This article was downloaded by: [University of Sydney] On: 04 May 2015, At: 11:37 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
A Clinical Practice Model for Treatment of College-Aged Incest Survivors Elaine E. Barney BSN, CCSN, ACSW
a
a
Student Psychological Services , University of North Carolina , Chapel Hill, USA Published online: 09 Jul 2010.
To cite this article: Elaine E. Barney BSN, CCSN, ACSW (1990) A Clinical Practice Model for Treatment of College-Aged Incest Survivors, Journal of American College Health, 38:6, 279-283 To link to this article: http://dx.doi.org/10.1080/07448481.1990.9936200
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
A Clinical Practice Model for Treatment of CollegeAged Incest Survivors
Downloaded by [University of Sydney] at 11:37 04 May 2015
ELAINE E. BARNEY, BSN, CCSN, ACSW
Adult incest survivors frequently exhibit signs and symptoms of posttraumatic stress disorder. Many clinicians have geared their group treatment of incest survivors to address these manifestations. Given the nature of the sexual abuse, the early developmental periods in which some trauma occurs, the past and current relationship between the victim and the perpetrator, and the dynamics inherent in this violation and betrayal of trust, love, and power within the family unit, additional clinical concerns and safeguards must be considered. In addition, the struggles of collegeaged incest survivors to come to terms with their history of sexual abuse often mirror the developmental tasks faced by their peers-autonomy, intimacy, sexuality, and formation of personal values and ethics. To focus solely on the incest without also considering these developmental‘issues may solidify a gridlock between inadequate resolution of the developmental issues and the continued victimization of the student incest survivor. The author discusses a timelimited group treatment for collegeaged incest survivors that uses a modified posttraumatic stress disorder model as a conceptual framework and addresses both sets of concerns.
Over the past few years, research has focused increasing attention on the long-term negative effects of childhood sexual abuse.’,2 Both individual and group treatment approaches, including recognition of posttraumatic stress disorder, have been utilized in clinical practice and described in the current l i t e r a t ~ r e . ~ , ~ Few authors, however, have specifically addressed the concerns and issues of the college-aged incest survivor. Clinicians know that college students must deal with such developmental tasks as achieving autonomy,
Elaine E. Barney, a clinical social worker with Student Psychological Services at the University of North Carolina, Chapel Hill, i s carrying out research on issues related to sexual assault and abuse.
V 0 1 3 8 , MAY 1990
developing the capacity for intimacy, and solidifying their sexual identity. In addition, they must learn to deal with authority, tolerate ambivalent feelings and ambiguity, and develop a set of personal values and ethic^.^,^ In looking at these issues for college-aged incest survivors, one is struck by the mirroring of these developmental tasks as reflected in the students’ efforts to come to terms with their history of childhood sexual abuse. Our group work with students who are incest survivors indicates that these students frequently find themselves feeling alone and isolated from other students in their efforts to develop mastery of these developmental milestones. For example, while most students are seeking to establish more lasting, intimate relationships, incest survivors may flee from such intimacy or may not be selective in their choice of a partner. Although the tasks may be the same as for other students, group members report that the struggle is intensified and hampered by the past sexual abuse that has undermined their sense of autonomy and capacity for intimacy, raised doubts about their sexuality and sexual identity, and left them with a sense of shame and self-doubt about themselves and their ability to function in the adult world. As increasing numbers of students begin disclosing their pasts and breaking the silence on the taboo of incest, it will be important for college and university mental health service providers to be responsive to the interwoven needs of these individuals. To focus solely on one set of concerns without a heightened awareness of the other’s impact (eg, to focus on developmental issues and ignore the incest issue or to focus on the incest without considering the developmental issues) could lead to solidifying a gridlock between inadequate resolution of the developmental issues and continued victimization of the student with a painful, often hidden, trauma of incest in her past. The treatment modality discussed below is one approach being used in a college setting that attempts to address both sets of concerns.
279
COLLEGE HEALTH
Downloaded by [University of Sydney] at 11:37 04 May 2015
This model’ is based on the conceptual framework of the posttraumatic stress disorder syndrome (PTSD) and the stress response syndrome. In brief, it has been found that female incest survivors frequently experience a cluster of PTSD symptoms’ similar to those noted by rape victims, Vietnam veterans, or others who have experienced traumatic events. These symptoms may be characterized as falling into one of two groups: (1) those involving intrusive memories, flashbacks, autonomic nervous system responses (sweating, rapid heartbeat, dizziness), and heightened affect (feeling “out of control”); or (2) symptoms involving denial of events, amnesia, diminished or dissociative response to situations similar to the original trauma, and constricted affect. This clustering of responses to the original trauma or to situations that replicate the trauma has been described and defined by Horowitz’ as a stress response syndrome. He notes two stages, each with its own discrete cluster of symptoms: an intrusive stage and a denial stage. Each stage contains those responses and symptoms described above in the PTSD syndrome. What is present, then, is a template of a series of responses to a stressor or trauma (the PTSD syndrome) that fits into this oscillating wave of intrusive and denial phases. These phases tend to occur-and reoccur-over an unspecified and often extended period of time, depending upon the nature and severity of the trauma and the individual’s attempt to cope with the effects of the trauma. Cole and Barney” posit that a band or ”therapeutic window” exists between the peaks and valleys of this oscillating wave. Little therapeutic work can be done if a client i s experiencing symptoms at the height of the intrusive stage or at the lowest point of the denial stage, given the nature of these symptoms, which frequently may frighten or “numb” the client. Within the therapeutic window, however, therapeutic work may take place because the symptoms are present, are within the client’s awareness, and she i s free to work in group on both a cognitive and an affective level. It is within this framework that the incest survivors group operates, taking into account the developmental tasks concurrently being faced by the group members as college students. Underscoring this practice model i s the. belief that empowering the participants to make decisions about their lives, in contrast to the helplessness and powerlessness they have experienced, is essential. Women are encouraged to tell their stories and to share their experiences with other group members in a supportive group setting; they are also informed about PTSD and the stress response syndrome. In this way, students and therapists work together to monitor the range of the participants’ own therapeutic window and to identify triggers-those psychosocial stressors that exacerbate their PTSD symptoms and responses. Additional clinical considerations and safeguards are
280
warranted, given the oft-repeated nature of the sexual abuse, the early developmental period within which the trauma occurred, the past and current relationship between the victim and the perpetrator, and the dynamics inherent in this violation and betrayal of love, trust, and power within the family unit.’
