: (a)raaritaltherapy is not a major coraponent of the therapeutic regiraen offered married adult survivors, and (b)raaritalissues, when addressed, are primarily addressed with the individual survivor only. The couples
participating in this project identified topics, in relation to the impact of childhood sexual abuse on the raarital relationship, which were classified as belonging to six areas for discussion: (a) sexual intiraacy; (b)
communication; (c) transference of anger with the perpetrator toward the partner (defined by Bass & Davis (1988) as "objective transference"); (d) physical (tactile)
90
intimacy; (e) inconsistency in patterns of behavior ; and (f) partners' adverse reactions to the sexual abuse.
Sexual Intimacy The couples in the study reported that their sexual interaction was a major issue. Often times, the
differentiation between physical and sexual intimacy becomes diffused for survivors and their partners. As a result,
clear communication about what is or is not desired by either meraber of the couple is lacking, producing feelings of confusion, frustration, and anger. INTERVIEWER: What would you say was the raost difficult thing about beingraarriedto an adult survivor? PARTNER #5: Our sex life. . . . There was none, hardly, you raight say. SURVIVOR #3: [Partner] is all into sex, sex, sex, sex, sex, where[as] I hate sex, Iraean,with a passion. And so, he's like, "Love is sex." Sex is not love. Not for me. And so, that's an "A #1" problem, sex. PARTNER #8: . . . in sex, she doesn't have a whole lot of vaginal feeling left. . . . The only time she can climax or reach orgasm is if I stimulate her digitally . . . . Maybe twice in three years of marriage have we ever reached orgasm together. . . . And so, that has been tough for rae because I feel like I can't satisfy this woraan. PARTNER #15: . . . frora the start, she [wife] always thought I had other motives any tirae sex was brought up. . . . 1 could always tell that there was just a little bit of hesitancy there . . . that she didn't totally trust rae. PARTNER #9: . . , There's been flashbacks that happened during intercourse . . .
91
Communication Given the magnitude of issues such as distrust of others, feelings of sharae and guilt, and a low self-esteera, insufficient coramunication with others often become problematic for adult survivors and their partners. As a
result, open comraunication within theraarriagebecomes impeded. Survivors reported having difficulty expressing
their feelings because they could not predict how their partner would respond. Partners, on the other hand, felt
betrayed if information was not shared by their wives. Disengagement was a coramon mechanisra used by survivors to protect theraselves emotionally. Consequently, a
dysfunctional comraunication pattern evolved as a residual effect of the survivor's past sexual abuse. INTERVIEWER: When was it, during your relationship with your wife, that you learned of her abuse? PARTNER #1: I suppose that would have been about [19]88-'89. We were raarried in '86. INTERVIEWER: And your response or reaction to that?
PARTNER #1: I think there were several responses. One is, "This explains a whole lot." The other is, "Oh, ray God! Could this really be the case?" And the third, probably the total frustration of, "What else are we gonna have to deal with?" PARTNER #5: Well, I didn't find out about it until, I guess we were raarried about nineteen or twenty years. SURVIVOR #2: I just disengaged. Because of ray own specific probleras in ray past, I wanted to disengage for protection. PARTNER #8: I didn't know anything about this when we got married. . . . A year and a half to a year and 92
three-quarters after we'd been married she said something about her having been abused as a child. SURVIVOR #12: . . .we were living two separate lives. It wasn't hira, it was rae. I totally shut down frora hira. He wasn't iraportant. PARTNER #11: We were in college dating. And on one of our dates she just asked rae if I knew she had been sexually abused as a child. . . . It really didn't pop up again until after we had been married for about eight years. PARTNER #16: . . . it was my brother-in-law who ended up telling me. And that didn't make rae happy because I didn't understand why she [wife] wouldn't tell me. . . . That made it kinda harder to be there for her [later] when she didn't think enough of rae to tell me. As reported earlier, sorae of the partners in this study felt alienated and/or angry when the survivor would not share her therapy experiences, especially if the failure to disclose was encouraged by her therapist. felt this way. PARTNER #13: . . . I didn't really ask a lot of questions because I didn't want to mess anything up that anybody else was doing. PARTNER #5: . . . 1 used to kinda push it a little bit. I've learned now just to leave her alone. She'll eventually tell me whenever she feels like it. However, not all partners
Transference of Anger Partners also expressed confusion and helplessness with regards to feeling they were being treated by the survivors as if they were the perpetrator(s). This state of object transference by the survivor toward her partner is not uncommon (Davis, 1991; Graber, 1991). However, it can cause
the partner to feel hurt, angry, and unjustly accused, 93
thereby increasing the sense of emotional distance within the couple's relationship. PARTNER #16: I just feel like because I want a normal sex life that I'm a bad person . . . SURVIVOR #11: j think that the things that other raen had done to rae, I acted out on hira [partner], and it's scarred hira and daraaged hira sorae. PARTNER #2: . . . there were times in our relationship that I would tell her [wife], "I'm not your perpetrator." And it would show up especially in our sexual relationship. SURVIVOR #17: He knew when I was acting out. when I was turning him into the perpetrator. He knew
INTERVIEWER: Did you ever feel like [your wife] was responding to you as if you were a perpetrator? PARTNER #15: Yeah, I expressed that to my [therapist] once . . . maybe it's just because I was another man, I don't know. I know she would withhold sex with me sometiraes . . .
Physical Intiraacy A recurring therae araong the couples of this study regarding the irapact of sexual abuse on their marriage centered around physical affection, the ways in which a couple comraunicated through tactile contact. Touch has been
reported in numerous studies as being a very significant component of any intimate relationship (Barnard & Brazelton, 1990), and cannot be corapletely delineated here. Issues of
touch and the effect they can have on relationships are alraost always referenced in the literature on childhood sexual abuse (e.g., Blurae, 1990; Courtois, 1988; Maltz & Holman, 1987; Westerlund, 1992). 94 Examples of how touch
played a significant role in theraaritalrelationship of the couples in this study reveal the feelings of confusion and frustration which were often reported. PARTNER #1: We went through a period where [wife] didn't want to be touched. SURVIVOR #1: We've gotten to a point where we can hug each other once in a while, now. And that was a big deal with us. PARTNER #11: She didn't want to be around . . . she didn't want rae to hold her. Physical contact was off. Sex was out. INTERVIEWER: home? What issues would make things turn bad at
PARTNER #17: Touching . . . I r a real touchy, feely, 'a huggy person. And that was a problera. Initially, it wasn't a problem, but when she started going to therapy, then it became a problem.
Inconsistency in Patterns of Behavior The confusion in determining how, when, and where to interact sexually with their wives was exacerbated for partners who reportedly received mixed messages around this type and other types of interaction. From the partners'
perspective, the survivors would display inconsistent behaviors frora one interaction to another, and not only in relation to sex. Partners reported feeling as if they could
do nothing right; that the rules changed continuously. PARTNER #5: . . . it was like, stay away with one hand and corae here with the other. PARTNER #1: . . . and those are very touch last week is told me I could or she [wife] has her ups and downs, fluid. Where she told rae not to gonna be different than where she couldn't touch this week. . . It 95
requires a constant understanding of where her boundary is. SURVIVOR #1: . . . I'm acting out . . . Acting out is the middle narae of any survivor. We've got so raany different ways to do it. We confuse the hell out of everyone.
Partners' Adverse Reactions Awareness of the sexual abuse reportedly produced reactions by partners which included blaraing the survivor, expressing disgust and anger toward the survivor, and feeling threatened by the survivor's continued relationship with her perpetrator(s). Such reactions were perceived by the survivors as contributing to a dysfunctional raarital systera. SURVIVOR #13: He [partner] felt insecure and threatened. He used a lot of things from [his own] therapy against me. SURVIVOR #3: My husband knew about it [sexual abuse], and we'd fight and he'd say, "Well, you just go over there and fuck your father. You liked it." He's jealous of ray father. PARTNER #3: I kept bringing it [sexual abuse] up 'cause I wanted to know. Because she stayed with thera [parents] all of the tirae whether herraotherwas there or not. And it really went throughrayraind,"She's still doing it [being sexual with her father]." SURVIVOR #4: He [partner] knew that I had been sexually abused by ray faraily, and he blaraed me [for it]. That's probably pretty much when our raarital probleras started because I was always tolerating hira telling rae, when we got into a fight, "Well, you screwed your brother." He blamed me because I didn't scream and kick and fight. PARTNER #4: I knew she'd [wife] been sexually abused, when we got raarried. It was a situation between her 96
and her brother. I really blaraed my wife for years. felt like she was a participant in the whole thing.
I
Impact of Therapy on the Marital Relationship The premise of systeras theory suggests that change in one part of the systera will have an effect on all other parts of the same system (Becvar & Becvar, 1988; Keeney, 1983; Watzalwick et al., 1974). The experiences of the
couples in this study stand as an example of the premise of systeras theory in operation. Although the amount of marital
therapy they received wasrainiraal,the otherraodalitiesof individual and group therapy, as experienced by these participants, had a direct irapact on their marital relationship.
Positive Impact The positive impact of therapy on the marital relationship was not araajortheme addressed by the couples. It is mentioned here merely as a counterweight to the more prevalent negative aspects discussed below. There were only
two direct references made regarding the positive impact past therapy had on theraaritalrelationship: (a) enhanced
couple coraraunication, and (b) forced focus of the partner on his personal issues. PARTNER #15: It helped us open up a lot to each other. . . . We felt secure in talking to each other about our feelings and our eraotions rather than just talking in light sentences. 97
PARTNER #17: [Wife's therapy] forces rae to have to be there. It provided an avenue for both of us to feel accepted and safe with whatever is going on. . . . It's been real positive for both of us. Her experience has been good, and yet the vicarious effects that I receive enable rae to be a part of that. I think it's been real good. References toraaritaltherapy tended to focus on how additional raarital therapy would be helpful, and is discussed later.
Negative Impact Past therapy experiences were also seen by the participants as having a negative irapact on their marital relationship. Many of the ways in which therapy adversely
affected the marital relationship have been previously discussed in earlier sections of this chapter. To
reiterate, therapy was seen to negatively impact the relationship by producing emotional volatility in the survivors, forcing rauch of the relational energy to be focused on the survivor's abuse issues, and adding financial strains to an already taxed marital system. SURVIVOR #3: The therapy seems to be making the marriage even worse, and he's angry that I r using the 'a raoney. He hated me going to therapy, and I'd have to sneak money and hide it to pay for [ a therapy]. ry SURVIVOR #4: Poor old [partner], I really felt sorry for hira a lot of tiraes. I'd go to group and I'd be angry. It was really hard to corae in frora therapy and say, "I realize I have been distraught, but I have to cook supper and be araaraaand a good little wife." . . . . He was real good about leaving rae alone then. I guess he knew that was in his best interest!
