Female Sexual Abuse Survivorsas Patients: AvoidingRetraumatization Deborah Doob
The literature on adult female psychiatric patients who are survivors of childhood sexual abuse is reviewed. This literature shows both high rates of such abuse and a characteristic pattern of symptoms that distinguishes these survivors from other patients. A theoretical framework is discussed which explains how psychiatric symptoms may develop after childhood sexual abuse and how diagnosis and treatment may serve to maintain or intensify such symptoms. Viewing patients from a posttraumatic treatment perspective is advocated as a strategy for nursing to effectively help these patients with the healing process.
Copyright
A
0 1992 by W.B. Saunders
SIGNIFICANT percentage of adult female psychiatric patients are survivors of incest and show a pattern of symptoms believed to be related to the experience of childhood sexual abuse (Bryer, Nelson, Miller, & Krol, 1987; Craine, Henson, Colliver, & MacLean, 1988; Jacobson & Herald, 1990; Surrey, Swett, Michaels, & Levin, 1990). When treatment is directed toward resolving the emotional and psychiatric sequelae of incest, the prognosis for these patients is good (Beahrs, 1982; Braun, 1989; Briere, 1989; Carmen & Rieker, 1989; Kluft, 1984; Summit, 1989). However, when the posttraumatic nature of the symptoms is disregarded in diagnosis and treatment, the professional response mimics the context of the original abuse and the prognosis is generally poor (Bryer et al., 1987; Carmen & Rieker, 1989; Carmen, Rieker, & Mills, 1984; Chu & Dill, 1990; Jacobson & Herald, 1990; Jacobson & Richardson, 1987; Ogata, Silk, Goodrich, Lohr, Westen, & Hill, 1990; Summit, 1989). In fact, it is increasingly apparent that there may be substantial numbers of incest survivors among the population of chronically mentally ill patients (Beck & van der Kolk, 1987). To foster healing instead of intensification and maintenance of symptoms, it is essential that psychiatric nurses recognize the persistent effects of abuse experiences and understand the particular treatment sensitivities that survivors may have. An unintentional attitude of denial recreates the context of childhood experiences when survivors may
Company
have been blamed for their victimization and when their suffering was ignored. The literature summarized in this review examines the prevalence of childhood sexual abuse among adult female psychiatric patients and the characteristic pattern of symptoms that distinguishes them from other patients. A theoretical framework is discussed for conceptualizing how psychiatric symptoms may develop after childhood sexual abuse. Also described are some ways in which diagnosis and treatment may recreate the past abuse context and result in intensified symptoms and chronicity. Instead, approaching the treatment of these patients from an abuse perspective may offer real hope of healing. PREVALENCE OF CHILDHOOD SEXUAL ABUSE AMONG ADULT FEMALE PSYCHIATRIC PATIENTS
In a study based on chart review, Carmen et al. (1984) reported a 43% prevalence of physical and/ or sexual assault histories among adult and adolescent male and female psychiatric inpatients. The rate of combined child and adult sexual victimiza-
From the School of Nursing, University of Wisconsin, Madison, WI. Address reprint requests to Deborah Doob, B.S., B.S.N., R.N., 844 Hughes Place, Madison, WI 53713. Copyright 0 1992 by W.B. Saunders Company 0883~9417/92lO604-0009$3.0000/0
Archives of Psychiatric Nursing, Vol. VI, No. 4 (August), 1992: pp. 245-251
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DEBORAH DOOB
tion was 20%. Since then, the prevalence of assault experiences revealed by direct questioning of patients has been found to be approximately twice the earlier chart review figures (Bryer et al., 1987; Chu & Dill, 1990; Jacobson, 1989; Jacobson & Richardson, 1987; Surrey et al., 1990). Among adult female psychiatric patients, the prevalence of childhood sexual abuse, defined as genital contact between a child and a significantly older person, was documented as between 20% and 40% (Table 1). Only a few studies reported the prevalence of incestuous abuse (child abuse, as defined above, perpetrated by family members). Incest was found in 14% to 23% of female psychiatric inpatients in acute-care facilities or outpatient settings (Bryer et al., 1987; Jacobson & Herald, 1990; Surrey et al., 1990). The rate of incest reported by female patients in a state psychiatric hospital system (including short-term and long-term adolescent and adult patients) was 42% (Craine et al., 1988). The rate of incest reported by caregivers or recorded in the charts of female long-term patients in a different state hospital was 46% (Beck & van der Kolk, 1987). The highest rate of incest (52%) was found among patients admitted to a major urban psychiatric emergency department (Briere & Zaidi, 1989). Reported prevalence rates are difficult to compare across studies because of differences in population, sampling method, and definition of abuse.