Group Formation The mental health division of the student health service at the University of North Carolina at Chapel Hill has offered a time-limited therapy group for incest survivors each semester for the past 4% years. There have been six groups, involving 32 women. This has been a collaborative effort with the Departments of Social Work and Psychiatry of North Carolina Memorial Hospital in Chapel Hill. The groups consist of 2 female therapists and 4 to 7 members. The groups meet weekly for a 9-week period. (The number of sessions is not a fixed, ”magical” figure but takes into account the constraints of operating within an academic calendar year and scheduling around student exams and vacations.) Group recruitment begins during the early part of each semester. Program leaders place ads in the student newspaper personals column; distribute fliers across campus; and send letters and fliers to the psychiatry faculty and residents, area mental health centers, the local rape crisis center, and women’s groups. Students are encouraged to telephone and to leave their first name and the time to be called back if the therapist i s unable to take the call. Confidentiality is emphasized at all times. Before the group begins, prospective members are seen for a 30- to 45-minute information-exchange interview. To empower women in the process, we emphasize that group participation is a mutual decision involving the student, her individual therapist, and the interviewer. The criteria for group participation are carefully explained. They include ( 1 ) no current drug or alcohol abuse; (2) no current disabling crisis; (3) no recent-within the past 6 months-suicide attempts; (4) willingness to be in individual therapy; and (5) if recently hospitalized for psychiatric reasons, information about the circumstances for the hospitalization. The students are advised that this specific group may be stressful because memories may be recovered or flashbacks triggered through telling one’s own story or through hearing the experiences of other group members. The therapist reviews the criteria, emphasizing that they reflect concern for the student who might resort to previously maladaptive or self-destructive ways of responding to stress while in the group. If the student is not in individual therapy at the time, arrangements are made for a staff member from student mental health or a psychiatry resident to follow her during the course of the group. During this structured interview, therapists encourage the student to ask questions and to talk about
IACH
TREATMENT OF INCEST SURVIVORS her interest in the group. The initial questions are general, becoming more specific and focused toward the latter half of the session. The interviewer carefully attempts to assess the student’s readiness for the group. If she appears too resistant to being in therapy or seems too fragile for the group, it is gently suggested that she may not be ready for the group this semester. She is encouraged to continue in individual treatment and to consider the group at a later date.
Downloaded by [University of Sydney] at 11:37 04 May 2015
Group Process and Themes At the beginning of each session, the group members are asked to ”check in” and, in a few words, let the rest of the group know how thing have gone the previous week. Frequently, particularly during the initial sessions, the members report feeling “down,“ sad, angry, or they note an increase in somatic complaints such as headaches, malaise, fatigue. As the sessions proceed, these complaints tend to diminish as the women learn that they can express their feelings and receive support and understanding from the rest of the group. In addition, discussion is focused on the PTSD syndrome, the stress response syndrome, and the concept of the therapeutic window. Group members notice a tendency to feel more comfortable tolerating feelings, become confident enough to monitor their own feelings and symptoms, and can place themselves fairly accurately on the stress response curve. This increased selfknowledge seems to enhance their sense of control, self-acceptance, and self-perception of their symptoms and behavior. Throughout the course of the group, certain themes that echo the concerns and issues facing most college students emerge. Because of the members’ history of incest, however, these themes resonate with a particular insistence as the sessions proceed. Issues of trust, control, intimacy, expressions of anger, confusion over ambivalent feelings about themselves, sex, being independent, and about family dynamics dominate the concerns that group members may confront each day. As they explore these issues, the students make connections between their current thoughts and feelings and their past sexual abuse. In one group, for example, a woman struggled to understand why she was unable to tolerate staying in her apartment or in her family’s home in the late afternoon. In processing her thoughts, she made the connection between her present anxiety and her feeling, as a little girl, of desperation and the desire to flee her house during that time of day when the abuse was occurring. On the basis of recent works by Carol Gilligan,” Jean Baker Miller,” and others at the Stone Center for Developmental Services and Studies at Wellesley College who are developing new theories on the development of female psychology, the therapists focus on helping the incest survivors develop a better sense of themselves in relation to significant others in their lives. This
VOL 38, MAY 1990