98
Additional factors of therapy which were specifically identified as negatively irapacting theraaritalrelationship included: (a) directives frora the therapist; (b) partner
conflict with the therapeutic process; and (c) unsolicited change in marital functioning. Directives from therapist. Many tiraes direct
instructions or interventions frora the therapist were perceived by the couples to be disruptive to their raarital systera. Survivors frequently reported feeling trapped
between the instructions of their therapist and the coramitment to their partner and raarriage. SURVIVOR #3: She [therapist] wanted hira [partner] to go to therapy, but he refused. So [therapist] told me, "You've gotta get out of there [the marriage] or I can't see you anymore. I can't help you because he's too abusive." So I left hira. . . . I ended up going back to hira. SURVIVOR #5: He [partner] would ask rae, "How was your therapy?" I never discussed it with hira. She [therapist] basically outlined, "Don't go horae and talk about this with your spouse." SURVIVOR #6: I would ask her [therapist] if [partner] could be a part of ray therapy so he could understand, and she told me that she would rather not. She did not want hira involved. . . . I wasn't even supposed to tell hira anything she told me. Participants referenced their sexual relationship as being the part of their marriage most negatively impacted by past therapy experiences. PARTNER #1: There are tiraes when, as a result of what she [wife] is dealing with in therapy, that we are not sexually intiraate. . . . I know sexual intiraacy is pretty dangerous eraotionally if we atterapt to do it on the night of her therapy. 99
PARTNER #3: When we first gotraarried,we had really good sex. Iraean,good sex. . . . Then she [wife] got into therapy and she brought these books home that her therapist had given her. And it said in there, "Sorae survivors raay hate sex. They raay not like it." And ever since then, she didn't like it. PARTNER #4: We've always had a problera with our sexual relationship. But during that counselling tirae, she just wasn't all that interested. . . . She usually puts up with me, but during that time, she just didn't want to put up with me at all. SURVIVOR #16: [Therapist] has suggested we don't have sex. That's just out of the question, [He] told me that as long as I do that, I am not going to get better, I just don't think he [therapist] ever looked into what I want as a person, because I can have sex if I want to. Partner conflict with the therapeutic process. The
participants of this study were unanimous in their belief that therapy ultimately was a beneficial and essential part of recovery. At tiraes, however, some partners were
perceived to be in conflict with the therapeutic process, SURVIVOR #7: His [partner] view of therapy and my view of therapy are two different things. He hates and despises it, and thinks it's not worth the tirae that is given to it. And I disagree. SURVIVOR #8: He [partner] and other faraily raerabers have questioned, "Is this getting worse, not better? How can therapy help when you're just wallowing in your probleras?" . . . He doesn't understand. He feels that [therapist] is leading me away, or leading me astray. SURVIVOR #13: He [partner] wasn't involved in ray therapy at all. He felt if he got involved, she [therapist] would side with rae and say, "You're looking at this all wrong. Can't you see what she went through?" He wanted soraebody to say that his feelings and his reactions were all right, and that everything I had done was wrong. Unsolicited change. As many therapists can attest,
change to any relational system is not always welcomed or 100
supported by the systeraraerabers.When change does occur, all members of the system are forced to adapt to an unfamiliar mode of operation and functioning. As the
following quotes exemplify, changes which occur as a result of the therapeutic process can disrupt familiar patterns, thereby resulting in marital discord, SURVIVOR #14: He [partner] didn't understand that things just wouldn't go on the way they had. There was a new emergence of me, I had to come from under cover. [In the past], he was always trying to run the show, and now it's different. He was real confused by that. SURVIVOR #7: All these years I've done what he told me to do. And then, getting into therapy, I was learning I didn't have to any more. And so, when I started making those decisions, he assuraed I was doing what the therapist was telling rae to do. We would fight, and I would say, "No, I'm doing what I want to do." SURVIVOR #4: , , , and when this [sexual abuse] surfaced, we quit going to marital therapy, and really didn't work on our marriage any raore. We raore or less kind of raade a coramitraent that we would survive in our raarriage until we could deal with the rest of this [sexual abuse].
Partner Involvement in the Recovery Process The raethods andraagnitudeof partner involveraent in the recovery process of adult survivors is a topic for consideration for clients and therapists alike. Involveraent
raay include the partner's active participation in therapy itself, or taking raore of a supportive role by offering a nurturing atraosphere at horae for the survivor. The results
of this study revealed that unstructured partner involveraent can pose a threat to the survivor's recovery. 101 However, the
total absence of partner involvement and support can also impede therapeutic progress. The positive and negative
aspects of partner involvement in the survivor's recovery from childhood sexual abuse are discussed next. Following
that, examples of the advice partners and survivors would offer other partners about their involvement in the therapeutic process are presented.
Positive Aspects The benefits gained from partner involvement demonstrate that this can be a positive addition to the survivor's therapeutic process. The majority of the
participants indicated feeling confused about the partner's role in the therapeutic process, and experienced limited, and often sporadic, partner involvement. Survivors were
emphatic that partner involvement was essential for adequately addressing individual and marital issues. SURVIVOR #2: If [partner] had not been willing to be involved, I don't think I would have had the courage to address these issues. I would have kept it sealed in. SURVIVOR #3: I don't think a survivor can heal unless the man, or whoever is in her life, is supportive, and caring, and wants to know what's really going on.
Negative Aspects In contrast to the positive aspects of partner involvement, overinvolvement by the partner placed stress on the recovery process and the raarriage. Although survivors 102
indicated a desire for raore partner involvement, inappropriate involvement of the partners was depicted by the survivors as being intrusive and disrespectful. Sorae of
the woraen in this study experienced this type of partner involvement which they felt had a negative impact on their recovery process and theirraaritalrelationship. SURVIVOR #3: . . . It's really been hard to journal. I still don't trust my husband enough to write my true, honest to God, feelings in that book. He does read it, and I can't stop him. He says that we're married, and that there's nothing we can't share. He wants to find out if there's anything new, and then he will take and use it against rae. SURVIVOR #7: He [partner] would always ask rae, "Well, what did you talk about [in therapy]." Anytirae I ever told hira anything, if we ever later got into an argument, he would find a way to sting me with it. So I got to where I didn't tell him anything, anymore. Then he'd accuse me of keeping secrets. SURVIVOR #12: I don't really talk to him [partner] a lot because he gets real angry. He gets real angry at my dad. He can't stand to be around him, and I can't talk about all this with him. I'm gonna deal with it, and not let him help me. He can't handle it.
Advice to Partners In regards to partner involveraent in the recovery process, participants were asked to share the advice they would offer other partners of adult survivors. The value
and richness of their responses is evident in the examples presented here. The predominant suggestion raade by survivors and partners alike focused on the need for the partner to acknowledge and address his own issues. 103 Specifically,
partners were urged to seek an appropriate support group for networking with other partners of survivors, and to recognize their own personal probleras and how these probleras impact their marital relationship. SURVIVOR #11: I felt that [partner] had some issues from his life that he needed to work on. And that if he had gone through some of this therapy process, it could have helped us connect better. That may be some of the problems we are having right now. I've gone through all this stuff, he's gone through stuff, too. Your spouse has got issues, too, and maybe he needs to look at these. I think that would feel really good to me if he would realize that he has some issues. SURVIVOR #17: He [partner] should be told that he should go to therapy, he also needs a support group. And if this were part of the therapeutic process, they could quit seeing it [sexual abuse] as her problem, so that she's not being pointed out as the sick one, SURVIVOR #1: Find some other people that are going through what you are going through, and they are few and far between, because few raen stick it out with us. You need a place to talk about the weird shit that we survivors do. You've gotta have a place to discharge, PARTNER #12: I did learn that I needed to work on rayself, I needed to corae face-to-face with sorae of ray own issues, I needed to not get sucked into trying to focus on ray wife's issues to the extent that I didn't see ray own needs, , , , There needs to be a balance, you need to be there for her but you also have to be there for yourself, PARTNER #13: Through learning about rayself, I learn a little bit raore about [ a wife]. Through getting in ry touch with ray own needs, I r a little more respectful 'a of her needs, SURVIVOR #2: There were patterns that had evolved over years of being married. We began to identify them and work on thera. We went [to therapy] knowing that we both had issues. I'd already identified that I suspected sexual abuse. But it wasn't that ray husband was going along to see what ray probleras were. He was adraitting that he had contributed as rauch to our unhappiness. 104
SURVIVOR #1: You [partner] need to look at your issues, and you need to be educated to know, you're gonna do this again in your next relationship [if you don't deal with it now]. Another strongraessageparticipants voiced as advice to survivors' partners is suraraed up in their words, "Be there." Participants felt it was very iraportant for the partner to be responsive to the survivor's requests, but acknowledged that the requests were raany times confusing and difficult to discern. Consequently, the partners were forced to rely
heavily on their patience and any level of understanding they possessed. PARTNER #8: . . . If they [wives] don't want you to touch them, don't touch them. If they want you to touch them, touch them. If they want to talk, listen. If they don't want to talk, shut up, don't say anything. . . . Dance their dance. Move with them instead of moving away from them. . . , It's gonna get deeper, and it's gonna get colder, and it's gonna get harder . , , SURVIVOR #1: Back off and take your cues from her. Be there for her. Let her be real weird, because she is gonna be real weird, and she's gonna get weirder before she gets better. . . . Take seriously what she is going through and what she is saying, and don't miniraize. PARTNER #1: You have to put your friendship and your love for your partner ahead of your sexual relationship and your unchecked sexual drives. . . PARTNER #9: You have to pretty rauch throw your needs out the window soraetiraes. Forget about your needs because they're not gonna be raet. And if that's a problera for you, then you just need to get into counselling, or chuck the whole thing 'cause you're not gonna make it. SURVIVOR #5: He [partner] needs to ask her what she needs right then. And whatever she says, do that. If she says, "Hold me," then hold her. If she says, "Just leave rae alone," then leave her alone. . . . Let her set the pace for the relationship. 105
PARTNER #5: . . . it will get better, but it's gonna take time. How much time, I don't know. And it raight get worse before it does get better. The iraportant thing is to give her roora, give her space. Don't push her, don't force her to have sex. . . . Just kinda be there when she needs you. Most of all, be extreraely patient. SURVIVOR #2: , , , Patience. It will feel impossible, but be patient. That's what they need . . . an extra dose of compassion and patience. PARTNER #13: . . , keep an open mind and realize that the root of the problera is way back in the past. . . . Realize that you gotta be the strength for her. That's your role for a while. As noted earlier, coramunication continued to be an issue that the participants felt warranted focused attention. An integral part of communication involves being Often times, survivors indicated a
able to listen.
preference for their partners' willingness to listen as opposed to their partner's attempts to discuss the therapeutic process. SURVIVOR #8: I would advise him [partner] to listen. Rather than taking her [survivor's] experience and reacting or responding to it for yourself, try to see what it's like to be her, PARTNER #8: , , , the biggest thing is just trying to listen and understand. And that's a tough, tough thing to do sometiraes, SURVIVOR #6: I can tell hira if I r having a problem, 'a or if I r having a flashback. He will sit down and 'a talk about it with rae, or he'll just listen. He's been real understanding, SURVIVOR #12: I just wanted hira [partner] to be able to listen to rae, and to know what I r going through, 'a but I don't want him to get his eraotions all stirred up. That's what I would tell other partners.
