Empowerment Support With Adult Female Survivors of ChildhoodIncest: Part I-Theories and Research Joan C. Urban&
This report is concerned with the concept of empowerment support as a nursing intervention that facilitates the development of mastery, competence, self-worth, and control in the adult female survivor of childhood incest. Empowerment support has been derived from Orem’s theory of nursing system. In that theory. empowerment support is encompassed in particular “methods of helping.”
Theories and research that relate to incest trauma and empowerment support are discussed from an interdisciplinary perspective. Copyright
A
0 1992 by W.B. Saunders
LTHOUGH RECENT research has reported a high prevalence of childhood incest (Russell, 1986; Wyatt, 1985) with serious short- and long-term effects for the survivor (Browne & Finkelhor, 1986; Courtois, 1988; Peters, 1988), too few health care professionals have identified and assisted clients to resolve the destructive effects of their incest experiences. Indeed, many professionals continue to contribute to the trauma of incest by denying, minimizing, and blaming the victim. Because incest is based on abuse of power, a demand for secrecy, betrayal of trust, and disregard for the child’s needs, the victim’s potential for developing profound feelings of helplessness, shame, guilt, and confusion are significant. Therefore, interventions for resolving incest trauma must focus on support, which will empower the victim to develop a sense of self-worth, mastery, competence, and control. If support is to be empowering, it must involve collaborative effort, rather than authoritarian designation of goals and interventions. In addition, the helping person must support the survivor to act on her new beliefs and knowledge and address societal forces that may impede progress and recovery. Because nurses are frequently in contact with adult survivors in a wide variety of settings, they need to develop the knowledge and skills to identify survivors and assist them to resolve their incest trauma by developing
Company
and implementing nursing interventions that incorporate empowerment support. The purpose of this report is to describe the concept of empowerment support as the basis for interventions to use with adult female incest survivors. It is hypothesized that such interventions will lead to an increase in mental health self-care behaviors, well-being, and resolution of incest trauma in incest survivors. The relationship of empowerment support, mental health self-care, wellbeing, and incest trauma resolution are currently being tested in the author’s dissertation research. THEORETICAL FRAMEWORK
Orem ( 1991) identified three theories that together form her self-care deficit or general theory of nursing. These three theories are self-care, selfcare deficit, and nursing system. Orem also identified six core concepts in her self-care deficit theory (SCDT): self-care, self-care agency, self-care deficit, therapeutic self-care demand, nursing agency, and nursing system. In addition. basic
From the University of Detroit Mercy, School of Nursing. Detroit MI. Address reprint requests to Joan C. Urbancic, R.N.. Ph.D., C.S., Assistant Professor of Nursing, University of Detroit Mercy, School of Nursing, 8200 W. Outer Dr., Detroit, MI 482 19. Copyright 0 1992 by W.B. Saunders Company 0883-9417/92/0605-0004$3.00/0
Archiues of Psychiatric Nursing, Vol. VI. No. 5 (October), 1992: pp. 275-281
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conditioning factors (BCFs) are described as a peripheral concept. This report is concerned with the concept of empowerment support as a type of nursing system and incest trauma as a basic conditioning factor within Orem’s SCDT (1991). The Concept of Nursing System
The concept of empowerment support has been derived from Orem’s theory of nursing system. In that theory, empowerment support is encompassed in particular ‘ ‘methods of helping’ ’ that make up in part, the nursing system concept. Orem (1991) has defined nursing systems as series andsequences of practicalactionsof nurses that may be conjdined with practical actions of nurses’ patients or their significant others to meet some or all components of patients’ therapeutic self-care demands and to regulate the exercise or development of their powers of self-care agency. (p. 269)
The five general methods of helping within the concept of nursing system (Orem, 1991) have application in a wide variety of settings. These methods of helping, either singly but usually in combinations, are used for the development of nursing systems with specialized nursing technologies that each situation demands. They include (1) acting for or doing for another, (2) guiding another, (3) supporting another (physically or psychologically), (4) providing a developmental environment, and (5) teaching another. Because this author views empowerment support as primarily psychological support, only the methods of helping that relate to psychological support and teaching will be included in the conceptualization of the concept. Empowerment Support
“Empowerment support” for the adult female survivor of childhood incest is defined as particular kinds of deliberate helping that are based on a collaborative helping relationship which facilitates the development of feelings of mastery, competency, self-worth, and control. Empowerment support may also be viewed as supportive psychotherapy, since it consists of personal and intimate caring interactions between the survivor and helper. However, empowerment support is based on a collaborative model of helping, rather than the traditional patriarchal model of psychotherapy. It also seeks to identify and address societal attitudes that
maintain family violence. It is essential that nurses learn what interventions are empowering, so that these methods can become part of a nursing system for use with clients in need of empowerment. The Concept of Basic Conditioning Factors
Although Orem does not identify incest trauma as a specific BCF, it appears compptible with her conceptualization. According to Orem (199 l), “factors internal or external to individuals that affect their abilities to engage in self-care or affect the kind and amount of self-care required are named basic conditioning factors” (p. 136). In this article, incest trauma is viewed as the BCF of health state. Incest Trauma as a Health State
Orem (199 1) referred to the construct of health as both an outcome state and a factor that influences an individual’s ability to engage in self-care. She specifies that the health state of an individual influences self-care agency and self-care, and selfcare in turn is necessary for health, human development , and well-being. Thus, incest trauma is viewed as a health state and is defined as a condition of residual destructive effects from exploitative childhood incest experiences that persists in adulthood and, if unresolved, influences human functioning in a negative, often debilitating way. Incest trauma can exist and be expressed in many different self-care deficits, even though the survivor has repressed all memories of the abuse. Since self-care is a form of human functioning and it is a prerequisite for health and wellbeing (Orem, 1991), it is proposed that incest trauma will negatively influence health and wellbeing. Theories and Research Related to Incest Trauma