new “self-in-relation” theory,13 by proposing a differing and more positive perception of women’s life experiences, places a high value on a woman’s ability to relate to people and to care for others. The incest group leaders recognize that college-aged incest survivors have been exposed to a self-in-relation experience in which their trust, love, self-perception, and sense of self have been repeatedly undermined, violated, or repudiated. It becomes critical, therefore, to validate the student’s past and current sense of self in relation to her family and to other relationships. A move toward autonomy has traditionally been viewed as one of the primary tasks for the psychological development of the late adolescent or young adult. Feminist theorists point to the phallocentric nature of this particular developmental task, noting that the thrust toward further separation-individuation from one’s family and consequent independence is more valid for a male’s life experience than a female’~.’~ Because this development is still highly valued in our society, a woman may be at risk of being seen or seeing herself as weak, ”too dependent,” or ”immature” if she experiences difficulty separating from her family and becoming more autonomous or of being conflicted about her future role(s) as mother and career woman. Group leaders take particular care to ensure that group members are not covertly encouraged or pushed to become more autonomous or more independent before they are ready. Although not negating the importance of becoming autonomous and independent, leaders must keep in mind that the bonds between the incest survivor and her family are brittle and may not be able to withstand attempts or actions on the part of the student to separate ,fully. These bonds must be understood within the context of the abuse and not be used to blame the victim if she continues to experience difficulty negotiating the fine balance between maintaining close ties with her family and becoming more autonomous. The self-in-relation theory emphasizes women’s capacity to relate to people and to care for others. This is seen as a strength rather than a weakness. Validating this capacity becomes more complex in working with incest survivors. Their ability to relate to and care for others has been exploited and warped by the perpetrator and by the family dynamics that served to protect the offender and family at the expense of the victim. This disconfirms or contradicts the incest survivor’s experience and undermines her perception of herself and of herself in relation to the perpetrator and other family members. Typically, many of the group members state that they no longer feel that they can trust their memory of what happened to them as children. Either they were so young at the time or the trauma was so severe that the only way that they could cope was to repress or suppress the experiences and the memories totally or significantly. If they had attempted to reveal their secret to
28 1
Downloaded by [University of Sydney] at 11:37 04 May 2015
COLLEGE HEALTH a family member or sought help from others, they may have been blamed, punished, or disbelieved. They may have grown up with a belief that they have “faulty” memories, have misperceived or misrepresented the sexual abuse, or have simply made it up. (Sadly, this latter belief at times may have been reinforced by a woman’s previous therapi~t’~;with increased knowledge about incest, it is hoped that this disconfirming practice is on the wane.) A dissonance soon develops between what the child experiences and what she is told and believes about these people on whom she is so dependent. She will often continue to harbor these misperceptions and self-doubts as an adult. To confront these misperceptions, participants are asked to bring in pictures of themselves around the age when the abuse began. This seems to confirm the woman’s sense of what did take place. It affords her an opportunity to receive validation within the group that she was victimized, was only a child at the time, and could not have fought off or have been responsible for the actions of the (usually) older, larger, and stronger offender. While these perceptions are being reexamined and validated, the women continue to process thoughts and feelings about current and past significant relationships. Many participants are frustrated by their inability to develop or maintain intimate relationships with men or women. Typically, they have problems with issues of trust, control, and sexual functioning in current relationships. Many report a heightened sense of vulnerability and an exacerbation of PTSD symptoms when they are involved in an intimate relationship or are being sexually active.
Friends and lovers may be unable to be supportive. All too frequently, they may use this disclosed information punitively against the survivor during stormy times in the relationship. The group helps the student tolerate and contain her impulsive behavior and supports and acknowledges her thoughts and feelings as valid, even as strong, powerful, and “unacceptable” as they may be to her. As she hears the expression of similar feelings from other group members, she begins to feel more understood, accepted, and “normal.” In no small way, these women are beginning to tolerate, understand, and accept their feelings and perceptions in a way that may have been denied them in the past. The foundation for further growth and awareness of the depth and extent of her ambivalent feelings, her sense of self, and of self in relation to others is enhanced and promoted. Clearly, all of the above issues and concerns are not fully addressed or processed in such a time-limited group. The coleaders frequently underscore the need for more ongoing intensive, individual therapy. This suggestion is framed as a way of encouraging group members to seek continuing support and understanding that can build on what they have come to understand about themselves and the incest experience. For example, grief work, involving mourning the loss of the idealized parents, lack of nurturing, and loss of their own childhood innocence may have begun, but students will usually need more time to work through this process.
Follow-up and Conclusion Some Closely Associated Issues Other issues closely associated with these concerns form an integral dynamic of the group. The women express difficulty tolerating ambivalent feelings, again associated with family members but also experienced with current relationships. The strength and complexity of family loyalties, combined with the powerful mix of love, hatred, fear, attachment, confusion, loss, and disappointment, cannot be underestimated. Whether or not to confront the perpetrator and disclose the incest to other family members or to current or future partners quickly surfaces within the group. The past feels so present and alive to group members that the impulse or need to act is strong, yet it also feels very frightening. A holding action is essential. The clinicians take time to explore all options and anticipate the possible consequences. They also process the wishes, fears, andabove all-the fantasies in confronting the offender or the family because taking such action impulsively may only serve to victimize the incest survivor again. The perpetrator rarely, if ever, acknowledges or assumes responsibility for his behavior. The family may (once more) turn against the victim for bringing it all up again.