Table 1. Rates of Child Sexual Abuse in Female Patient Populations Revealed by Direct Questioning
of Patients Abuse WI
A
6
C
Inpatient
54
20
14
Surrey et al. (1990)
Outpatient
15
Inpatient
-
33
Chu and Dill (1990)
36
-
Jacobson (1969)
Outpatient
-
Inpatient
-
42
Bryer et al. (1987)
44
23
Craine et al. (1988)
Inpatient
51
46
42
Currey (1990)
Outpatient
57
-
-
Briere and Zaidi
Psychiatric
-
70
52
Study
Jacobson and Herald
Population
(1990)
(1989)
emergency department
NOTE. Abuse A is defined as sexual abuse with or without genital contact, Abuse B is defined as abuse involving genital contact. Abuse C is defined as genital contact with a family member (incest).
In summary, regardless of wide variations in incidence rates, the literature shows that substantial numbers of adult psychiatric patients report histories of incest or other childhood sexual abuse. These numbers are probably understated. Survivors of childhood sexual abuse often do not recall or disclose this history (Briere, 1989; Bryer et al., 1987; Chu & Dill, 1990; Summit, 1989). Most patients view childhood sexual abuse as shameful and stigmatizing (Briere, 1989; Briere & Zaidi, 1989; Browne & Finkelhor, 1986). Therefore, underreporting is far more likely than fabrication and overreporting. In addition, the researchers excluded from their studies the most disturbed patients and those who were otherwise unable or unwilling to give informed consent. Although this exclusion would avoid purely delusionally based responses, it may also have lowered the reported prevalence because there is evidence that the more severely disturbed patients on a unit are more likely to have been abused during childhood (Bryer et al., 1987). However, it appears clear that sizable subgroups of populations of adult female psychiatric patients are survivors of childhood sexual abuse. CHILDHOOD SEXUAL ABUSE AND PSYCHIATRIC SYMPTOMATOLOGY
It is generally recognized that adult psychiatric patients with histories of childhood sexual abuse show a characteristic pattern of symptoms (Browne & Finkelhor, 1986). In their study of psychiatric inpatients, Carmen et al. (1984) found that victims of physical and sexual assault had extreme difficulties with anger and aggression, self-image, and trust. Adult survivors tend to blame themselves for their victimization, explaining that they were abused because of their essential “badness.” The women directed their hatred and aggression against themselves in ways ranging from depression to repeated episodes of self-mutilation and suicide attempts. They had more treatment difficulties, possibly as a result of their inability to trust (impacting negatively on therapeutic alliance), impaired self-esteem (feeling undeserving of treatment), and difficulty coping with aggression (directing anger against the self or others). Bryer et al. (1987) claimed that both clinical experience and research data suggest that the most distressed patients in the hospital may have been abused as
FEMALE SEXUAL ABUSE SURVIVORS
247
AS PATIENTS
children. Surrey et al. (1990) also found that the abuse survivors in his sample of outpatients showed the most severe symptomatology. Several other studies also found a preponderance of certain symptoms in patients who reported sexual abuse during childhood. Persistent symptoms of anxiety and distrust, hostility, interpersonal sensitivity, negative self-esteem, depression, and sexual problems were reported by Herman, Russell, and Trocki ( 1986) and Surrey et al. (1990) in their sexually abused adult populations. An emergency department sample of women reporting childhood sexual abuse was significantly different from the nonabused sexually comparison group in having histories of self-mutilation, suicidal ideation, suicide attempts, drug use. and in having acquired more psychiatric diagnoses (Briere & Zaidi, 1989). The sexually abused group studied by Bryer et al. (1987) also differed significantly from the comparison nonabused group by showing more severe and possibly psychotic or psychoticlike acute symptoms, by having more suicidal symptoms, and by receiving pharmacological treatment more often. Chu and Dill (1990) investigated the relationship between dissociative symptoms and a history