This section will focus primarily on the theories and research that relate to long-term effects of incest among female survivors. This does not negate or minimize the existence of short-term effects of childhood incest. Unfortunately, many studies of childhood incest have not used standardized measures, adequate sample size, and comparison groups, and have based their studies on clinical populations. Intrafamilial versus extrafamilial sexual abuse was not always distinguished in these studies. The definition of “incest” used here is derived
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from Russell (1986): any type of exploitative sexual contact or attempted contact that occurred between relatives or surrogate relatives before the victim turned 18 years old. In this report, surrogate relatives include such people as stepfathers, mother’s boyfriends, and close family friends that may assume caretaker roles. A number of cognitive theories have been presented to explain the traumatic effects of childhood sexual abuse. One such theory is Carmen and Rieker’s psychosocial model of the victim-topatient process (1989). Reiker and Carmen (1986) studied the differences between psychiatric patients (N = 186) with histories of sexual and/or physical abuse and those without abuse. They claimed that three cognitive strategies are involved in defending the self from the abuse: denial, changing the affective response to the abuse, and changing the meaning of the abuse. When the victim is denied the experience of knowing and remembering , assigning meaning, and responding affectively to the sexual abuse, a process called “defensive exclusion” occurs. This process is similar to one discussed by researchers Burgess, Hartman. Wolbert, & Grant (1987), which they called “trauma encapsulation.” Both of these models explain that victims attempt to cope by using defense mechanisms such as denial, repression, dissociation, and compartmentalization to decontextualize their traumatic experiences. Thus, the defenses that originally were adaptive forms of self-care for the victim eventually become the core of the adult survivor’s mental health problems. It is postulated that these same mechanisms serve as a barrier to further development of mental health self-care behaviors and well-being. Figley (1985) and van der Kolk (1987) claimed that incest trauma can be considered as posttraumatic stress disorder (PTSD) and, indeed, many incest survivors show symptoms that fulfill the DSM-III criteria for PTSD. Other incest researchers have maintained that explaining incest trauma as a form of PTSD is incomplete as a theory to explain the traumatic effects of the incest experience. These researchers (Briere & Runtz, 1987) have identified many characteristics in women (N = 152) who have been sexually abused as children that cannot be neatly subsumed within PTSD, such as dissociation, suicide attempts, revictimization, distorted beliefs about self, and substance abuse.
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Finkelhor (1986) rejected the PTSD explanation in favor of his own model, which consists of four trauma-causing factors called “traumagenic dynamics.” Finkelhor maintained that some of these four factors occur in all types of psychologically traumatic situations, but it is only in the incest experience that all four occur together. The four factors are (1) traumatic sexualization, (2) betrayal, (3) powerlessness, and (4) stigmatization. Fromuth (1986), Sedney and Brooks (1984), and Seidner and Calhoun ( 1984) used samples of college students and control groups to compare the long-term effects of childhood sexual abuse. These three studies found that sexually abused women demonstrated more depression, anxiety, and substance abuse than nonabused women. In two different randomly sampled community studies, Bagley and Ramsey (1985) and Briere and Runtz (1988) also found that women with childhood sexual abuse histories were more depressed, had more somatic anxiety, more suicide attempts, and substance abuse and lower self-esteem scores than nonabused controls (N = 387 and N = 152, respectively). Other researchers have documented problems such as deficiencies with male and female relationships, sexual dysfunctions, and multiple somatic complaints that are often related to the type of abuse that was experienced (Carmen, Reiker, & Mills. 1984; Rew. 1989; Urbancic. 1992). In a review of the literature, Browne and Finkelhor (1986) concluded that empirical research seems to support the clinical impression of low esteem among adult women with childhood sexual abuse experiences. Research also supported the probability that incest victims are more likely to experience sexual and physical revictimization as adults by strangers, husbands, boyfriends, and therapists (Briere & Runtz, 1988; Brown & Garrison, 1990; Kluft. 1990: Russell, 1986; Urbancic, 1992). Theories and Research on Empowerment Support
There are no specific studies on empowerment support, since it is a concept proposed by the author. Research studies on “empowerment” have also been scarce, because the concept has not been clearly defined or operationalized even though the term “empowerment” is very popular today. Rappaport (1987) states that one cannot “give” empowerment to another; it can only be taken. But
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nurses and other health care professionals can use methods of helping that provide the language, beliefs, psychological support, and developmentally appropriate conditions to facilitate the empowerment of others. In this report, “empowerment’ ’ refers to a client characteristic, while “empowerment support” refers to caregiver intervention directed at facilitating the development of this characteristic through collaboration with the client. It is clear that a variety of interventions can facilitate the empowerment of individuals. It also is clear that studies have been performed of empowerment support, but they have not been labeled as such. Rappaport (1987) states, “We do not know what empowerment is, but like obscenity, we know it when we see it” (p. 2). Freire (1974), a Brazilian educator, has written extensively on empowering education and his ideas have stimulated worldwide programs in literacy, peace, health, youth discipline, and community development. A central thesis for Freire is that education must be liberating for learners so that they can become subjects and actors, rather than objects and observers in their own lives and in society. Freire believes that collective knowledge emerges from people sharing their experiences and understandings of social influences. “The teacher is no longer merely the one-who-teaches, but one who is himself taught in dialogue with the students, who in turn while being taught also teaches. They become jointly responsible for a process in which all grow” (p. 67). In addition to understanding and gaining knowledge, Freire emphasizes that the learning process also requires action and subsequent reflection on this action. Swift and Levin (1987) are in agreement with Freire as they point out that empowerment is both a subjective experience and objective reality, that is, both a process (developing feelings of competency and worth) and a goal (restructuring the environment in order to redistribute power). Cognitive awareness and affective energy are necessary before a person can participate in empowering activities. In addition, Swift and Levin insist that true empowerment encompasses more than involvement; it involves making decisions and doing. For Brown and Ziefert (1988), empowerment for women “means affecting the environment in a manner that directly confronts oppressive patriarchial social and political institutions that support