282
A 3- to 6-month follow-up of individual members has shown a fairly uniform positive response to participation in the group. To date, 20 out of the 32 group members, or 62.5%, have been interviewed. Nineteen of the women were seen individually by one of the coleaders in a 30- to 45-minute interview and 1 woman, who moved out of state, responded by letter. The initial 6 group members were not contacted; the remaining 6 women either did not respond or had moved, leaving no forwarding telephone number. Permission to call for a follow-up appointment was obtained during the last session. In order to preserve confidentiality, letters were not sent unless explicit permission to do so had been obtained. Seventy-five percent of the women interviewed indicated a wish for a longer-term group; the remaining 25% cited academic and/or employment demands during the semester and said they felt the length of time devoted to the group was sufficient. The participants generally agreed that the group was particularly helpful in decreasing their sense of isolation and in heightening their understanding of the longterm effects of the incest as it related to their individual lives. They said that they continued to identify triggers
jACH
Downloaded by [University of Sydney] at 11:37 04 May 2015
TREATMENT OF INCEST SURVIVORS that exacerbated anxiety or posttraumatic stress symptoms and reported an improved ability to monitor and, at times, reduce these responses. Many reported an increase in self-awareness and a better understanding and acceptance of themselves and of their families. These feelings were accompanied by a striking reduction in self-blame, which they attributed to their participation in the group. Trust, intimacy, and sexual concerns were listed as the major unresolved issues for group members. Although some participants noted a slight-to-moderate improvement in these areas, they felt that a longer-term group, in addition to ongoing individual therapy, would be best suited to address these long-standing issues. A few women, in acknowledging a fantasy that the group would “cure” them, expressed disappointment that further therapy was indicated and was continuing on an individual basis. Although these women continue to experience conflicts and difficulties in their lives, they reported an improved understanding of the linkages between their present developmental concerns and their history of sexual abuse within the family. In conclusion, the developmental tasks facing college-aged women can be complicated by a history of incest. The time-limited group described in this paper seeks to address both sets of concerns through a conceptual framework that empowers, supports, and educates the group members. Sharing their story in this manner not only decreases their sense of isolation, but it enables them to make connections between present and past concerns and t o take further steps toward mastery of developmental tasks that might otherwise be neglected or negated.
INDEX TERMS incest, group psychotherapy, students
REFERENCES 1. Gelinas D. The persisting negative effects of incest. Psychiatry 1983 (November);46:312-332. 2. Faria G, Belohlavek N. Treating female adult survivors of childhood incest. Social Casework 1984;65:465-471. 3. Herman J, Schatzow E. Time limited group therapy for women with a history of incest. Int Group Psychother 1984 (October);34:605-616. 4. Donaldson MA, Gardner R. Diagnosis and treatment of traumatic stress among women after childhood incest. In Figley C, ed, Trauma and Its Wake. New York, BrunnerlMazel, 1985. 5. Farnsworth DL. Psychiatry, Education, and the Young Adult. Springfield, IL, Thomas, 1966. 6. Chickering AW. Education and Identity. San Francisco, Jossey-Bass, 1972.
VOL 38, MAY 7990
7. Barney E, Cole C. A clinical practice model for the group treatment of adult incest survivors. Presented to the NASW National Conference on Clihical Social Work, San Francisco, California, September, 1986. 8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, ed 3, rev. Washington, DC, American Psychiatric Association, 1987. 9. Horowitz M. Stress response syndrome: A review of post traumatic and adjustment disorders. Hosp Community Psychiatry 1986;37(3):241-248. 10. Cole C, Barney E. Safeguards and the therapeutic window: A group treatment strategy for adult incest survivors. Am Orthopsychiatry 1987;57(4):601-609. 11. Gilligan C. In a Different Voice: Psychological Theory and Women’s Development. Cambridge, Harvard University Press, 1982. 12. Miller JB. Toward a New Psychology of Women. Boston, Beacon Press, 1976. 13. Surrey J. The ”self-in-relation”: A theory of women’s development. Work in Progress 84:02, Stone Center Working Papers Series, 1984. 14. Kaplan A, Klein R. The relational self in late adolescent women. Work in Progress 85:17 (Paper 1: Women’s self-development in late adolescence), Stone Center Working Papers Series, 1985. 15. Herman J. Father-Daughter Incest. Cambridge, Harvard University Press, 1981, chap 11.
C A R E E R
O P P O R T U N I T Y
Health Education Coordinator rl[ (Nutrition Specialist) The University of Texas at Austin Student Health Center is seeking a health educator to coordinate nutrition education services for a campus of approximately 50,000 students. Requires a Master’s degree in health education, public health, exercise physiology or nutrition and two years’ work experience in nutritional counseling or educational program planning. Some evening work will be necessary. Competitive applicants should be Registered Dietitians or eligible for registration. Prefer experience with individual nutritional counseling and a knowledge of eating disorders and their treatment. Responsibilities include coordinating, teaching and evaluating the Student Nutrition Advisor Peer Instructor Program (S.N.A.P.); supervising and providing individual nutrition consultations; coordinating the Eating Disorders Treatment Program; assessing needs; d e veloping, implementing and evaluating nutrition education campaigns, and classes and other duties as defined by the goals and objectives of the Health Education D e partment. Salary and benefits are competitive. Position available July 2, 1990. To apply, send letter of interest and resume by June 15, 1990, to: Lisa Kessler, M.P.H., R.D., Department of Health Education, Student Health Center, The University of Texas at Austin, P.O. Box 7339, University Station, Austin, TX 78713. An Equal OpportunitylAffirmative Action Employer
283
Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
A Clinical Practice Model for Treatment of College-Aged Incest Survivors Elaine E. Barney BSN, CCSN, ACSW
a
a
Student Psychological Services , University of North Carolina , Chapel Hill, USA Published online: 09 Jul 2010.