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Finally, participants advised partners of adult survivors to learn all they could about childhood sexual abuse, PARTNER #17: They need to read everything they can get their hands on, , , . They need to ask a whole lot of questions and know that raany of the responses they get are not going to be good. SURVIVOR #2: The advice I'd give is, "Read, read, read the books." Read whatever books she's reading, and dialogue with her about it. SURVIVOR #1: They've gotta get educated about it [childhood sexual abuse]. For exaraple, that book that goes along with Courage To Heal [Allies In Healingi is written for partners, and that's been real helpful to [partner]. SURVIVOR #13: When I would read The Courage To Heal, he [partner] would sit down and read with me and would ask, "What part of this relates to you?" or "In what part do you see yourself?" Then we would discuss what I had worked through and what I had remerabered. It was very helpful and affirraing. I think other partners need to know that.
Suggestions for Iraproveraent The participants were able to be very specific about what they perceived to be absent frora their therapeutic experiences. The result is a clear conceptualization of (a) psychoeducation
areas for consideration which include:
about the effects of childhood sexual abuse, (b) more emphasis on the partner/therapist relationship, (c) supplemental integration of marital and sex therapy, (d) integration of faraily therapy and parenting skills, and (e) erapathy for the partner's needs.
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Psychoeducation Perhaps the raajor coraponent which was lacking frora the participants' past therapeutic experiences was a full explanation by their therapists of the raraifications of childhood sexual abuse. Survivors and partners alike
repeatedly referred to the need to know early on what they were facing. PARTNER #5: I had to learn everything the hard way, but if the spouse was inforraed of what was going on, he might be a little bit raore understanding with his wife. SURVIVOR #11: We just needed education. We needed a class or soraething that would say, "Here's what is sexual abuse and how it affects people. Here's the dynamics that probably went on in your family. Here's what the healing process requires." We felt like we just kinda walked down a blind path. Education has not really been done with survivors and partners. The education I got is because I read and I dug for it. PARTNER #11: I think the spouse can be helped more if you bring him in early and talk to him. You need to have at least one session with him at the very beginning, where you sit down and say, "Okay, let me tell you what is going to occur." SURVIVOR #3: The first thing we need is to be educated on incest and its effects . . . enough to get knowledge and understand what's going on. Maybe just three sessions would do it. PARTNER #15: . . . I think that would have really helped us, for [therapist] to have sat down and really explained sexual abuse to me . . . because I felt dumb. I felt, here I am, a college-educated man, a successful man, and I don't know one cent's worth of what sexual abuse is about. PARTNER #11: [Wife's] major criticism early on in therapy was that she had no idea what was going on. She was not getting an idea about what was coming out [of therapy]. . . . She wanted to know where she was going.
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The participants' plea for more timely information is understandable given the elevated state of confusion so often reported in their interviews.
Partner/Therapist Relationship Another area for improvement, as seen by the participants of this study, involved the need for the therapist and partner to remain in contact throughout the therapeutic process. The importance of the therapist
remaining accessible to the survivor has been discussed in an earlier section of this chapter. Partners also expressed
the importance of feeling free to contact the therapist in times of need. PARTNER #3: I can call her therapist and I can just get a "Yes" answer and I feel one hundred percent better. SURVIVOR #8: What would be ideal is if [therapist] would work with us both. Somehow, then, we would be able to develop a relationship between [partner and therapist] so that there wasn't such an alliance between rae and [therapist] against [partner]. I don't like that at all, I really don't. PARTNER #17: There have been a couple of times when things have been so crappy, at the house, that I didn't know what to do. And I have called [therapist] and I have gone in. I have access to her to be able to do that if I need to. SURVIVOR #17: He [partner] needs to be able to be in touch. I think as part of the [therapy] process, he should be told he should go to therapy, or that he can call when things get rough.
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Supplemental Integration of Marital/Sex Therapy As noted earlier, 12 of the couples had received marital therapy; however, only 2 reported that marital therapy directly addressed sexual abuse issues. Although
the desired amount of increased raarital therapy varied araong the couples of this study, all of thera expressed a desire for raore. Marital therapy was seen as being beneficial in helping the partner become raore involved, educated, and understanding of the survivor's past and present experiences. INTERVIEWER: If you were talking to a roora full of therapists who traditionally work with the survivor only, regardless of the marital status or the relational status of that person, how would you address that? PARTNER #1: I would tell them they're making a mistake. . . . I think it limits it because so much of this is a relationship issue. . . . You're gonna have to have soraebody on the other side, the spouse, that is willing to go through it and support. . . . I don't think that the survivor can recover without the spouse. I really don't think they can do it. PARTNER #8: Once you [therapists] find out what the raarital relationship is like, consider including the husband, at least a little bit, in some joint sessions. SURVIVOR #4: As I look back on all this [sexual abuse], dealing with it is more of a relational issue than just a personal issue. PARTNER #9: I would think that it is a very important component to deal, at least to some degree, with what is happening in the raarriage. SURVIVOR #6: It's very hard having been sexually abused. You start pushing that abuse more into your present relationship than dealing with it. It becomes your present, like it's happening now, all over again. 110
And in both of us going to therapy, it's both of ours, it's affecting both of us. PARTNER #17: I think there should always be some ongoing, periodic couple's therapy. It doesn't matter how much you know, when you're involved with a survivor, different stuff comes up. And all you know goes out the door. And it's [marital therapy] about going in and re-clarifying objectives and goals, and the relationship itself. SURVIVOR #14: I would recommend therapy, but I would also recomraend if she [survivor] is married, that her partner be in on it from the very first. Couples expressed a need to have their sexual relationship addressed more. Perhaps in no other arena of
intimate relationships is the residual effect of childhood sexual abuse more pronounced than in the sexual arena (Maltz & Holman, 1987; Westerlund, 1992). It is in the sexual
relationship that all of the relational factors of childhood sex abuse surface: trust, fear, touch, insecurity, confusion, etc. PARTNER #12: There's a lot of skills I didn't grow up having . . . as far as my sexuality and her [wife] sexuality [goes] . . . communication skills, and just understanding sometiraes how a relationship works. I think raarriage counseling would be great . . . SURVIVOR #3: We needed to go to therapy for a lot of things . . . and about sexuality. That's one of our main, main, raajor probleras. . .
Integration of Faraily Therapy and Parenting Skills In addition toraaritaland sex therapy, participants also expressed a desire for an opportunity to address family and parenting issues. Survivors stated they were comraitted 111
to seeing that their own children would not have to experience childhood trauma of any kind. Learning more
about appropriate parenting techniques and how to address sexual abuse issues with their own children was felt to be a missing element in therapeutic services offered to adult survivors. SURVIVOR #11: I can see a point when the whole family is pulled in together [for therapy], and having some group-sharing time with other families, for support. . . . The children in the family are very iraportant, and they need education. They need to know what has happened to Mora, and how it may affect the family, and that they are not alone. PARTNER #7: . . . Maybe therapists don't encourage having everybody there [in therapy]. Maybe it'd be harder to get all the issues to the surface, but, hey guys, kids are affected by it [sexual abuse], too. SURVIVOR #1: Someone needs to help us with parenting. How do you as a parent not send out bad messages about sex? How do you help your children establish healthy boundaries? How do you do this as parents together? We need to be educated. SURVIVOR #12: I see ray issues coraing up with her [daughter]. I'm constantly worried that soraething may happen to her. It's hard for me not to be overly concerned about her well-being because nobody seemed concerned about raine when I was her age. And I don't know if all ray concern is good for her. Maybe therapy would help with this.
Erapathy for Partner's Needs The participants also eraphasized a need for others to appreciate and validate the partners' atterapts to be supportive, and to show erapathy for the partners' position. Partner support groups and increased awareness by the
112
survivor of her partner's difficult role were specifically referenced in the interviews. SURVIVOR #17: What about his [partner's] needs? What about when the survivor coraes horae and starts taking it out on hira? The survivor needs to be told that they can't just go in and act out everything on this raan. He has his needs as well. Go ahead and cry, bitch, raoan, whatever you need to do, however, don't beat him up and call him a son-of-a-bitch. PARTNER #2: It would seera like araen'sgroup for partners would be good. . . SURVIVOR #13: If I had been allowed to corae in just to sit and listen to what he had to say [in his therapy], I think it would have let me have a better understanding of why he acts the way he does at times. I could have understood my husband better, and what he was going through, as well. SURVIVOR #11: We never did couple therapy, but one of the reasons I wanted to was because [partner] did not have any support like I did, a chance to tell his side, a place to release his anger or vent his frustrations. He hadn't had any of that throughout the whole process. He had just been the one watching rae corae in and go out.
Suraraary The participants of this study offered explicit descriptions of the unique issues facing married adult survivors. The complexities of a marital relationship can
become magnified when introduced to the phenomena of childhood sexual abuse. The demands of a committed
relationship require that special attention and energy be focused on such issues as trust, communication, and physical and sexual intiraacy, all of which have been shown to be
113
probleraatic for the adult survivor of childhood sexual abuse. The systeraic consequences of the survivor's past
sexual abuse becorae a personal issue for the partner as a secondary victira.