JOAN C. URBANCIC
and reinforce violence against women” (p. 99). An example of patriarchial oppression is the reluctance of psychiatry to recognize the significance of incest trauma for the survivor despite the growing body of research on the traumatic effects of incest. According to the eminent psychiatrist, Roland Summit (1989, p. 413), “In spite of, and in part because of historical precedent to the contrary, therapists seem reluctant to acknowledge that a background of sexual abuse may be crucial to the understanding of a person’s need and vital to an optimistic plan for recovery. ” NURSING EMPOWERMENT RESEARCH No nursing studies have been identified that claim to be empowerment studies per se. However, upon examination it is clear that nursing studies investigate strategies that use guidance, psychological support, teaching methods, and developmental environments to facilitate self-care behaviors. Since these strategies assist people to gain a sense of self-worth, mastery, control, and competence over their lives, increase self-care behaviors, and identify barriers to the achievement of self-care, they may be viewed as empowerment support. Thus, from this perspective innumerable nursing studies can qualify as empowerment support research. The following nursing studies are based on Orem’s self-care deficit theory and include a number of different methods of helping and their effects/relationships on self-care agency and/or selfcare. While most of these studies used adequate sample size some designs were nonexperimental. Several nursing studies found support for the hypothesis that self-care behaviors can be taught in children (Blazek & McClellan, 1983; Moore, 1987; Rew, 1987). In a study of pregnant women, Riesch (1988) found self-care agency to be significantly higher after childbirth classes for both the women and their coaches (N = 78). A series of experimental design studies have shown an increase in self-care agency/self-care behaviors after interventions that could be described as empowering with adults: education classes on self-care agency of patients with COPD (Stockdale-Wooley, 1984), teaching self-care management of chemotherapy side effects in cancer patients (Dodd, 1983, 1984), dramatic classes to increase self-care behaviors in schizophrenic patients (Whetstone, 1986), group therapy to de-
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crease feelings of helplessness and hopelessness among depressed women (Rothlis, 1984), and medication education among black, elderly, hypertensive patients (Harper, 1984). An exception to the increase in self-care agency/ self-care behaviors was a study by Karl (1982). She instituted a range-of-motion exercise program for the elderly, but found no differences between experimental and control groups in their independent self-care abilities. Both the Whetstone (1986) and Karl (1982) studies had problems of convenience samples, small sample size, and interventions that were probably insufficient in duration to establish lasting change. These studies generally provide support that nursing interventions that use Orem’s methods of helping can increase self-care behaviors in patients. The cumulative evidence is persuasive, because for the most part sufficient sample size, random assignment, and experimental design were used. Most of the above studies identified teaching interventions as the method of helping, but one wonders if perhaps other methods of helping, such as guiding, supporting, and providing a developmental environment, were used by nurses but not identified as such. Only Riesch (1988) clearly identified various methods of helping in her study. COMMUNITY
AND SOCIAL PSYCHOLOGY
EMPOWERMENT RESEARCH
In community and social psychology research on empowerment, Rappaport (198 1) noted the vast body of research that exists on personal control. He maintains that these studies support the belief that people benefit from more, rather than less control, over their lives and resources. Rappaport concluded that “social problems, paradoxically, require that experts turn to nonexperts in order to discover the many different, even contradictory, solutions that they use to gain control, find meaning, and empower their own lives” (p. 21). Since empowerment per se is a new concept, most research on it is descriptive and, therefore, causality cannot be supported. Nevertheless, although experimental research is minimal, descriptive and correlational studies of empowerment appear promising. In some of the studies, professionals use intervention strategies that this author would describe as empowerment support. Rappaport, Swift, and Hess (1984) published a
variety of theory and research reports on empowerment with methodologies ranging from phenomenological to experimental. Descriptive studies included a study of how empowerment works in a religious setting (Maton & Rappaport, 1984), political power of Puerto Ricans (Serrano-Garcia, 1984), the structure and process of feminist organizations (Riger, 1984), and empowerment strategies with welfare and other community groups (Fawcett, Seekins, Whang, Muiu, & Suarez de Balcazar, 1984). Other studies that developed and examined empowerment strategies include empowerment strategies for the elderly (Gallant, Cohen, & Wolff. 1985), alternate schools (Gruber & Trickett. 1987)) substance abuse prevention programs (Roberts & Thorsheim, 1986; Wallerstein & Berstein. 1988). and the negative psychological effects of sexist language and recommendations to deal with this problem (Miller & Swift, 1976). The empowerment research prioritizes the need for working collaboratively with clients to identify and develop strategies that will build on client strengths and increase their sense of control over their lives while supporting them to take action to change their lives. This approach is clearly compatible with Orem (1991), who emphasized that nurse-client relationships must be based on collaboration and nursing actions that will facilitate the development of self-care behaviors. Thus, it is hypothesized that methods of helping that incorporate empowerment support will increase self-care behaviors, well-being, and incest trauma resolution in adult female survivors. REFERENCES Bagley, C.. & Ramsey, R. (1985). Sexual abuse in childhood: Psychosocial outcomes and implications for social work practice. Social Work Practice in Sexual Problems, 4. 33-47. Blazek. B.. & McClellan. M. (1983). The effects of selt-care instruction on locus on control in children. Journal of School Health, 53, 554-556. Briere, J., & Runtz, M. (1987). Post-sexual abuse trauma: Data and implications for clinical practice. Journal of fnrerpersonal Violence, 2. (4), 367-319. Briere. J., & Runtz, M. (1988). Post sexual abuse trauma. In G. Wyatt & G. Powell (Eds.). Lasfing effects of child sexual abuse (pp. 61-82). Newbury Park. CA: Sage. Brown,
B.E., & Garrison, C.J. (1990). Patterns of symptomatology of adult women incest survivors. Western Journal of Nursing Research, 12, 587-600.