To cite this article: Elaine E. Barney BSN, CCSN, ACSW (1990) A Clinical Practice Model for Treatment of College-Aged Incest Survivors, Journal of American College Health, 38:6, 279-283 To link to this article: http://dx.doi.org/10.1080/07448481.1990.9936200
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
A Clinical Practice Model for Treatment of CollegeAged Incest Survivors
Downloaded by [University of Sydney] at 11:37 04 May 2015
ELAINE E. BARNEY, BSN, CCSN, ACSW
Adult incest survivors frequently exhibit signs and symptoms of posttraumatic stress disorder. Many clinicians have geared their group treatment of incest survivors to address these manifestations. Given the nature of the sexual abuse, the early developmental periods in which some trauma occurs, the past and current relationship between the victim and the perpetrator, and the dynamics inherent in this violation and betrayal of trust, love, and power within the family unit, additional clinical concerns and safeguards must be considered. In addition, the struggles of collegeaged incest survivors to come to terms with their history of sexual abuse often mirror the developmental tasks faced by their peers-autonomy, intimacy, sexuality, and formation of personal values and ethics. To focus solely on the incest without also considering these developmental‘issues may solidify a gridlock between inadequate resolution of the developmental issues and the continued victimization of the student incest survivor. The author discusses a timelimited group treatment for collegeaged incest survivors that uses a modified posttraumatic stress disorder model as a conceptual framework and addresses both sets of concerns.
Over the past few years, research has focused increasing attention on the long-term negative effects of childhood sexual abuse.’,2 Both individual and group treatment approaches, including recognition of posttraumatic stress disorder, have been utilized in clinical practice and described in the current l i t e r a t ~ r e . ~ , ~ Few authors, however, have specifically addressed the concerns and issues of the college-aged incest survivor. Clinicians know that college students must deal with such developmental tasks as achieving autonomy,
Elaine E. Barney, a clinical social worker with Student Psychological Services at the University of North Carolina, Chapel Hill, i s carrying out research on issues related to sexual assault and abuse.
V 0 1 3 8 , MAY 1990
developing the capacity for intimacy, and solidifying their sexual identity. In addition, they must learn to deal with authority, tolerate ambivalent feelings and ambiguity, and develop a set of personal values and ethic^.^,^ In looking at these issues for college-aged incest survivors, one is struck by the mirroring of these developmental tasks as reflected in the students’ efforts to come to terms with their history of childhood sexual abuse. Our group work with students who are incest survivors indicates that these students frequently find themselves feeling alone and isolated from other students in their efforts to develop mastery of these developmental milestones. For example, while most students are seeking to establish more lasting, intimate relationships, incest survivors may flee from such intimacy or may not be selective in their choice of a partner. Although the tasks may be the same as for other students, group members report that the struggle is intensified and hampered by the past sexual abuse that has undermined their sense of autonomy and capacity for intimacy, raised doubts about their sexuality and sexual identity, and left them with a sense of shame and self-doubt about themselves and their ability to function in the adult world. As increasing numbers of students begin disclosing their pasts and breaking the silence on the taboo of incest, it will be important for college and university mental health service providers to be responsive to the interwoven needs of these individuals. To focus solely on one set of concerns without a heightened awareness of the other’s impact (eg, to focus on developmental issues and ignore the incest issue or to focus on the incest without considering the developmental issues) could lead to solidifying a gridlock between inadequate resolution of the developmental issues and continued victimization of the student with a painful, often hidden, trauma of incest in her past. The treatment modality discussed below is one approach being used in a college setting that attempts to address both sets of concerns.
279
COLLEGE HEALTH
Downloaded by [University of Sydney] at 11:37 04 May 2015
This model’ is based on the conceptual framework of the posttraumatic stress disorder syndrome (PTSD) and the stress response syndrome. In brief, it has been found that female incest survivors frequently experience a cluster of PTSD symptoms’ similar to those noted by rape victims, Vietnam veterans, or others who have experienced traumatic events. These symptoms may be characterized as falling into one of two groups: (1) those involving intrusive memories, flashbacks, autonomic nervous system responses (sweating, rapid heartbeat, dizziness), and heightened affect (feeling “out of control”); or (2) symptoms involving denial of events, amnesia, diminished or dissociative response to situations similar to the original trauma, and constricted affect. This clustering of responses to the original trauma or to situations that replicate the trauma has been described and defined by Horowitz’ as a stress response syndrome. He notes two stages, each with its own discrete cluster of symptoms: an intrusive stage and a denial stage. Each stage contains those responses and symptoms described above in the PTSD syndrome. What is present, then, is a template of a series of responses to a stressor or trauma (the PTSD syndrome) that fits into this oscillating wave of intrusive and denial phases. These phases tend to occur-and reoccur-over an unspecified and often extended period of time, depending upon the nature and severity of the trauma and the individual’s attempt to cope with the effects of the trauma. Cole and Barney” posit that a band or ”therapeutic window” exists between the peaks and valleys of this oscillating wave. Little therapeutic work can be done if a client i s experiencing symptoms at the height of the intrusive stage or at the lowest point of the denial stage, given the nature of these symptoms, which frequently may frighten or “numb” the client. Within the therapeutic window, however, therapeutic work may take place because the symptoms are present, are within the client’s awareness, and she i s free to work in group on both a cognitive and an affective level. It is within this framework that the incest survivors group operates, taking into account the developmental tasks concurrently being faced by the group members as college students. Underscoring this practice model i s the. belief that empowering the participants to make decisions about their lives, in contrast to the helplessness and powerlessness they have experienced, is essential. Women are encouraged to tell their stories and to share their experiences with other group members in a supportive group setting; they are also informed about PTSD and the stress response syndrome. In this way, students and therapists work together to monitor the range of the participants’ own therapeutic window and to identify triggers-those psychosocial stressors that exacerbate their PTSD symptoms and responses. Additional clinical considerations and safeguards are
280
warranted, given the oft-repeated nature of the sexual abuse, the early developmental period within which the trauma occurred, the past and current relationship between the victim and the perpetrator, and the dynamics inherent in this violation and betrayal of love, trust, and power within the family unit.’