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CHAPTER V DISCUSSION AND CONCLUSION
This final chapter will suramarize and interpret the results of this study. First, a discussion of each of the
raajor topics of Chapter IV ("Entering Therapy," "Therapy for Sexual Abuse Issues," "An Assessraent of the Therapeutic Process," and "Marital Issues") will be presented. Next, a
discussion of reliability and validity issues and the liraitations of the study will be addressed, followed by the theoretical, clinical, and research iraplications of the findings.
Discussion Entering Therapy The results of this study confirraed that childhood sexual abuse issues are rarely the presenting problem of adult survivors and/or their partners. Instead, other
symptoms such as depression, substance abuse, suicidal tendencies, and relational dysfunction are coramon complaints. Previous studies of childhood sexual abuse
identified depression, fear, anxiety (Briere, 1984; Finkelhor, 1984, 1979; Gelinas, 1983; Gorcey et al., 1986; Russell, 1984), and relational and sexual dysfunction (Bass & Davis, 1988; Briere, 1984; Courtois, 1979, 1983; Herman, 1981; Maltz & Holman, 1987; Meiselman, 1978; Westerlund, 115
1992) as comraonly presented symptoms of woraen who had been sexually abused as children. As the different symptoms become problematic, the survivor and her partner raay enter therapy for assistance with those issues raost easily identified. Problera-focused
therapy may allow for temporary relief of the symptora, but the underlying issue, childhood sexual abuse, raay manifest itself later as a different symptom which brings the couple or individual back into therapy for more temporary relief. Consequently, a pattern of entering and exiting therapy becomes established, and the unaddressed issues of childhood sexual abuse continue to fester until they burst through the surface. For many survivors, it is not until they enter therapy that they become aware that past experiences can be defined as being abusive or problematic. Sorae survivors do not
realize that these experiences are not coramonplace in non-abusive farailies. While these experiences are undesired and trauraatic, they becorae a norraalized coraponent of the survivor's faraily systera. Norraalization andrainiraizationof
the sexual abuse offers the survivor a way to deny the power this childhood trauraa continues to have over her adult life. Therapy itself redefines the survivor's experience as being catalytic, and through this refrarae, the adult survivor begins to recognize theraagnitudeof the trauraa of childhood sexual abuse and its lifelong impact. 116 Once the sexual abuse
was acknowledged and accepted by the survivors of this study as being their core issue, they became hypervigilant in their attempts to eradicate the power the abuse still had in their lives.
Therapy for Sexual Abuse Issues Based on the descriptions by the participants of this study, sorae therapists are emotionally and professionally equipped to work well with childhood sexual abuse issues, and some are not. SURVIVOR #1: I'd done independent therapy, which really was not that helpful for me, with a psychiatrist. . . . I don't think he knew what else to do with someone like me. He didn't have the techniques. . . . [H]e was poorly trained. He probably dealt more with schizophrenics, people that you raedicated the hell out of because, if you didn't, they were dangerous. SURVIVOR #7: If they're [therapists] aren't comfortable [with sexual abuse issues] then they don't need to be doing therapy with a survivor. In fact, participants expressed concern that a therapist who is unwilling to address sexual abuse issues could actually be harmful for a recovering adult survivor. Care must be taken when the survivor is selecting a therapist with whom to work. Unfortunately, financial The
concerns raany times dictate the therapist of choice.
cost of therapeutic assistance can prevent survivors and their partners from receiving the services they feel they need. Given the current changes in the mental health care
system which provide limited therapeutic coverage, 117
therapists and coraraunities raust find ways to develop resources of Qualified therapeutic assistance. Another clear raessage from the participants of this study addressed the necessity of building a strong therapeutic relationship between the client(s) and the therapist. The important factors of such a relationship
include the characteristics of the therapist, his/her accessibility and availability, and the establishment of adequate therapeutic boundaries. The importance of a
positive relationship between the therapist and client, as well as the therapist's personal qualities, is well documented in the therapeutic literature (e.g., Gurman & Kniskern, 1991; Horwitz, 1974; Strupp, 1983). According to the couples in this study, the therapist must be willing to take the tirae to establish a safe and trusting relationship with the client(s) before directly addressing childhood sexual abuse issues. The araount of tirae required to establish this relationship will vary between clients and between therapists. Taking the tirae to
do this, however, poses a dilerama when the health care systera pays for such liraited therapeutic services. It was also iraportant to the survivors and partners that the therapist show sincere interest in wanting to understand what their experiences have been. The therapist
listening to what the client(s) have to say without "puraping
118
them for information" or placing meaning on it prematurely was also important for successful recovery. For survivors, the gender of the therapist is a significant factor in the therapeutic process. Other
researchers have also found gender issues to be of significance when addressing therapy outcorae (Lieberraan & Lieberman, 1986; Strupp, 1983). However, to assume that all
female survivors prefer to have a female therapist would be a mistake. The results of this study revealed that what may
be more significant to the survivor is the freedora to choose a therapist, rather than the therapist's gender alone. freedora to choose appears to be raore significant for survivors, especially once the therapeutic bond is established. Another therapist trait which was uniquely addressed in this study was the survivorship status of the therapist. Although it was not necessary for the therapist to be an adult survivor in order to work with adult survivors, the survivors expressed having a personal need to be advised early in the therapy process if the therapist was, indeed, a survivor. Other iraportant issues for survivors in therapy included the therapist's accessibility, and the establishraent of therapeutic boundaries. The survivors and This
partners expressed feeling secure in the knowledge they could reach their therapist in times of crisis. 119 There was
no evidence that the participants in this study took undue advantage of the therapist's willingness to remain available. Accessibility does not need to raean providing a
home telephone number to a client, as one therapist did, but it does mean having a 24-hour answering service that knows how to reach the therapist promptly. Establishment of therapeutic boundaries involved helping the clientraaintaina sense of autonomous self. Survivors were appreciative of those incidents when the therapist would validate them as having personal characteristics that were not defined solely by their survivor status. Also, allowing the client toraaintainsome
control over the therapeutic process by defining the pace and araount of partner involveraent was affirming of the survivor's personal capabilities. The treatmentraodalitiesused in therapy with adult survivors of childhood sexual abuse were also addressed in this study. The results show that there exists a common
progression of survivors from individual therapy into group therapy. That this moveraent is viewed as a progression is
no raistake. There is a sense that survivors must advance therapeutically to earn the opportunity to join a group. This evaluation is most often determined by the therapist, and is apparently based on the therapist's sense of strength and preparedness of the survivor.
120
Interestingly, survivors perceived that therapists most often preferred thera to attend group sessions if financial constraints prevented thera frora attending both raodalities (individual and group). The majority of the survivors,
however, expressed a desire to continue individual therapy in a tight financial situation. This study also revealed that marital therapy tends to be a small to nonexistent component of the therapy experiences of married adult survivors. For those who
received marital therapy, the extent to which such therapy directly addressed childhood sexual abuse issues was even smaller, indicating the absence of this modality as a coraponent of the therapeutic process.
An Assessraent of the Therapeutic Process Frora the results of this study it can be ascertained that the overall perception of the therapeutic process, as experienced by the participants, was that therapy was absolutely essential. This perception is in keeping with
the nuraerous studies of therapy effectiveness which show that raost clients benefit frora therapy (e.g., Gurraan & Kniskern, 1978a, 1991; Luborsky, Singer, & Luborsky, 1975; Sraith, Glass, & Miller, 1980; Strupp, 1983). A raore detailed assessraent of the therapeutic process revealed that the traditionalraodalitiesof individual and group therapy were perceived by the participants as being 121
equally beneficial and essential.
This belief held true
even when taking into consideration the eraotional and financial costs of therapy as experienced by the survivors and their partners. It was obvious, however, that survivors
were able to address more of the positive as well as the negative aspects of therapy than were their partners. Perhaps this is an indication of the lack of partner inclusion in the therapeutic process. That is, the partners
found it difficult to expound upon the positive aspects of the survivors' therapy experience because of their exclusion from the process. As detailed in Chapter IV, the specific benefits realized from individual therapy included: (a) providing
safety, security, and a sense of privacy for self-disclosure with one trusted individual; (b) feeling free from blame and responsibility; (c) discovering reasons for unexplained past behaviors; (d) relating the past sexual abuse to present behavior patterns; (e) developing a stronger sense of self; (f) learning to construct more stable personal and relational boundaries resulting in improved decision-making skills; and (g) providing a sense of hope for the future. Group therapy created an opportunity for: (a) identifying with other survivors; (b) developing a supportive network; (c) receiving vicarious therapy through assisting other groupraeraberswith their issues; and (d) assirailating other raerabers' positive attributes into a stronger sense of self, 122
all of which were experienced by the participants as positive results. The reason these experiences were seen as beneficial by the participants in this study is open to interpretation. review of these experiences suggests a correlation between them and the validated sense of self one can receive from them. Each can be interpreted as being conducive to A
assisting the survivor in attaining a sense of identity which is differentiated from her survivor status. In fact,
an unspoken measureraent of therapeutic success with adult survivors is their ability to differentiate the past (victimization) from the present (survivorship). This study also revealed that participation in the therapeutic process as a survivor or her partner is not void of unpleasant and negative experiences. The most frequently
referenced negative aspects of individual therapy included: (a) the eraotional expenditure required; (b) the exhaustive focus on self; (c) the adherence to the therapist's sense of tiraing; (d) the intentional exclusion of the partner in the therapeutic process; and (e) the resistance by the partner to systeraic change. Three factors which were reported to (a)
adversely affect the group therapy experience were:
concerns for confidentiality; (b) the inability to identify with other groupraerabers;and (c) the absence of group focus.
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A description of these experiences shows that, no matter how essential and, eventually, beneficial therapy can be for adult survivors and their partners, the benefits are not cost free. Of greater significance, however, is the
fact that, regardless of the costs, survivors and their partners continue to believe in the therapeutic process as an essential means of recovery from the trauma of childhood sexual abuse.