Brown. S.K., & Ziefert. M. (1988). Crisis resolution,
compe-
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tence, and empowerment: A service model for women. Journal of Primary Prevenrion, 9, 92-103. Browne, A., & Finkelhor, D. (1986). Impact of child sexual abuse: A review of the literature. Psychological Bulletin, 99, 66-77. A., Hartman, C.R., Wolbert, W., & Grant, C.A. (1987). Child molestation: Assessing impact in multiple victims (part 1). Archive of Psychiarric Nursing, I, 3339. Carmen, E., & Rieker, P.P. (1989). A psychosocial model of the victim-to-patient process. Psychiatric Clinics of North America, 12, 431-443. Carmen, E., Rieker, P.P., & Mills. T. (1984). Victims of violence and psychiatric illness. American Journal of Psychiatry, 141, 378-383. Courtois, C. (1988). Healing the incest wound. New York: W.W. Norton. de Shazer, S. (198.5). Keys to solution in brief therapy. New York: W.W. Norton & Co. Burgess,
Dodd, M.J. (1983). Self-care for side effects in cancer chemotherapy: An assessment of nursing interventions. Part II. Cancer Nursing. 6, 63-67. Dodd, M.J. (1984). Measuring informational intervention for chemotherapy knowledge and self-care behavior. Research in Nursing and Health, 7. 43-50. Fawcett, S.B., Seekins, T., Whang, P.I., Muiu, C., Suarez de Balcazar, Y. (1984). Creating and using social technologies for community empowerment. Prevention in Human Services, 3, 145-171. Figley, C.R. (1985). Trauma and its wake: The study and treatment of post-traumatic stress disorder. New York: Brunner/Mazel. Finkelhor, D. (1986). A sourcebook on child sexual abuse. Beverly Hills: Sage. Fromuth, M.E. (1986). The relationship of childhood sexual abuse with later psychological adjustment in a sample of college women. Child Abuse and Neglect, 10, 5-15. Freire, P. (1974). Pedagogy of the oppressed. New York: Seabury Press. Gallant, R., Cohen, C., & Wolff, T. (1985). Change of older persons’ image, impact on public policy result from Highland Valley empowerment plan. Perspectives on Aging, 14, 9-13. Gruber, J., & Trickett, E.J. (1987). Can we empower others? The paradox of empowerment in an alternative public high school. American Journal of Community Psychology, 15, 353-372. Harper, D.C. (1984). Application of Orem’s theoretical constructs to self-care medication behaviors in the elderly. Advances in Nursing Science. 6, 29-46. Karl, C.A. (1982). The effect of an exercise program on selfcare activities for the institutionalized elderly. Journal of Gerontological Nursing, 8, 282-285. Kluft, R.P. (1990). Incest-related syndromes of adult psychopathology. Washington, DC: American Psychiatric Press. Maton,
K.I., & Rappaport, M. (1984). Empowerment in a religious setting. Prevention in Human Services, 3, 3772. Miller, C., & Swift, K. (1976). Words and Women. Garden City, NY: Anchor.
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Moore. J.B. (1987). Effects of assertion training and first aid instruction on children’s autonomy and self-care agency. Research in Nursing and Health. 10, lOI- 109. Orem, D.E. (1991). Nursing: Concepts of pracrice (4th ed.). St. Louis: Mosby Yearbook. Peters, S. ( 1988). Child sexual abuse and later psychological problems. In G. Wyatt & G. Powell (Eds.). Lasting effects of child sexual abuse. Beverly Hills: Sage. Rappaport, J. (1981). In praise of paradox: A social policy of empowerment over prevention. American Journal of Communit_vPsychology, 9. l-25. Rappaport, J. (1987). Terms of empowerment/exemplars of prevention: Toward a theory for community psychology. American Journal of Community Psychology, 15, 121-145. Rappaport, J., Swift, C., & Hess, R. (Eds.). (1984). Studies in empowerment: Steps toward understanding and action. Prevention in Human Services, 3, l-230. Reiker. P.P., & Carmen, E. (1986). The victim-to-patient process: The disconfinnation and transformation of abuse. American Journal of Orthopsychiatv, 56. 360-370. Rew, L. (1987). The relationship between self-care behaviors and selected psychosocial variables in children with asthma. Journal of Pediarric Nursing, 2, 333-341. Rew, L. (1989). Long-term effects of childhood sexual exploitation. Issues in Menial Health Nursing, 6, 229-244. Riesch,
S.K. (1988). Changes in the exercise of self-care agency. Western Journal of Nursing Research, 10. 257. 213.
Riger, S. (1984). Vehicles for empowerment: The case of feminist movement organizations. Prevention in Human Services, 3. 99-l 17. Roberts,
B.B., & Thorsheim, H.I. (1986). A partnership approach to consultation: the process and results of a major primary prevention field experiment. In J.G. Kelly (Ed.), Community basedprevention research. Washington DC: National Institute of Mental Health.
Rothlis, J. (1984). The effect of a self-help group on feelings of hopelessness and helplessness. Wesfern Journal of Nursing Research, 6. 157-173. Russell, D. (1986). The secret trauma. New York: Basic Books. Sedney,
M.A., & Brooks, B. (1984). Factors associated with history of childhood sexual experience in a nonclinical female population. Journal of the American Academy of Child Psychiatry, 23. 215-218.
Seidner, M.A., & Calhoun, B. (1984, August). Childhood sexual abuse: Factors related to differential adult adjustment. Paper presented at the Second Annual National Family Violence Research Conference, Durham, NH. Serrano-Garcia, I. (1984). The illusion of empowerment: Community development within a colonial context. Prevention in Human Services, 3, 173-200. Stockdale-Wooley, R. (1984). The effects of education on selfcare agency. Public Health Nursing, 1. 97-106. Summit, R. (1989). The centrality of victimization: Regaining the focal point of recovery for survivors of child sexual abuse. Psychiatric Clinics of North America, 12. 413430. Swift, C.. & Levin, G. (1987). Empowerment:
An emerging
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mental health technology. Journal of Primary Prevention, 8, 11-94. Urbancic, I. (1992). The relationship between empowerment support. mental health self-care, well-being, and incest trauma resolution in adultfemale survivors of childhood incest. Unpublished doctoral dissertation, Wayne State University, Detroit. van der Kolk, B.A. (1987). Psychological trauma. Washington. DC: American Psychiatric Press.
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Wallerstein, N., & Berstein. E. (1988). Empowerment education: Freire’s ideas adapted to health education. Health Education Quarterly. 15. 319-394. Whetstone, W.R. (1986). Social dramatics: Social skills development for the chronically mentally ill. Journal of Advanced Nursing. I I, 67-74. Wyatt, G.E. (1985). The sexual abuse of Afro-American and White-American women in childhood. Child Abuse and Neglect. 9, 507-519.