Group Formation The mental health division of the student health service at the University of North Carolina at Chapel Hill has offered a time-limited therapy group for incest survivors each semester for the past 4% years. There have been six groups, involving 32 women. This has been a collaborative effort with the Departments of Social Work and Psychiatry of North Carolina Memorial Hospital in Chapel Hill. The groups consist of 2 female therapists and 4 to 7 members. The groups meet weekly for a 9-week period. (The number of sessions is not a fixed, ”magical” figure but takes into account the constraints of operating within an academic calendar year and scheduling around student exams and vacations.) Group recruitment begins during the early part of each semester. Program leaders place ads in the student newspaper personals column; distribute fliers across campus; and send letters and fliers to the psychiatry faculty and residents, area mental health centers, the local rape crisis center, and women’s groups. Students are encouraged to telephone and to leave their first name and the time to be called back if the therapist i s unable to take the call. Confidentiality is emphasized at all times. Before the group begins, prospective members are seen for a 30- to 45-minute information-exchange interview. To empower women in the process, we emphasize that group participation is a mutual decision involving the student, her individual therapist, and the interviewer. The criteria for group participation are carefully explained. They include ( 1 ) no current drug or alcohol abuse; (2) no current disabling crisis; (3) no recent-within the past 6 months-suicide attempts; (4) willingness to be in individual therapy; and (5) if recently hospitalized for psychiatric reasons, information about the circumstances for the hospitalization. The students are advised that this specific group may be stressful because memories may be recovered or flashbacks triggered through telling one’s own story or through hearing the experiences of other group members. The therapist reviews the criteria, emphasizing that they reflect concern for the student who might resort to previously maladaptive or self-destructive ways of responding to stress while in the group. If the student is not in individual therapy at the time, arrangements are made for a staff member from student mental health or a psychiatry resident to follow her during the course of the group. During this structured interview, therapists encourage the student to ask questions and to talk about
IACH
TREATMENT OF INCEST SURVIVORS her interest in the group. The initial questions are general, becoming more specific and focused toward the latter half of the session. The interviewer carefully attempts to assess the student’s readiness for the group. If she appears too resistant to being in therapy or seems too fragile for the group, it is gently suggested that she may not be ready for the group this semester. She is encouraged to continue in individual treatment and to consider the group at a later date.
Downloaded by [University of Sydney] at 11:37 04 May 2015
Group Process and Themes At the beginning of each session, the group members are asked to ”check in” and, in a few words, let the rest of the group know how thing have gone the previous week. Frequently, particularly during the initial sessions, the members report feeling “down,“ sad, angry, or they note an increase in somatic complaints such as headaches, malaise, fatigue. As the sessions proceed, these complaints tend to diminish as the women learn that they can express their feelings and receive support and understanding from the rest of the group. In addition, discussion is focused on the PTSD syndrome, the stress response syndrome, and the concept of the therapeutic window. Group members notice a tendency to feel more comfortable tolerating feelings, become confident enough to monitor their own feelings and symptoms, and can place themselves fairly accurately on the stress response curve. This increased selfknowledge seems to enhance their sense of control, self-acceptance, and self-perception of their symptoms and behavior. Throughout the course of the group, certain themes that echo the concerns and issues facing most college students emerge. Because of the members’ history of incest, however, these themes resonate with a particular insistence as the sessions proceed. Issues of trust, control, intimacy, expressions of anger, confusion over ambivalent feelings about themselves, sex, being independent, and about family dynamics dominate the concerns that group members may confront each day. As they explore these issues, the students make connections between their current thoughts and feelings and their past sexual abuse. In one group, for example, a woman struggled to understand why she was unable to tolerate staying in her apartment or in her family’s home in the late afternoon. In processing her thoughts, she made the connection between her present anxiety and her feeling, as a little girl, of desperation and the desire to flee her house during that time of day when the abuse was occurring. On the basis of recent works by Carol Gilligan,” Jean Baker Miller,” and others at the Stone Center for Developmental Services and Studies at Wellesley College who are developing new theories on the development of female psychology, the therapists focus on helping the incest survivors develop a better sense of themselves in relation to significant others in their lives. This
VOL 38, MAY 1990