Marital Issues One of the prominent theraes which eraerged frora this study was the perception of the couples that childhood sexual abuse issues are relational issues for married adult survivors and their partners, not merely the survivor's personal issues. However, the absence of marital therapy
and integrated partner involvement in the therapy process is evidence that this relational perspective is not being directly addressed in the traditional treatment modalities of individual and group therapy. Sorae therapists will undoubtedly argue that relational issues da get addressed in individual and group therapy with the survivors. However, as noted earlier, there is evidence
that suggests conducting raarital therapy with only one of the partners raay not only be less effective, but raay indeed be detriraental to the stability of the marital relationship (Gurman & Kniskern, 1978a). As evidenced in Chapter IV, 124
partner exclusion from the therapy process can result in his feeling confused, alienated, and angry when confronted with unsolicited changes in the survivor's behavior and changes in the rules governing their marital relationship. Specific marital issues which the participants felt needed to be addressed as a couple included: (a) sexual
intimacy; (b) communication; (c) transference of anger toward the partner; (d) physical (tactile) intimacy; (e) patterns of behavior inconsistency; and (f) partners' negative reactions to the sexual abuse. Previous studies
abound which support the need to directly address the issues of sexual intimacy (e.g., Courtois, 1988; Gorcey et al., 1986; Gurman & Kniskern, 1991; Jacobson, 1978; Maltz & Holman, 1987; Westerlund, 1992) and communication (e.g., Birchler, 1979; Gurraan & Kniskern, 1977, 1978a, 1991; Jacobson, 1978). The evidence is sufficient to deraand that
addressing sexual intimacy and comraunication patterns should becorae a standard component of couples therapy. The marital
issues identified as being unique in this study involved transference of anger toward the partner, physical (tactile) intimacy, patterns of behavior inconsistency, and partners' negative reactions to the sexual abuse; none of these has been sufficiently addressed in the current literature. The couples of this study expressed a need for therapeutic assistance in: (a) understanding how childhood
sexual abuse manifests itself within the marital 125
relationship and (b) establishing appropriate role definitions for the partner. Participants did not perceive
that the traditional treatraentraodalitieswere sufficient in teaching thera how to accomplish their marital goals. the suggestions they had for improving the therapeutic service offered survivors of childhood sexual abuse who were in comraitted relationships involved incorporating psychoeducation as araeansof clarification. This is not One of
unique to this sample, as many references exist which address the benefits of a psychoeducation-based therapeutic model for dealing with issues such as schizophrenia (Anderson, Hogarty, & Reiss, 1980; Anderson, Reiss, & Cahalane, 1986), sexual dysfunction (Kuriansky, Sharpe, & O'Conner, 1982), attention deficit disorders of childhood (Dulcan, 1985), bulimia (Conners, Johnson, & Stuckey, 1984), and general family issues (MacFarlane, 1991). One of the
main benefits of the psychoeducation raodel, as put forth by MacFarlane (1991), is that it can help to achieve a rebalancing of family relationships. From the evidence
presented in this study, an integration of a psychoeducational component in treating adult survivors of childhood sexual abuse is clearly warranted. In addition to psychoeducation, the participants of this study also expressed a need for supplemental couples/sex therapy. As evident in earlier discussions of
the existing literature, sexual issues are a major component 126
of those issues addressed by adult survivors of childhood sexual abuse. The need to address sexual relationship
issues within the couple/marital context and effectiveness of doing so has been presented in previous studies (e.g., Gurraan & Kniskern, 1991; Heiman, 1986; Hof, 1987; Schnarch, 1991). The participants of this study were very clear in
their dissatisfaction with the lack of a couple/sex therapy coraponent in their past therapeutic experiences. In addition to integrating couple and sex therapy, the participants of this study suggested that some form of faraily therapy and parenting skills training be included in the therapeutic process. Concern was expressed that the
children of adult survivors needed to have sorae understanding of what was happening in the faraily system. Also, survivor parents wanted to know how best to parent their children in order to protect them from similar dysfunctional family systems. Gurman and Kniskern (1978a,
1991) found evidence to suggest the incorporation of the family and to add parenting skills training to therapeutic strategies.
Reliability and Validity The issues of reliability and validity must always be considered in erapirical research, whether the chosen methodology is qualitative or quantitative in nature. In an
effort to obtain valid data which was consistent with the 127
stated purpose of the study, specific decisions were made by the researcher regarding the project's research design and procedures.
Method of Data Collection In-depth Interviews The chosen raethod of data collection for this study was in-depth interviews which were audio-taped and transcribed into written versions of the interviews. Alternative
methods of data collection such as mail surveys, telephone interviews, or door-to-door surveys were rejected for different reasons. The sensitive topic of childhood sexual
abuse does not provide the researcher the freedom to mail, telephone, or knock on the door and begin asking questions about sexual abuse, while maintaining some sense of respect for the participant. For the researcher to do so could be
perceived by the participants as being intrusive and impersonal, thus jeopardizing the validity of the data. Through the events that led up to the actual interviews, the participants of this study were given ample opportunity to choose whether or not to participate. First
of all, the participants were provided a response form with the initial invitation to participate which they returned indicating their willingness to participate. Next, the
researcher telephoned those couples who indicated interest in participating, and explained the interview process. 128
Finally, prior to being interviewed, the participants were briefed on the confidentiality protocol, and asked to sign a written consent to participate. The face-to-face
briefing allowed the participants to assess the interview process and the interviewers raore corapletely. In addition,
by independently interviewing eachraemberof the participating couple simultaneously in separate offices, the chance that their responses could be influenced by their partners' presence was eliminated. This could not have been
as easily controlled by using mail, telephone, or door-todoor data collection techniques. These procedures ensured
that all participants of this study voluntarily participated and felt comfortable in doing so, thereby reducing concern that the data could be inaccurate.
Same-gender Interviewer When considering the issue of validity, it is necessary to examine researcher bias in the data collection process. In this case, interviewer bias should be addressed. in the designing phase of this research project, some consideration was given regarding the gender of the respective interviewers. Specifically, the question arose Early
as to whether the male partners should all be interviewed by the male researcher, and the female survivors be interviewed by the researcher's female assistant, or should the interviewers switch at some point in the data collection 129
process to include interviewees of both genders.
Other
sources (Lieberman & Lieberraan, 1986; Strupp, 1983) have presented gender issues as a legitiraate therapeutic consideration. Corabining this with the fact that two of the
first five male partners interviewed had stated they would not have been as open about their sexual issues had they been interviewed by the female assistant, the decision was made to keep the interview process gender-specific. Given
that most of the survivors in this study indicated they preferred a female therapist, this decision appears well founded. When forced to work with smaller sample sizes, it
is particularly iraportant to take every precaution to decrease the amount of biased data which raay result from extraneous factors such as, in this case, the interviewer's gender. Other factors such as the interviewer's style, body
language, and personal appearance, which could have had an effect on the interview outcome of this study, are open to speculation as they would be for any research project.
Inter-rater Reliability In identifying emergent themes from the interviews in this study, researcher bias was addressed by utilizing some level of inter-rater reliability. As explained earlier in
Chapter III, the researcher and his assistant independently read all of the transcribed interviews, listing what appeared to be major themes that were repeatedly addressed 130
by the participants. A subsequent coraparison of the identified themes revealed a high level of consistency between the researcher and his assistant, providing evidence that the participants' responses were conceptually congruent. It must be acknowledged, however, that the interviews were guided by several specific questions which were designed to address the issues of therapy effectiveness. Although the interviews were not rigidly structured by the order or wording of the questions, the general theme of the interviews was kept within the identified scope of the project, and therefore could easily explain why the emergent themes araong respondents were highly congruent (see Tables 1 and 2). An open-ended, single question regarding therapy
effectiveness (e.g., "Tell rae about your therapy") raight have produced a less congruent collection of eraergent themes. However, it is believed that the themes identified
in this study would comprise a major portion of the themes that might have arisen frora a single open-ended question. Another factor of inter-rater reliability in identifying emergent theraes involves the researcher's decision to arbitrarily choose nine as being the rainiraum nuraber of survivors or partners who identified a therae before it was considered to be an emergent or common theme of the interviews. This is not to say that any theme
referred to by the participants less than nine tiraes was 131
insignificant or unimportant.
However, it would be
impossible to include in this document every issue that was identified by the participants as being an important component of their therapeutic experiences without virtually reproducing the transcribed interviews in their entirety. Therefore, the miniraura level of nine occurrences was arbitrarily chosen in an atterapt to provide an adequate suminary of the raost coraraonly addressed aspects of the participants' experiences and assessment; nine represented a majority of the respondents.
Sample The sample for this project was highly selective in that the couples had to meet certain selection criteria to be considered as appropriate candidates. These criteria
have been outlined in Chapter III of this docuraent. Selective sarapling refers to a decision raade prior to beginning a project to saraple subjects according to a preconceived, but reasonable initial set of criteria (Sandelowski, Holditch-Davis, & Harris, 1992). As a result,
several questions arise as to how these selection criteria might affect the project's outcorae. Saraple-specific issues which should be considered when interpreting the results of this study include the facts that the couples tended to be pro-therapy, had intact raarriages, were college educated, and reported raiddle-class 132
incoraes. All of these factors could have an irapact on the outcorae of this study, including the participants' ratings of therapy effectiveness and identification ofraajortheraes However, given the similarity between the themes identified in this study and those addressed in other discussions of adult survivors, the reliability of such themes is not suspect. Another issue regarding the sample for this study involves the inclusion of the two pilot couples as raerabers of the participating population. The decision to include
the couples in the final analysis was raade after the data from the other couples were analyzed. It was discovered
that information gained frora the pilot interviews was congruent with that collected frora the other couples, and could be included in the saraple without contaminating the data.
Participants' Responses to the Study Participants' responses to the study also present evidence of reliability and validity. Post-interview
evaluations obtained frora the participants of this study revealed that couples reported no detriraental effects frora their participation in the project. In raany cases, they
stated that the interviews were beneficial and even therapeutic for thera. Qualitative research which obtains valid data on sensitive topics has been found to have a 133
therapeutic role, a factor that influences both the nature of knowledge developed frora the research, and respondents' well-being (Collins, Given, & Berry, 1989; Cowles, 1988). The researcher also received reports frora sorae of the participants' therapists that their clients had expressed positive feelings about their participation in the interviews. In addition, it is difficult to question the
"truthfulness" of responses from a sample that included participants willing to travel up to 120 miles for the interview to discuss painful issues surrounding childhood sexual abuse.