This report is concerned with the concept of empowerment support as a nursing intervention that facilitates the development of mastery, competence, self-worth, and control in the adult female survivor of childhood incest. Empowerment support has been derived from Orem’s theory of nursing system. In that theory. empowerment support is encompassed in particular “methods of helping.”
Theories and research that relate to incest trauma and empowerment support are discussed from an interdisciplinary perspective. Copyright
A
0 1992 by W.B. Saunders
LTHOUGH RECENT research has reported a high prevalence of childhood incest (Russell, 1986; Wyatt, 1985) with serious short- and long-term effects for the survivor (Browne & Finkelhor, 1986; Courtois, 1988; Peters, 1988), too few health care professionals have identified and assisted clients to resolve the destructive effects of their incest experiences. Indeed, many professionals continue to contribute to the trauma of incest by denying, minimizing, and blaming the victim. Because incest is based on abuse of power, a demand for secrecy, betrayal of trust, and disregard for the child’s needs, the victim’s potential for developing profound feelings of helplessness, shame, guilt, and confusion are significant. Therefore, interventions for resolving incest trauma must focus on support, which will empower the victim to develop a sense of self-worth, mastery, competence, and control. If support is to be empowering, it must involve collaborative effort, rather than authoritarian designation of goals and interventions. In addition, the helping person must support the survivor to act on her new beliefs and knowledge and address societal forces that may impede progress and recovery. Because nurses are frequently in contact with adult survivors in a wide variety of settings, they need to develop the knowledge and skills to identify survivors and assist them to resolve their incest trauma by developing
Company
and implementing nursing interventions that incorporate empowerment support. The purpose of this report is to describe the concept of empowerment support as the basis for interventions to use with adult female incest survivors. It is hypothesized that such interventions will lead to an increase in mental health self-care behaviors, well-being, and resolution of incest trauma in incest survivors. The relationship of empowerment support, mental health self-care, wellbeing, and incest trauma resolution are currently being tested in the author’s dissertation research. THEORETICAL FRAMEWORK
Orem ( 1991) identified three theories that together form her self-care deficit or general theory of nursing. These three theories are self-care, selfcare deficit, and nursing system. Orem also identified six core concepts in her self-care deficit theory (SCDT): self-care, self-care agency, self-care deficit, therapeutic self-care demand, nursing agency, and nursing system. In addition. basic
From the University of Detroit Mercy, School of Nursing. Detroit MI. Address reprint requests to Joan C. Urbancic, R.N.. Ph.D., C.S., Assistant Professor of Nursing, University of Detroit Mercy, School of Nursing, 8200 W. Outer Dr., Detroit, MI 482 19. Copyright 0 1992 by W.B. Saunders Company 0883-9417/92/0605-0004$3.00/0
Archiues of Psychiatric Nursing, Vol. VI. No. 5 (October), 1992: pp. 275-281
275
276
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conditioning factors (BCFs) are described as a peripheral concept. This report is concerned with the concept of empowerment support as a type of nursing system and incest trauma as a basic conditioning factor within Orem’s SCDT (1991). The Concept of Nursing System
The concept of empowerment support has been derived from Orem’s theory of nursing system. In that theory, empowerment support is encompassed in particular ‘ ‘methods of helping’ ’ that make up in part, the nursing system concept. Orem (1991) has defined nursing systems as series andsequences of practicalactionsof nurses that may be conjdined with practical actions of nurses’ patients or their significant others to meet some or all components of patients’ therapeutic self-care demands and to regulate the exercise or development of their powers of self-care agency. (p. 269)
The five general methods of helping within the concept of nursing system (Orem, 1991) have application in a wide variety of settings. These methods of helping, either singly but usually in combinations, are used for the development of nursing systems with specialized nursing technologies that each situation demands. They include (1) acting for or doing for another, (2) guiding another, (3) supporting another (physically or psychologically), (4) providing a developmental environment, and (5) teaching another. Because this author views empowerment support as primarily psychological support, only the methods of helping that relate to psychological support and teaching will be included in the conceptualization of the concept. Empowerment Support
“Empowerment support” for the adult female survivor of childhood incest is defined as particular kinds of deliberate helping that are based on a collaborative helping relationship which facilitates the development of feelings of mastery, competency, self-worth, and control. Empowerment support may also be viewed as supportive psychotherapy, since it consists of personal and intimate caring interactions between the survivor and helper. However, empowerment support is based on a collaborative model of helping, rather than the traditional patriarchal model of psychotherapy. It also seeks to identify and address societal attitudes that
maintain family violence. It is essential that nurses learn what interventions are empowering, so that these methods can become part of a nursing system for use with clients in need of empowerment. The Concept of Basic Conditioning Factors
Although Orem does not identify incest trauma as a specific BCF, it appears compptible with her conceptualization. According to Orem (199 l), “factors internal or external to individuals that affect their abilities to engage in self-care or affect the kind and amount of self-care required are named basic conditioning factors” (p. 136). In this article, incest trauma is viewed as the BCF of health state. Incest Trauma as a Health State
Orem (199 1) referred to the construct of health as both an outcome state and a factor that influences an individual’s ability to engage in self-care. She specifies that the health state of an individual influences self-care agency and self-care, and selfcare in turn is necessary for health, human development , and well-being. Thus, incest trauma is viewed as a health state and is defined as a condition of residual destructive effects from exploitative childhood incest experiences that persists in adulthood and, if unresolved, influences human functioning in a negative, often debilitating way. Incest trauma can exist and be expressed in many different self-care deficits, even though the survivor has repressed all memories of the abuse. Since self-care is a form of human functioning and it is a prerequisite for health and wellbeing (Orem, 1991), it is proposed that incest trauma will negatively influence health and wellbeing. Theories and Research Related to Incest Trauma