new “self-in-relation” theory,13 by proposing a differing and more positive perception of women’s life experiences, places a high value on a woman’s ability to relate to people and to care for others. The incest group leaders recognize that college-aged incest survivors have been exposed to a self-in-relation experience in which their trust, love, self-perception, and sense of self have been repeatedly undermined, violated, or repudiated. It becomes critical, therefore, to validate the student’s past and current sense of self in relation to her family and to other relationships. A move toward autonomy has traditionally been viewed as one of the primary tasks for the psychological development of the late adolescent or young adult. Feminist theorists point to the phallocentric nature of this particular developmental task, noting that the thrust toward further separation-individuation from one’s family and consequent independence is more valid for a male’s life experience than a female’~.’~ Because this development is still highly valued in our society, a woman may be at risk of being seen or seeing herself as weak, ”too dependent,” or ”immature” if she experiences difficulty separating from her family and becoming more autonomous or of being conflicted about her future role(s) as mother and career woman. Group leaders take particular care to ensure that group members are not covertly encouraged or pushed to become more autonomous or more independent before they are ready. Although not negating the importance of becoming autonomous and independent, leaders must keep in mind that the bonds between the incest survivor and her family are brittle and may not be able to withstand attempts or actions on the part of the student to separate ,fully. These bonds must be understood within the context of the abuse and not be used to blame the victim if she continues to experience difficulty negotiating the fine balance between maintaining close ties with her family and becoming more autonomous. The self-in-relation theory emphasizes women’s capacity to relate to people and to care for others. This is seen as a strength rather than a weakness. Validating this capacity becomes more complex in working with incest survivors. Their ability to relate to and care for others has been exploited and warped by the perpetrator and by the family dynamics that served to protect the offender and family at the expense of the victim. This disconfirms or contradicts the incest survivor’s experience and undermines her perception of herself and of herself in relation to the perpetrator and other family members. Typically, many of the group members state that they no longer feel that they can trust their memory of what happened to them as children. Either they were so young at the time or the trauma was so severe that the only way that they could cope was to repress or suppress the experiences and the memories totally or significantly. If they had attempted to reveal their secret to
28 1
Downloaded by [University of Sydney] at 11:37 04 May 2015
COLLEGE HEALTH a family member or sought help from others, they may have been blamed, punished, or disbelieved. They may have grown up with a belief that they have “faulty” memories, have misperceived or misrepresented the sexual abuse, or have simply made it up. (Sadly, this latter belief at times may have been reinforced by a woman’s previous therapi~t’~;with increased knowledge about incest, it is hoped that this disconfirming practice is on the wane.) A dissonance soon develops between what the child experiences and what she is told and believes about these people on whom she is so dependent. She will often continue to harbor these misperceptions and self-doubts as an adult. To confront these misperceptions, participants are asked to bring in pictures of themselves around the age when the abuse began. This seems to confirm the woman’s sense of what did take place. It affords her an opportunity to receive validation within the group that she was victimized, was only a child at the time, and could not have fought off or have been responsible for the actions of the (usually) older, larger, and stronger offender. While these perceptions are being reexamined and validated, the women continue to process thoughts and feelings about current and past significant relationships. Many participants are frustrated by their inability to develop or maintain intimate relationships with men or women. Typically, they have problems with issues of trust, control, and sexual functioning in current relationships. Many report a heightened sense of vulnerability and an exacerbation of PTSD symptoms when they are involved in an intimate relationship or are being sexually active.
Friends and lovers may be unable to be supportive. All too frequently, they may use this disclosed information punitively against the survivor during stormy times in the relationship. The group helps the student tolerate and contain her impulsive behavior and supports and acknowledges her thoughts and feelings as valid, even as strong, powerful, and “unacceptable” as they may be to her. As she hears the expression of similar feelings from other group members, she begins to feel more understood, accepted, and “normal.” In no small way, these women are beginning to tolerate, understand, and accept their feelings and perceptions in a way that may have been denied them in the past. The foundation for further growth and awareness of the depth and extent of her ambivalent feelings, her sense of self, and of self in relation to others is enhanced and promoted. Clearly, all of the above issues and concerns are not fully addressed or processed in such a time-limited group. The coleaders frequently underscore the need for more ongoing intensive, individual therapy. This suggestion is framed as a way of encouraging group members to seek continuing support and understanding that can build on what they have come to understand about themselves and the incest experience. For example, grief work, involving mourning the loss of the idealized parents, lack of nurturing, and loss of their own childhood innocence may have begun, but students will usually need more time to work through this process.
Follow-up and Conclusion Some Closely Associated Issues Other issues closely associated with these concerns form an integral dynamic of the group. The women express difficulty tolerating ambivalent feelings, again associated with family members but also experienced with current relationships. The strength and complexity of family loyalties, combined with the powerful mix of love, hatred, fear, attachment, confusion, loss, and disappointment, cannot be underestimated. Whether or not to confront the perpetrator and disclose the incest to other family members or to current or future partners quickly surfaces within the group. The past feels so present and alive to group members that the impulse or need to act is strong, yet it also feels very frightening. A holding action is essential. The clinicians take time to explore all options and anticipate the possible consequences. They also process the wishes, fears, andabove all-the fantasies in confronting the offender or the family because taking such action impulsively may only serve to victimize the incest survivor again. The perpetrator rarely, if ever, acknowledges or assumes responsibility for his behavior. The family may (once more) turn against the victim for bringing it all up again.