Representativeness and Generalizability In quantitative research, sampling is based on selecting a portion of the population to represent the entire population for generalizability (Strauss & Corbin, 1990). In qualitative research, the major concern is with
representativeness of concepts. not of the sampled population. Therefore, the sample interviewed for this
study cannot be said to be representative of any population outside of the specified criteria. However, the occurrence
(i.e., representativeness) of the concepts of emergent themes araong theraerabersof the saraple couples in this study has been docuraented and discussed in earlier chapters. According to Strauss and Corbin (1990), in terras of making generalizations to a larger population, qualitative 134
research does not attempt to generalize as such, but to specify the conditions under which the phenomena exist. is generalizable to those specific conditions only. The specific conditions and process of sarapling in this study have been clearly defined, and the representativeness of the concepts is evident in the quotes frora the participants themselves. The question remains, however, It
"Would the same results (emergent themes) be found in a larger saraple, one with more characteristic diversity, or by using more open-ended questions?" The answer to such a
question would require a different methodological approach, and is not within the scope of this exploratory study.
Liraitations This study was exploratory and descriptive in nature. While the specific goal of this study was to understand clients' perceptions of the effectiveness of past therapeutic experiences, the initial goal was not to prove or verify any existing theory. Although the results of this
study may clarify certain theoretical issues, verification of the present results by employing different research designs is the next necessary investigative step. The collection of data which are sensitive and perhaps emotional in nature entails certain difficulties for any researcher involved in this type of project. Data obtained
from within this context could potentially be liraited by the 135
respondents' unwillingness or inability to disclose to the researcher inforraation they consider to be daraaging to the self, the partner, or the relationship. The issues
addressed with raost adult survivors of childhood sexual abuse are particularly sensitive to feelings of sharae, secrecy, embarrassraent, and guilt, any of which could be perceived by the survivor as being personally damaging. Like most qualitative research, this study involves only a sraall nuraber of participants from a very selective population. The value in qualitative analysis lies in the It is
richness of the data, not the size of the sample.
likely that information gathered from this qualitative study would not have been available from quantitative methods of data collection. Nonetheless, the results of a study
utilizing such a small saraple size as this one cannot be generalized to be representative of the population as a whole, nor is that the purpose of exploratory research. Researcher bias is always a concern when conducting erapirical research, whether it be qualitative or quantitative in nature and design. The researcher's
subjectivity in analyzing the data for this study is fully acknowledged here. Personal perceptions, values, and
assuraptions are all an integral part of the data collection and analytical process.
136
Iraplications The results and subsequent discussion of this study have produced several points for further consideration. this section, the theoretical, clinical, and research iraplications of this study will be discussed. In
Theoretical Implications As noted earlier, the traditionalraodalitiesof treatraent of childhood sexual abuse are based priraarily on a psychoanalytical focus on the individual. The limitations
of such an approach to working with marital systems have been discussed in earlier sections of this paper. The purpose of marital therapy is to bring about change within the raarital system in an effort to restore interpersonal functioning. In the same light, individual To date, the role
therapy maintains an intrapersonal focus.
of partner involvement in the therapeutic process of adult survivors of childhood sexual abuse has not been sufficiently addressed. Direct partner involveraent in the therapeutic processing of sexually-sensitive issues, and the effects these issues may have on a relationship have been addressed most often in studies of sexual compulsion (Carnes, 1983, 1989, 1991; Earle & Crow, 1989; Sprenkle, 1987). Perhaps
this is due to the family-systems and interrelational perspectives of these researchers and family therapists. 137
The importance of the relational dyad is expressed in Games' (1991) statement that "if a committed relationship is involved, then that partner needs to be informed and also involved in therapy because sooner or later he or she must deal with the [problem]" (p. 252). Earle and Crow (1989) acknowledge the iraportance of marital and familial involvement as well. It is the contention of these authors
that if each individual in the family or relationship deals with recovery separately, some parts of the problem do not get treated. Given the complex nature of childhood sexual abuse, and the impact it tends to have, not only on the survivor, but on the people with whom the survivor must interact as well, a raore systeraic therapeutic approach would appear preferable. By including systeraic integration of all
raerabers of the relational systera as a coraponent of the therapeutic regiraen, breakdown of focus in the system could be miniraized, resulting in less confusion and frustration by theraerabersof the systera. The results of this study
support the contention that a systems perspective of therapeutic intervention may offer additional benefits to the married adult survivor and his/her partner which are not being realized from the current modalities.
138
Clinical Implicatinpg Given the lack of available inforraation regarding the effectiveness of therapeuticraodalitiesand interventions traditionally used with adult survivors, the results of this study have clinical iraplications and suggestions worthy of consideration. Most of the iraplications eraerge frora the
earlier discussion of the results, and frora the words of the study participants theraselves. However, several
iraplications warrant special attention and clarification, and they will be presented here. First of all, it is absolutely essential that therapists and otherraentalhealth providers becorae more sensitized to clients' presenting issues whichraightbe indicative of childhood sexual abuse. As Nadelson and
Polonsky (1991) have indicated, such a task is not necessarily an easy one. By continuing to educate
theraselves about childhood sexual abuse and its raraifications, therapists frora allraentalhealth professions can learn raore efficientraethodsof therapeutic assessraent. This is particularly relevant given the suspected high concentration of sexually abused women in the clinical population. In addition, therapists raust be willing and professionally responsible enough to address their personal issues around childhood sexual abuse. If they are not
emotionally equipped to adequately assist survivors and 139
their partners in dealing with sex abuse issues, therapists should not attempt to resolve their own issues by working through the issues of their clients. Because of escalating health care costs, which include mental health care, and rising insurance premiums, many survivors and their partners are not able to receive the services they need. New systems of financial support need
to be developed by therapists and public/governmental agencies. Private practitioners raight consider developing a
"package deal" in which a contracted araount of therapy involving all treatraentraodalitiesis provided the survivor couple for a specified fee, rather than requiring the clients to pay for each hour of service. Other clinical iraplications deraand that therapists remain sensitive to: (a) the need for survivors to know of
the therapist's survivorship status, (b) ways to remain easily accessible to their clients in time of crisis, (c) allowing the survivor client(s) to control the pace of therapy, and (d) validating the survivor as a person, not merely a survivor. The results of the participants' assessment of the therapeutic process clearly indicate that the traditional modalities of individual and group therapy should continue to be utilized as the foundation of therapy for adult survivors. The commonly used interventions of journaling,
bibliotherapy, networking, and experiential role-play were 140
seen as being beneficial.
Therapists who work with adult
survivors should continue to incorporate them in their treatment plans. Care should be taken when introducing a
survivor into group therapy to ensure a "goodness of fit" with the groupraerabersalready present. The purpose of the
group should be well defined and the focus adequately raaintained. Special attention should be focused on how the therapist raight successfully reduce the negative aspects of the therapeutic process. Perhaps the raost significant clinical iraplication of this study is the perceived need for a more systematic integration of supplemental marital and sexual therapy into the therapist's treatment plan. The participating couples
very clearly suggested that marital therapy in which the irapact of childhood sexual abuse was directly addressed would be of particular assistance in addressing: (a) their
sexual relationship; (b) comraunication skills; (c) empathy for the partner; (d) how childhood sexual abuse impacts their relationship; and (e) ways to differentiate the partner (present) frora the perpetrator (past). It was obvious that marital therapy as a continuous supplement to ongoing individual and group therapy was neither necessary, desired, nor financially possible. Instead, the couples felt it would be sufficient if marital therapy was a routinely experienced component of the overall treatraent plan, utilized to provide education about 141
childhood sexual abuse and the subsequent therapy process, and to act as a "re-grounding" tool and "reality check" in tiraes of relationship crisis.
Research Implications Given the fact that no previous attempt has been made to ascertain the effectiveness of therapy for married adult survivors and their partners, a qualitative assessment of the couples' perception was indeed the appropriate methodological choice for this project. One of the values
of qualitative research lies in its ability to be used as a theoretical springboard from which to launch new research questions and potentially testable hypotheses. The richness of the data collected in this study will provide a foundation for further development of subsequent research designs aimed at obtaining more inforraation about the therapeutic effectiveness of utilized treatraent raodalities for childhood sexual abuse. Using the
inforraation generated frora the in-depth interviews with the participants of this study, it is believed a comprehensive survey can be constructed for collecting data from a larger, more diverse saraple of adult survivors and their partners. Frora the data collected in this study, several questions eraerged which lend theraselves for further erapirical consideration. Though nowhere near coraplete, the
list might include questions such as: 142
1,
Which treatment modalities are most effective with
whichraerabersof the survivor population? 2, Do the issues ofraarriedsurvivors differ from the
issues of single and/or divorced survivors? 3, What impact do variables such as length of marriage
and severity of abuse have on perceived effectiveness of the therapeutic process? 4, Does the addition of marital therapy actually
enhance the survivor couple's perception of therapy effectiveness and/or marital satisfaction? 5, Does the araount of time spent in therapy influence
the survivor couple's perception of therapy effectiveness? 6, Is there a correlation between marital satisfaction
and perceived therapy effectiveness? 7, How does the level of partner involveraent irapact
perceived effectiveness of the therapeutic process? 8, Which raodel of supplemental integration of raarital
therapy has a greater positive effect on the survivor couple's relationship?
Conclusion As therapists we are allowed to enter sacred territory anytirae we sit with our clients in session. We must respect
having been given the privilege to tread with them in their pain, as well as to celebrate with them in their journey towards wholeness. As therapists we are often given the 143
opportunity to raarvel at the resiliency of the human spirit. Perhaps in no other population is this strength more apparent than araong adult survivors of childhood sexual abuse. It is the hope of this researcher that this study stands as a tribute to the tenacity and indoraitability of all who have emerged from the trauma of childhood sexual abuse as true survivors. Asraerabersof the therapeutic
coraraunity, the tirae has corae that we must listen to those who can best teach usour survivor clients. The road from
victim to survivor is one these men and women have carved frora their own pain and suffering; a road which provides hope for future survivors, and direction for the therapeutic coraraunity.