This section will focus primarily on the theories and research that relate to long-term effects of incest among female survivors. This does not negate or minimize the existence of short-term effects of childhood incest. Unfortunately, many studies of childhood incest have not used standardized measures, adequate sample size, and comparison groups, and have based their studies on clinical populations. Intrafamilial versus extrafamilial sexual abuse was not always distinguished in these studies. The definition of “incest” used here is derived
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from Russell (1986): any type of exploitative sexual contact or attempted contact that occurred between relatives or surrogate relatives before the victim turned 18 years old. In this report, surrogate relatives include such people as stepfathers, mother’s boyfriends, and close family friends that may assume caretaker roles. A number of cognitive theories have been presented to explain the traumatic effects of childhood sexual abuse. One such theory is Carmen and Rieker’s psychosocial model of the victim-topatient process (1989). Reiker and Carmen (1986) studied the differences between psychiatric patients (N = 186) with histories of sexual and/or physical abuse and those without abuse. They claimed that three cognitive strategies are involved in defending the self from the abuse: denial, changing the affective response to the abuse, and changing the meaning of the abuse. When the victim is denied the experience of knowing and remembering , assigning meaning, and responding affectively to the sexual abuse, a process called “defensive exclusion” occurs. This process is similar to one discussed by researchers Burgess, Hartman. Wolbert, & Grant (1987), which they called “trauma encapsulation.” Both of these models explain that victims attempt to cope by using defense mechanisms such as denial, repression, dissociation, and compartmentalization to decontextualize their traumatic experiences. Thus, the defenses that originally were adaptive forms of self-care for the victim eventually become the core of the adult survivor’s mental health problems. It is postulated that these same mechanisms serve as a barrier to further development of mental health self-care behaviors and well-being. Figley (1985) and van der Kolk (1987) claimed that incest trauma can be considered as posttraumatic stress disorder (PTSD) and, indeed, many incest survivors show symptoms that fulfill the DSM-III criteria for PTSD. Other incest researchers have maintained that explaining incest trauma as a form of PTSD is incomplete as a theory to explain the traumatic effects of the incest experience. These researchers (Briere & Runtz, 1987) have identified many characteristics in women (N = 152) who have been sexually abused as children that cannot be neatly subsumed within PTSD, such as dissociation, suicide attempts, revictimization, distorted beliefs about self, and substance abuse.
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Finkelhor (1986) rejected the PTSD explanation in favor of his own model, which consists of four trauma-causing factors called “traumagenic dynamics.” Finkelhor maintained that some of these four factors occur in all types of psychologically traumatic situations, but it is only in the incest experience that all four occur together. The four factors are (1) traumatic sexualization, (2) betrayal, (3) powerlessness, and (4) stigmatization. Fromuth (1986), Sedney and Brooks (1984), and Seidner and Calhoun ( 1984) used samples of college students and control groups to compare the long-term effects of childhood sexual abuse. These three studies found that sexually abused women demonstrated more depression, anxiety, and substance abuse than nonabused women. In two different randomly sampled community studies, Bagley and Ramsey (1985) and Briere and Runtz (1988) also found that women with childhood sexual abuse histories were more depressed, had more somatic anxiety, more suicide attempts, and substance abuse and lower self-esteem scores than nonabused controls (N = 387 and N = 152, respectively). Other researchers have documented problems such as deficiencies with male and female relationships, sexual dysfunctions, and multiple somatic complaints that are often related to the type of abuse that was experienced (Carmen, Reiker, & Mills. 1984; Rew. 1989; Urbancic. 1992). In a review of the literature, Browne and Finkelhor (1986) concluded that empirical research seems to support the clinical impression of low esteem among adult women with childhood sexual abuse experiences. Research also supported the probability that incest victims are more likely to experience sexual and physical revictimization as adults by strangers, husbands, boyfriends, and therapists (Briere & Runtz, 1988; Brown & Garrison, 1990; Kluft. 1990: Russell, 1986; Urbancic, 1992). Theories and Research on Empowerment Support
There are no specific studies on empowerment support, since it is a concept proposed by the author. Research studies on “empowerment” have also been scarce, because the concept has not been clearly defined or operationalized even though the term “empowerment” is very popular today. Rappaport (1987) states that one cannot “give” empowerment to another; it can only be taken. But
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nurses and other health care professionals can use methods of helping that provide the language, beliefs, psychological support, and developmentally appropriate conditions to facilitate the empowerment of others. In this report, “empowerment’ ’ refers to a client characteristic, while “empowerment support” refers to caregiver intervention directed at facilitating the development of this characteristic through collaboration with the client. It is clear that a variety of interventions can facilitate the empowerment of individuals. It also is clear that studies have been performed of empowerment support, but they have not been labeled as such. Rappaport (1987) states, “We do not know what empowerment is, but like obscenity, we know it when we see it” (p. 2). Freire (1974), a Brazilian educator, has written extensively on empowering education and his ideas have stimulated worldwide programs in literacy, peace, health, youth discipline, and community development. A central thesis for Freire is that education must be liberating for learners so that they can become subjects and actors, rather than objects and observers in their own lives and in society. Freire believes that collective knowledge emerges from people sharing their experiences and understandings of social influences. “The teacher is no longer merely the one-who-teaches, but one who is himself taught in dialogue with the students, who in turn while being taught also teaches. They become jointly responsible for a process in which all grow” (p. 67). In addition to understanding and gaining knowledge, Freire emphasizes that the learning process also requires action and subsequent reflection on this action. Swift and Levin (1987) are in agreement with Freire as they point out that empowerment is both a subjective experience and objective reality, that is, both a process (developing feelings of competency and worth) and a goal (restructuring the environment in order to redistribute power). Cognitive awareness and affective energy are necessary before a person can participate in empowering activities. In addition, Swift and Levin insist that true empowerment encompasses more than involvement; it involves making decisions and doing. For Brown and Ziefert (1988), empowerment for women “means affecting the environment in a manner that directly confronts oppressive patriarchial social and political institutions that support