282
A 3- to 6-month follow-up of individual members has shown a fairly uniform positive response to participation in the group. To date, 20 out of the 32 group members, or 62.5%, have been interviewed. Nineteen of the women were seen individually by one of the coleaders in a 30- to 45-minute interview and 1 woman, who moved out of state, responded by letter. The initial 6 group members were not contacted; the remaining 6 women either did not respond or had moved, leaving no forwarding telephone number. Permission to call for a follow-up appointment was obtained during the last session. In order to preserve confidentiality, letters were not sent unless explicit permission to do so had been obtained. Seventy-five percent of the women interviewed indicated a wish for a longer-term group; the remaining 25% cited academic and/or employment demands during the semester and said they felt the length of time devoted to the group was sufficient. The participants generally agreed that the group was particularly helpful in decreasing their sense of isolation and in heightening their understanding of the longterm effects of the incest as it related to their individual lives. They said that they continued to identify triggers
jACH
Downloaded by [University of Sydney] at 11:37 04 May 2015
TREATMENT OF INCEST SURVIVORS that exacerbated anxiety or posttraumatic stress symptoms and reported an improved ability to monitor and, at times, reduce these responses. Many reported an increase in self-awareness and a better understanding and acceptance of themselves and of their families. These feelings were accompanied by a striking reduction in self-blame, which they attributed to their participation in the group. Trust, intimacy, and sexual concerns were listed as the major unresolved issues for group members. Although some participants noted a slight-to-moderate improvement in these areas, they felt that a longer-term group, in addition to ongoing individual therapy, would be best suited to address these long-standing issues. A few women, in acknowledging a fantasy that the group would “cure” them, expressed disappointment that further therapy was indicated and was continuing on an individual basis. Although these women continue to experience conflicts and difficulties in their lives, they reported an improved understanding of the linkages between their present developmental concerns and their history of sexual abuse within the family. In conclusion, the developmental tasks facing college-aged women can be complicated by a history of incest. The time-limited group described in this paper seeks to address both sets of concerns through a conceptual framework that empowers, supports, and educates the group members. Sharing their story in this manner not only decreases their sense of isolation, but it enables them to make connections between present and past concerns and t o take further steps toward mastery of developmental tasks that might otherwise be neglected or negated.
INDEX TERMS incest, group psychotherapy, students
REFERENCES 1. Gelinas D. The persisting negative effects of incest. Psychiatry 1983 (November);46:312-332. 2. Faria G, Belohlavek N. Treating female adult survivors of childhood incest. Social Casework 1984;65:465-471. 3. Herman J, Schatzow E. Time limited group therapy for women with a history of incest. Int Group Psychother 1984 (October);34:605-616. 4. Donaldson MA, Gardner R. Diagnosis and treatment of traumatic stress among women after childhood incest. In Figley C, ed, Trauma and Its Wake. New York, BrunnerlMazel, 1985. 5. Farnsworth DL. Psychiatry, Education, and the Young Adult. Springfield, IL, Thomas, 1966. 6. Chickering AW. Education and Identity. San Francisco, Jossey-Bass, 1972.
VOL 38, MAY 7990
7. Barney E, Cole C. A clinical practice model for the group treatment of adult incest survivors. Presented to the NASW National Conference on Clihical Social Work, San Francisco, California, September, 1986. 8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, ed 3, rev. Washington, DC, American Psychiatric Association, 1987. 9. Horowitz M. Stress response syndrome: A review of post traumatic and adjustment disorders. Hosp Community Psychiatry 1986;37(3):241-248. 10. Cole C, Barney E. Safeguards and the therapeutic window: A group treatment strategy for adult incest survivors. Am Orthopsychiatry 1987;57(4):601-609. 11. Gilligan C. In a Different Voice: Psychological Theory and Women’s Development. Cambridge, Harvard University Press, 1982. 12. Miller JB. Toward a New Psychology of Women. Boston, Beacon Press, 1976. 13. Surrey J. The ”self-in-relation”: A theory of women’s development. Work in Progress 84:02, Stone Center Working Papers Series, 1984. 14. Kaplan A, Klein R. The relational self in late adolescent women. Work in Progress 85:17 (Paper 1: Women’s self-development in late adolescence), Stone Center Working Papers Series, 1985. 15. Herman J. Father-Daughter Incest. Cambridge, Harvard University Press, 1981, chap 11.
C A R E E R
O P P O R T U N I T Y
Health Education Coordinator rl[ (Nutrition Specialist) The University of Texas at Austin Student Health Center is seeking a health educator to coordinate nutrition education services for a campus of approximately 50,000 students. Requires a Master’s degree in health education, public health, exercise physiology or nutrition and two years’ work experience in nutritional counseling or educational program planning. Some evening work will be necessary. Competitive applicants should be Registered Dietitians or eligible for registration. Prefer experience with individual nutritional counseling and a knowledge of eating disorders and their treatment. Responsibilities include coordinating, teaching and evaluating the Student Nutrition Advisor Peer Instructor Program (S.N.A.P.); supervising and providing individual nutrition consultations; coordinating the Eating Disorders Treatment Program; assessing needs; d e veloping, implementing and evaluating nutrition education campaigns, and classes and other duties as defined by the goals and objectives of the Health Education D e partment. Salary and benefits are competitive. Position available July 2, 1990. To apply, send letter of interest and resume by June 15, 1990, to: Lisa Kessler, M.P.H., R.D., Department of Health Education, Student Health Center, The University of Texas at Austin, P.O. Box 7339, University Station, Austin, TX 78713. An Equal OpportunitylAffirmative Action Employer
283