144
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Smith, C. G. (1967). Marital influences on treatment outcome in alcoholism. Journal of the Irish Medical Association, 6 i 433-434, f/ Smith, C, G, (1969). Alcoholics: Their treatment and their ^'ives. British Journal of Psychiatry. 115. 1039-1042. Smith, M. L., Glass, G. V., & Miller, T. I. (1980). The benefits of psychotherapy. Baltimore: Johns Hopkins University Press. Sprenkle, D, H, (1987), Treating a sex addict through raarital sex therapy, Faraily Relations, 36, 11-14. Strauss, A., & Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures and techniques. Newbury Park, CA: Sage Publications. Strupp, H. H. (1983). Psychoanalytic psychotherapy. In M. Hersen, A. E. Kazdin, & A. S. Bellack (Eds.), The clinical psychology handbook (pp. 471-487). New York: Pergamon Press. Suramit, R. (1983). The child sexual abuse accoraraodation syndrorae. Child Abuse and Neglect, Z, 177-193. Taylor, S. J., & Bogdan, R. (1984). Introduction to qualitative researchraethods:The search for meanings (2nd ed.). New York: John Wiley & Sons. Tsai, M., & Wagner, N. N. (1978). Therapy groups for women sexually molested as children. Archives of Sexual Behavior. 7, 417-427. Watzalwick, P., Weakland, J. H., & Fisch, R. (1974). Change: Principles of problem forraation and problem resolution. New York: W. W. Norton. Westerlund, E. (1992). Women's sexuality after childhood incest. New York: W. W. Norton & Company. Whitfield, C. L. (1987). Healing the child within: Discovery and recovery for adult children of dysfunctional families. Deerfield Beach, FL: Health Coramunications, Inc.
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APPENDIX A RESPONSE FORM
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Please indicate your decision by checking the appropriate response and then by signing your names below along with your telephone nuraber(s). _We hereby consent to have Kary S. Reid (licensed marriage and faraily therapist, and researcher) to contact us via telephone as willing participants in his research project in order to schedule an interview. .We hereby consent to have Kary S. Reid (licensed raarriage and family therapist, and researcher) to contact us via telephone in order to answer our questions about his research project before we decide whether or not to participate. _We do NOT wish to participate in this research project. nor do we give our consent to be contacted by Kary S. Reid or anyone associated with this project. Name: , Please Print Date
Signature:. Spouse: Please Print Signature: Phone Numbers: Daytime. Evening. Date
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APPENDIX B INTERVIEW GUIDES
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Interview with Survivor
"I really appreciate you agreeing to participate in this research project. We are asking you and other adult survivors to help us as therapists better understand how we can be of greater assistance in addressing the issues of childhood sexual abuse. As therapists we study theories that can be applied to a multitude of settings, and from this we design techniques to assist our clients. However, we suspect that the best teachers for how to work with the issues of childhood sexual abuse are the survivors themselves. You know far better than anyone else what was most helpful and least helpful in therapy. I am going to ask you some questions about your therapeutic journey in attempting to deal with your sexual abuse issues. Your answers to these questions will help us as therapists better understand the process you went through - what seemed to help, what seemed to get in the way. There are several ways I could collect this information, such as just asking you questions and then checking off the answers on a sheet of paper. But I'm afraid that might limit you in a way that prevents you from sharing what you think is most important for me to know. There are some specific questions I would like to get answered, so I'm going to refer to my list from time to time, and at the end of this interview I will ask you to review these questions to make sure we covered all of them. I invite you to share any information about your therapy experiences that you feel might be important. I'd like to start off talking with you about your most recent therapy experiences. I'm interested in who you saw, what kinds of things were helpful, and where you saw things change."
Questions regarding therapy: 1, What did you do in therapy early on? " " " in the middle? " " " later? How long were you in each type? 2, 3, What brought about the change in therapy types? Who raade the decision to change?
4, What was going on in your life at the tirae this change was raade? 5, What was raost helpful about therapy? over tirae? 155 Did that change
6, Who was the first to address the issue of childhood sexual abuse, you or [therapist]? 7, Was there ever a time when you felt therapy was doing you more harm than good? What was going on at this time? 8, Was there ever a time when you felt you wanted to attend therapy more often? What was going on then? 9, What changes were you hoping to see as a result of your therapy? 10. Overall, how effective was therapy in helping you deal with your sexual abuse issues? 11. What kinds of helpful things did you do outside the therapy room to take care of yourself (journaling, etc.)? 12. What was the raost difficult part of therapy for you?
13. What advice would you give another adult survivor about therapy? 14. At the time you were in therapy, did things ever get worse at home? What did you do about this? 15. How do you see your past sexual abuse affecting your current relationship? Questions regarding therapist: 16. 17. How did you happen to end up seeing [therapist]? How long did you see [therapist]?
18. What would you describe as being [therapist's] particular strengths in helping you deal with your issues around sexual abuse? 19. Were there things that bothered you about [therapist]?
20. Why do you think [therapist] chooses to work with adult survivors? 21. If [therapist] was a survivor of childhood sexual abuse, do you think this would be helpful to you or not? 22. What did [therapist] do or say that let you know you could trust [him/her]?
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23. What was going on when you felt you couldn't trust him/her? 24. Would you recomraend [therapist] to another survivor? Why/why not? 25. What advice would you give other therapists about how best to work with adult survivors of childhood sexual abuse? Questions regarding partner involveraent: 26. How would you describe your husband's involveraent in your sexual abuse issues? 27. How could your husband have been more helpful to you?
28. What impact do you think your therapy has had on your raarriage? 29. In what ways did you encourage your partner to becorae raore involved? 30. Were there tiraes when you discouraged your partner about becoming more involved? 31. Were there times when your partner seemed too interested in your sexual abuse issues? What happened? 32. Was there ever a time when you would have appreciated more direct involvement of your partner in therapy itself? Around what issue(s)? 33. Did you ever express your desire for more partner involvement to your partner? How did he respond? 34. Did you ever express your desire for more partner involvement to your therapist? How did your therapist respond? 35. What has your partner done that was helpful to you in dealing with your abuse issues? 36. What has your partner done that was least helpful?
37. How would it have helped you to have your husband involved in therapy early on? n " " in the middle? It " " later on? 38. How would it have hurt to have your husband involved in therapy [early, middle later on]? 157
39. During your therapy with [therapist], was there ever a crisis point? What was going on? 40. To what extent did you discuss your marriage or raarital problems in therapy? What resulted from this?
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Interview with Partner
"I really appreciate you and your wife agreeing to participate in this research project. We are asking you and other couples in which the wife is an adult survivor of childhood sexual abuse to help us as therapists better understand how we can be of greater assistance. We have some theories about how to work with adult survivors themselves, but very little has been explored regarding the marital partner's role in addressing sexual abuse issues. I am going to ask you to tell me about what it has been like for you to be married to an adult survivor of childhood sexual abuse. I have gathered from other clients of mine that there are special concerns for couples who are forced to deal with the impact of childhood sexual victimization on their marital relationship. In many ways, the fact that you are married to a victim means you, too, even if indirectly, are a victim of the same abusive past. I have some specific questions that I think will get answered as we discuss your experiences, but I may refer to my list from time to time to make sure I have covered them all. Also, by audio-taping the interview I won't have to try and write everything down. I can review the tape at a later time and call you if I have any (juestions if that is okay with you. In order to get started, why don't you tell me what you know about your wife's therapy experiences. For instance, who did she see, what did she do in therapy, how long did she go to therapy, that kind of thing."
Questions regarding wife's therapy: 1. What appeared to be raost helpful about therapy? that change over tirae? Did
2. Was there ever a time when you felt therapy was doing your wife more harm than good? What was going on at this tirae? 3. What changes did you see as a result of your wife's therapy? 4. Overall, how effective do you think therapy was in helping your wife deal with her sexual abuse issues? 5. At the tirae your wife was in therapy, did things ever get worse at horae? What did you do about this? 6. Did you ever raeet your wife's therapist?
7. How did your wife's therapy seem to get in the way of your relationship with her? 159
8. How do you see your wife's sexual abuse affecting your marriage? 9. Did you ever feel angry as a result of what your wife was doing in therapy? What about? 10. What other issues do you think should have been addressed in therapy? Questions regarding partner involveraent: 11. When would you like to have been raore involved in your wife's therapy? 12. Did you ever attend therapy with your wife? going on at this tirae? What was
13. What impact do you think the therapy has had on your marriage? 14. In what ways did you try to help your wife deal with her sexual abuse issues? How did she respond? 15. Did your wife ever express a desire for you to become raore involved in therapy? What did you do? 16. What would you say is the raost difficult thing about being raarried to an adult survivor during the early part of her therapy? During the middle part? During the latter part? 17. Did you ever talk to soraeone about this? Who? How did you
18. When did you learn of your wife's abuse? react?
19. When would you have appreciated an opportunity to talk to your wife's therapist? 20. Did you ever feel blaraed by your wife?
21. Given where you and your wife are now with your relationship, are you glad she sought therapy for her sexual abuse issues?
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APPENDIX C DEMOGRAPHIC SURVEYS
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COUPLE #
DEMOGRAPHIC DATA Survivor
How long have you been in therapy for sex abuse issues?
As best you can reraeraber, how old were you when the sexual abuse started? How old were you when it ended? How raany different perpetrators have you been able to identify? Who perpetrated you? Did you tell anyone at that tirae? Yes If so, who? What was their response?. No
Do you have siblings?
Brothers
Sisters
If so, were any of these siblings also sexually abused? Yes If so, who was perpetrated? By whora?^ What brought your sexual abuse to an end? No Don't know
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Who else is aware of your sexual abuse now?.
Length of current raarriage Age Prior Marriages? (how raany) (how many)
Long-terra relationships?
Ethnic origin
.Anglo African-American .Other (specify).
.Hispanic
Religion:
.None .Protestant .Catholic .Jewish .Other (specify).
Education:
.Less than high school .High school .Some college .Bachelor's degree .Master's degree .Doctoral degree
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Father's education:
.Less than high school .High school .Some college .Bachelor's degree .Master's degree .Doctoral degree
Father's occupation: Mother's education: .Less than high school .High school .Some college .Bachelor's degree .Master's degree .Doctoral degree Mother's occupation: Your occupation: (specify). Husband's occupation: (specify). What would you estiraate you and your husband's corabined annual gross incorae for 1992 was? 0 - $10,000 10,001 - 20,000 20,001 - 30,000 30,001 - 40,000 40,001 - 50,000 50,001 - 60,000 60,001 - 80,000 Above 80,000
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What would you estiraate your family's average combined annual income was while you were living at home?
0 - $10,000 10,001 - 20,000 20,001 - 30,000 30,001 - 40,000 40,001 - 50,000 50,001 - 60,000 60,001 - 80,000 Above 80,000
Is there anything else you would like to tell me that you think might be iraportant for others to know?
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COUPLE #
DEMOGRAPHIC DATA Partner
How long has your wife been in therapy for sex abuse issues?
As best you can reraeraber, how old was your wife when her sexual abuse started? How old was she when it ended? How raany different perpetrators has your wife been able to identify? Who perpetrated her?^ Did she tell anyone at that tirae? Yes If so, who? What was their response?. No
Does your wife have any siblings? Brothers Sisters
If so, were any of these siblings also sexually abused? Yes If so, who was perpetrated? By whora? No Don't know
What brought your wife's sexual abuse to an end?