JOAN C. URBANCIC
and reinforce violence against women” (p. 99). An example of patriarchial oppression is the reluctance of psychiatry to recognize the significance of incest trauma for the survivor despite the growing body of research on the traumatic effects of incest. According to the eminent psychiatrist, Roland Summit (1989, p. 413), “In spite of, and in part because of historical precedent to the contrary, therapists seem reluctant to acknowledge that a background of sexual abuse may be crucial to the understanding of a person’s need and vital to an optimistic plan for recovery. ” NURSING EMPOWERMENT RESEARCH No nursing studies have been identified that claim to be empowerment studies per se. However, upon examination it is clear that nursing studies investigate strategies that use guidance, psychological support, teaching methods, and developmental environments to facilitate self-care behaviors. Since these strategies assist people to gain a sense of self-worth, mastery, control, and competence over their lives, increase self-care behaviors, and identify barriers to the achievement of self-care, they may be viewed as empowerment support. Thus, from this perspective innumerable nursing studies can qualify as empowerment support research. The following nursing studies are based on Orem’s self-care deficit theory and include a number of different methods of helping and their effects/relationships on self-care agency and/or selfcare. While most of these studies used adequate sample size some designs were nonexperimental. Several nursing studies found support for the hypothesis that self-care behaviors can be taught in children (Blazek & McClellan, 1983; Moore, 1987; Rew, 1987). In a study of pregnant women, Riesch (1988) found self-care agency to be significantly higher after childbirth classes for both the women and their coaches (N = 78). A series of experimental design studies have shown an increase in self-care agency/self-care behaviors after interventions that could be described as empowering with adults: education classes on self-care agency of patients with COPD (Stockdale-Wooley, 1984), teaching self-care management of chemotherapy side effects in cancer patients (Dodd, 1983, 1984), dramatic classes to increase self-care behaviors in schizophrenic patients (Whetstone, 1986), group therapy to de-
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crease feelings of helplessness and hopelessness among depressed women (Rothlis, 1984), and medication education among black, elderly, hypertensive patients (Harper, 1984). An exception to the increase in self-care agency/ self-care behaviors was a study by Karl (1982). She instituted a range-of-motion exercise program for the elderly, but found no differences between experimental and control groups in their independent self-care abilities. Both the Whetstone (1986) and Karl (1982) studies had problems of convenience samples, small sample size, and interventions that were probably insufficient in duration to establish lasting change. These studies generally provide support that nursing interventions that use Orem’s methods of helping can increase self-care behaviors in patients. The cumulative evidence is persuasive, because for the most part sufficient sample size, random assignment, and experimental design were used. Most of the above studies identified teaching interventions as the method of helping, but one wonders if perhaps other methods of helping, such as guiding, supporting, and providing a developmental environment, were used by nurses but not identified as such. Only Riesch (1988) clearly identified various methods of helping in her study. COMMUNITY
AND SOCIAL PSYCHOLOGY
EMPOWERMENT RESEARCH
In community and social psychology research on empowerment, Rappaport (198 1) noted the vast body of research that exists on personal control. He maintains that these studies support the belief that people benefit from more, rather than less control, over their lives and resources. Rappaport concluded that “social problems, paradoxically, require that experts turn to nonexperts in order to discover the many different, even contradictory, solutions that they use to gain control, find meaning, and empower their own lives” (p. 21). Since empowerment per se is a new concept, most research on it is descriptive and, therefore, causality cannot be supported. Nevertheless, although experimental research is minimal, descriptive and correlational studies of empowerment appear promising. In some of the studies, professionals use intervention strategies that this author would describe as empowerment support. Rappaport, Swift, and Hess (1984) published a
variety of theory and research reports on empowerment with methodologies ranging from phenomenological to experimental. Descriptive studies included a study of how empowerment works in a religious setting (Maton & Rappaport, 1984), political power of Puerto Ricans (Serrano-Garcia, 1984), the structure and process of feminist organizations (Riger, 1984), and empowerment strategies with welfare and other community groups (Fawcett, Seekins, Whang, Muiu, & Suarez de Balcazar, 1984). Other studies that developed and examined empowerment strategies include empowerment strategies for the elderly (Gallant, Cohen, & Wolff. 1985), alternate schools (Gruber & Trickett. 1987)) substance abuse prevention programs (Roberts & Thorsheim, 1986; Wallerstein & Berstein. 1988). and the negative psychological effects of sexist language and recommendations to deal with this problem (Miller & Swift, 1976). The empowerment research prioritizes the need for working collaboratively with clients to identify and develop strategies that will build on client strengths and increase their sense of control over their lives while supporting them to take action to change their lives. This approach is clearly compatible with Orem (1991), who emphasized that nurse-client relationships must be based on collaboration and nursing actions that will facilitate the development of self-care behaviors. Thus, it is hypothesized that methods of helping that incorporate empowerment support will increase self-care behaviors, well-being, and incest trauma resolution in adult female survivors. REFERENCES Bagley, C.. & Ramsey, R. (1985). Sexual abuse in childhood: Psychosocial outcomes and implications for social work practice. Social Work Practice in Sexual Problems, 4. 33-47. Blazek. B.. & McClellan. M. (1983). The effects of selt-care instruction on locus on control in children. Journal of School Health, 53, 554-556. Briere, J., & Runtz, M. (1987). Post-sexual abuse trauma: Data and implications for clinical practice. Journal of fnrerpersonal Violence, 2. (4), 367-319. Briere. J., & Runtz, M. (1988). Post sexual abuse trauma. In G. Wyatt & G. Powell (Eds.). Lasfing effects of child sexual abuse (pp. 61-82). Newbury Park. CA: Sage. Brown,
B.E., & Garrison, C.J. (1990). Patterns of symptomatology of adult women incest survivors. Western Journal of Nursing Research, 12, 587-600.
Brown. S.K., & Ziefert. M. (1988). Crisis resolution,
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tence, and empowerment: A service model for women. Journal of Primary Prevenrion, 9, 92-103. Browne, A., & Finkelhor, D. (1986). Impact of child sexual abuse: A review of the literature. Psychological Bulletin, 99, 66-77. A., Hartman, C.R., Wolbert, W., & Grant, C.A. (1987). Child molestation: Assessing impact in multiple victims (part 1). Archive of Psychiarric Nursing, I, 3339. Carmen, E., & Rieker, P.P. (1989). A psychosocial model of the victim-to-patient process. Psychiatric Clinics of North America, 12, 431-443. Carmen, E., Rieker, P.P., & Mills. T. (1984). Victims of violence and psychiatric illness. American Journal of Psychiatry, 141, 378-383. Courtois, C. (1988). Healing the incest wound. New York: W.W. Norton. de Shazer, S. (198.5). Keys to solution in brief therapy. New York: W.W. Norton & Co. Burgess,
Dodd, M.J. (1983). Self-care for side effects in cancer chemotherapy: An assessment of nursing interventions. Part II. Cancer Nursing. 6, 63-67. Dodd, M.J. (1984). Measuring informational intervention for chemotherapy knowledge and self-care behavior. Research in Nursing and Health, 7. 43-50. Fawcett, S.B., Seekins, T., Whang, P.I., Muiu, C., Suarez de Balcazar, Y. (1984). Creating and using social technologies for community empowerment. Prevention in Human Services, 3, 145-171. Figley, C.R. (1985). Trauma and its wake: The study and treatment of post-traumatic stress disorder. New York: Brunner/Mazel. Finkelhor, D. (1986). A sourcebook on child sexual abuse. Beverly Hills: Sage. Fromuth, M.E. (1986). The relationship of childhood sexual abuse with later psychological adjustment in a sample of college women. Child Abuse and Neglect, 10, 5-15. Freire, P. (1974). Pedagogy of the oppressed. New York: Seabury Press. Gallant, R., Cohen, C., & Wolff, T. (1985). Change of older persons’ image, impact on public policy result from Highland Valley empowerment plan. Perspectives on Aging, 14, 9-13. Gruber, J., & Trickett, E.J. (1987). Can we empower others? The paradox of empowerment in an alternative public high school. American Journal of Community Psychology, 15, 353-372. Harper, D.C. (1984). Application of Orem’s theoretical constructs to self-care medication behaviors in the elderly. Advances in Nursing Science. 6, 29-46. Karl, C.A. (1982). The effect of an exercise program on selfcare activities for the institutionalized elderly. Journal of Gerontological Nursing, 8, 282-285. Kluft, R.P. (1990). Incest-related syndromes of adult psychopathology. Washington, DC: American Psychiatric Press. Maton,
K.I., & Rappaport, M. (1984). Empowerment in a religious setting. Prevention in Human Services, 3, 3772. Miller, C., & Swift, K. (1976). Words and Women. Garden City, NY: Anchor.
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Moore. J.B. (1987). Effects of assertion training and first aid instruction on children’s autonomy and self-care agency. Research in Nursing and Health. 10, lOI- 109. Orem, D.E. (1991). Nursing: Concepts of pracrice (4th ed.). St. Louis: Mosby Yearbook. Peters, S. ( 1988). Child sexual abuse and later psychological problems. In G. Wyatt & G. Powell (Eds.). Lasting effects of child sexual abuse. Beverly Hills: Sage. Rappaport, J. (1981). In praise of paradox: A social policy of empowerment over prevention. American Journal of Communit_vPsychology, 9. l-25. Rappaport, J. (1987). Terms of empowerment/exemplars of prevention: Toward a theory for community psychology. American Journal of Community Psychology, 15, 121-145. Rappaport, J., Swift, C., & Hess, R. (Eds.). (1984). Studies in empowerment: Steps toward understanding and action. Prevention in Human Services, 3, l-230. Reiker. P.P., & Carmen, E. (1986). The victim-to-patient process: The disconfinnation and transformation of abuse. American Journal of Orthopsychiatv, 56. 360-370. Rew, L. (1987). The relationship between self-care behaviors and selected psychosocial variables in children with asthma. Journal of Pediarric Nursing, 2, 333-341. Rew, L. (1989). Long-term effects of childhood sexual exploitation. Issues in Menial Health Nursing, 6, 229-244. Riesch,
S.K. (1988). Changes in the exercise of self-care agency. Western Journal of Nursing Research, 10. 257. 213.
Riger, S. (1984). Vehicles for empowerment: The case of feminist movement organizations. Prevention in Human Services, 3. 99-l 17. Roberts,
B.B., & Thorsheim, H.I. (1986). A partnership approach to consultation: the process and results of a major primary prevention field experiment. In J.G. Kelly (Ed.), Community basedprevention research. Washington DC: National Institute of Mental Health.
Rothlis, J. (1984). The effect of a self-help group on feelings of hopelessness and helplessness. Wesfern Journal of Nursing Research, 6. 157-173. Russell, D. (1986). The secret trauma. New York: Basic Books. Sedney,
M.A., & Brooks, B. (1984). Factors associated with history of childhood sexual experience in a nonclinical female population. Journal of the American Academy of Child Psychiatry, 23. 215-218.
Seidner, M.A., & Calhoun, B. (1984, August). Childhood sexual abuse: Factors related to differential adult adjustment. Paper presented at the Second Annual National Family Violence Research Conference, Durham, NH. Serrano-Garcia, I. (1984). The illusion of empowerment: Community development within a colonial context. Prevention in Human Services, 3, 173-200. Stockdale-Wooley, R. (1984). The effects of education on selfcare agency. Public Health Nursing, 1. 97-106. Summit, R. (1989). The centrality of victimization: Regaining the focal point of recovery for survivors of child sexual abuse. Psychiatric Clinics of North America, 12. 413430. Swift, C.. & Levin, G. (1987). Empowerment:
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mental health technology. Journal of Primary Prevention, 8, 11-94. Urbancic, I. (1992). The relationship between empowerment support. mental health self-care, well-being, and incest trauma resolution in adultfemale survivors of childhood incest. Unpublished doctoral dissertation, Wayne State University, Detroit. van der Kolk, B.A. (1987). Psychological trauma. Washington. DC: American Psychiatric Press.
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Wallerstein, N., & Berstein. E. (1988). Empowerment education: Freire’s ideas adapted to health education. Health Education Quarterly. 15. 319-394. Whetstone, W.R. (1986). Social dramatics: Social skills development for the chronically mentally ill. Journal of Advanced Nursing. I I, 67-74. Wyatt, G.E. (1985). The sexual abuse of Afro-American and White-American women in childhood. Child Abuse and Neglect. 9, 507-519.