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Who else is aware of your wife's sexual abuse now?.
Length of current raarriage Age Prior Marriages? (how many) (how raany)
Long-terra relationships?
Ethnic origin:
.Anglo African-American .Other (specify).
.Hispanic
Religion:
None Protestant Catholic Jewish .Other (specify).
Education:
.Less than high school .High school .Some college .Bachelor's degree .Master's degree .Doctoral degree
Father's education:
Less than high school .High school .Some college .Bachelor's degree .Master's degree .Doctoral degree 167
Father's occupation: Mother's education: .Less than high school .High school .Some college .Bachelor's degree .Master's degree .Doctoral degree Mother's occupation: Your occupation: (specify).
What would you estiraate you and your wife's corabined annual gross incorae for 1992 was? 0 - $10,000 10,001 - 20,000 20,001 - 30,000 30,001 - 40,000 40,001 - 50,000 50,001 - 60,000 60,001 - 80,000 Above 80,000
What would you estiraate your family's average combined annual income was while you were living at horae? 0 - $10,000 10,001 - 20,000 20,001 - 30,000 30,001 - 40,000 40,001 - 50,000 50,001 - 60,000 60,001 - 80,000 Above 80,000
Is there anything else you would like to tell me that you think raight be iraportant for others to know? 168
APPENDIX D THERAPY EFFECTIVENESS SURVEYS
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COUPLE # Survivor Looking back on it, how satisfied are you with the Individual Therapy you received? NA Very Dissatisfied Very Satisfied
How satisfied are you with the Group Therapy you received? 1 NA Very Very Dissatisfied Satisfied How satisfied are you with the Marital Therapy you and your husband received? NA Very Very Dissatisfied Satisfied Overall, how satisfied were you with your husband's participation in therapy sessions? NA Very Very Dissatisfied Satisfied Overall, how satisfied were you with your husband's participation in your recovery process outside of therapy sessions? 2 3 4 5
Very Dissatisfied
Very Satisfied
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How important is it for a female adult survivor to have a female therapist?
Not Absolutely Important Essential At All How iraportant is it that the therapist be a sex abuse survivor? 1 2 Not Iraportant At All 3 4 5 Absolutely Essential
How effective do you think your therapist was in helping you deal with your sex abuse issues?
Not Effective At All
Very Effective
How effective do you think your therapist was in helping your husband deal with your sex abuse issues?
Not Effective At All
Very Effective
At the tirae you began therapy for sex abuse issues: How satisfied were you with your marriage?
Not Satisfied
Very Satisfied
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At the time you began therapy for sex abuse issues: How satisfied were you with your relationship with your husband?
Not Satisfied At the time you began therapy for sex abuse issues:
Very Satisfied
How satisfied were you with your husband as a spouse?
Not Satisfied How satisfied are you with your marriage today?
Very Satisfied
Not Satisfied
Very Satisfied
How satisfied are you with your relationship with your husband today?
Not Satisfied
Very Satisfied
How satisfied are you today with your husband as a spouse?
Not Satisfied
Very Satisfied
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COUPLE # Partner Looking back on it, how satisfied are you with the Individual Therapy your wife received? 1 Very Dissatisfied 2 3 4 5 Very Satisfied NA
How satisfied are you with the Group Therapy your wife received? 1 Very Dissatisfied 2 3 4 5 Very Satisfied NA
How satisfied are you with the Marital Therapy you and your wife received? 1 Very Dissatisfied 2 3 4 5 Very Satisfied NA
Overall, how satisfied were you with your level of participation in therapy sessions? 1 Very Dissatisfied 2 3 4 5 Very Satisfied NA
Overall, how satisfied were you with your level of participation in your wife's recovery process outside of therapy sessions? 1 2 Very Dissatisfied 3 4 5 Very Satisfied
How important is it for a female adult survivor to have a female therapist? 1 2 Not Important At All 173 3 4 5 Absolutely Essential
How iraportant is it that the therapist be a sex abuse survivor? 1 2 Not Important At All 3 4 5 Absolutely Essential
How effective do you think your wife's therapist was in helping her deal with her sex abuse issues? 1 2 Not Effective At All 3 4 5 Very Effective
How effective do you think your wife's therapist was in helping you deal with your wife's sex abuse issues? 1 2 Not Effective At All At the time your wife began therapy for sex abuse issues: How satisfied were you with your marriage? 1 2 Not Satisfied 3 4 5 Very Satisfied 3 4 5 Very Effective
At the time your wife began therapy for sex abuse issues: How satisfied were you with your relationship with your wife? 1 2 Not Satisfied 3 4 5 Very Satisfied
At the time your wife began therapy for sex abuse issues: How satisfied were you with your wife as a spouse? 1 2 Not Satisfied 174 3 4 5 Very Satisfied
How satisfied are you with your marriage today? 1 2 Not Satisfied 3 4 5 Very Satisfied
How satisfied are you with your relationship with your wife today? 1 2 Not Satisfied 3 4 5 Very Satisfied
How satisfied are you today with your wife as a spouse? 1 2 Not Satisfied 3 4 5 Very Satisfied
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APPENDIX E CONSENT FORM
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Participant Consent Form
1 . _^.^____ hereby agree to participate in the research entitled "Therapeutic Experiences of Female Adult Survivors of Childhood Sexual Abuse, and Their Spouses" being conducted by Kary S. Reid, M.A. I understand that this participation is entirely voluntary; I can withdraw my consent at any time and have the results of the participation, to the extent that it can be identified asraine,removed from the experimental records, destroyed or returned to me. In addition, I also have the right to review any results that can be identified as mine, and if I have any objection I can ask for the records to be withdrawn from publication. The following points have been explained to me: 1) The purpose of this research is to determine couples' perceptions of therapeutic effectiveness in addressing childhood sexual abuse issues. 2) The extent of my participation in this project involves my being interviewed regarding ray past and/or present therapeutic experiences as a client or the spouse of a client dealing with the issue of my being sexually abused as a child. I understand that the interview is NOT to be considered a therapy session, and that the focus of the interview questions is on the therapy process, NOT the therapy issue. I understand that the interview will be audio-taped, transcribed, and reviewed by the researcher and/or his assistant, and that the tapes will be erased as soon as the review is completed. I further understand that any reference to me by ray personal narae during the interview will be omitted from the transcription in order to maintain anonymity and confidentiality. The length of time required to complete the interview will be approximately one and onehalf to two hours. 3) The researcher is a licensedraarriageand faraily therapist who is currently a doctoral candidate in the Marriage and Faraily Therapy Program at Texas Tech University, and is qualified to conduct this type of research.
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4) The results of my participation in this study will be confidential, and strict procedures will be eraployed to maintain that confidentiality. I understand that any individually identifiable material will not be released without my prior written consent or unless required by law. If I happen to reveal activities which are illegal, it is possible that the researcher and/or interviewer, under court order, might be required to disclose such activities, and if those activities involve harm to others or rayself, the researcher/interviewer would be required to report such activities to the appropriate authorities. I also understand that there is a risk that soraeone who knows me very well raay be able to identify rae from the content of the reports. 5) The researcher, Kary S. Reid, and his faculty supervisor, Dr. Richard S. Wampler, of the Departraent of Huraan Developraent and Faraily Studies, College of Huraan Sciences, Texas Tech University, have both agreed to answer any further questions about the study either now or during the course of the project. Mr. Reid can be contacted at [phone], and Dr. Warapler at [phone]. I further understand that I raay contact the Texas Tech University Institutional Review Board for the Protection of Huraan Subjects by writing thera in care of the Office of Research Services, Texas Tech University, Lubbock, Texas 79409, or by calling [phone]. 6) Although physical injury is not considered a potential risk as a result of my participation in this project, I understand that should this occur, treatraent is not necessarily available at Texas Tech University of the Student Health Center, nor is there necessarily any insurance carried by the University or its personnel applicable to cover such injury. Financial corapensation for any such injury raust be provided through ray own insurance prograra. Further inforraation about these raatters raay be obtained frora Dr. Robert M. Sweazy, Vice Provost for Research, [phone], Roora 203 Holden Hall, Texas Tech University, Lubbock, Texas 79409-1035. 7) I acknowledge that in appreciation for our participation in this research project ray spouse and I will be issued a voucher to be redeeraed at one of two restaurants for a free dinner which will be direct billed by the restaurant to Kary S. Reid. I further acknowledge that the voucher has a statedraaxirauravalue, and that ray spouse or I are responsible for paying any reraaining balance that exceeds that lirait to the restaurant before leaving.
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8)
I have received a copy of this signed consent form
Signature of Researcher Date PLEASE SIGN BOTH COPIES. THE RESEARCHER.
Signature of Participant Date KEEP ONE AND RETURN THE OTHER TO
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APPENDIX F INTERVIEW EVALUATIONS
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INTERVIEW EVALUATION FORM SURVIVOR Please respond to the following questions by circling the nuraber on the scale which best describes your feelings about the interview process itself. How comfortable were you in participating in this project? 1 2 Very Uncomfortable 3 4 5 Very Comfortable
How comfortable was the setting in which the interview took place? 1 2 Very Uncomfortable 3 4 5 Very Comfortable
How comfortable are you with the manner in which confidentiality and anonymity were handled? 1 2 Very Uncomfortable 3 4 5 Very Comfortable
How comfortable were you with your interviewer? 1 2 Very Uncomfortable 3 4 5 Very Comfortable
How important was it that your interviewer was a female? 1 2 Not Important At All 3 4 5 Very Important
Please add any coraraents you have about the interview process.
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INTERVIEW EVALUATION FORM PARTNER Please respond to the following questions by circling the nuraber on the scale which best describes your feelings about the interview process itself. How corafortable were you in participating in this project? 1 2 Very IZncorafortable 3 4 5 Very Comfortable
How corafortable was the setting in which the interview took place? 1 2 Very Uncomfortable 3 4 5 Very Comfortable
How comfortable are you with the manner in which confidentiality and anonymity were handled? 1 2 Very Uncomfortable 3 4 5 Very Comfortable
How corafortable were you with your interviewer? 1 2 Very IZncorafortable 3 4 5 Very Corafortable
How important was it that your interviewer was a male? 1 2 Not Iraportant At All 3 4 5 Very Iraportant
Please add any comments you have about the interview process.
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