of childhood sexual abuse in a sample of adult female psychiatric hospital patients. Compared with other major symptoms, they found that only dissociation was predicted significantly by such history. Furthermore, survivors of incest reported more dissociative symptoms and were more likely to have auditory hallucinations, numerous diagnoses, and repeated hospitalizations than survivors with histories of nonfamilial abuse. These findings are similar to those of Ogata et al. (1990), who reported that chronic dysphoria (manifested by feelings of emptyness, loneliness, and boredom) and derealization (a dissociative symptom) each separately or together predicted childhood sexual abuse among hospitalized women with diagnoses of depression alone or borderline personality disorder. In summary, the pattern of characteristics expected of adult female patient survivors of childhood sexual abuse include symptoms that appear more severe than those of nonabused patients, more self-destructive behaviors, chronic dysphoria, depression, dissociative symptoms including psychotic-like symptoms, history of substance
abuse, anxiety, hostility, interpersonal problems, and lack of diagnostic clarity. The symptoms may be particularly severe in survivors of incest. ACCOMMODATION: VICTIMIZATION
A LINK BETWEEN
AND SYMPTOMATOLOGY
Carmen et al. (1984) stated that although the psychosocial consequences of abuse are known, the process whereby a victim becomes a patient has not been appreciated by clinicians or adequately conceptualized by researchers. They developed a psychosocial model of the victim-topatient process to explain how chronic abuse damages the self and sets into motion psychological processes that may evolve into various forms of mental illness (Carmen & Rieker, 1989). According to Carmen and Rieker ( 1989), the victim accommodates to the interplay between the abuse events, family relationships, and other life contexts. These accommodations, originally adaptive survival strategies, later form the core of the survivor’s psychopathology. After abuse occurs, the victim must accommodate to the judgments of others about the abuse. This accommodation takes the form of denying the occurrence of the abuse, altering the affective responses to the abuse, and denying the importance of the abuse by disconfirmation and transformation. Carmen and Rieker assert that the victim of familial child abuse is in a situation in which acknowledging the abuse means acknowledging that the world is dangerous and that those who are supposed to protect and nurture instead failed to protect or caused harm. Reports of abuse are often denied or discounted by family and society. Thus, victims have the negative choices of revealing the abuse (acknowledging lack of safety and nurturing, being disbelieved or discounted) or denying and discounting the abuse, altering their affective response and transforming the abuse. In a sense, victims choose between revealing the abuse at the time (being discredited or discounted and punished) and transforming the abuse and the normal response to it (developing strategies that will become pathological as an adult). The victim can transform the abuse by assuming responsibility for the abuse, thereby suffering guilt but restoring an illusion of control, or by redefining the trauma as not abusive, thereby denying cognitive and affec-
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DEBORAH DOOB
tive experience but restoring the illusion of a safe world. By accommodating to the judgments of others, the victim is denied an acknowledgment of the accurate abuse experience, the true feelings connected with the abuse, and an understanding of the meaning of the abuse (Carmen & Rieker, 1989). There is a profound disconfirmation of the victim’s reality. The normal affective response to abuse is fear, anxiety, helplessness, and rage, but these feelings must be distorted or suppressed to conform to the abusive family’s delusion of safety and nurturing. Therefore, victims must deny reality and alter their thoughts, feelings, and behaviors to conform to their family norms and expectations. Victims ultimately transform the meaning of the abuse to the familial explanation (either nonoccurrence or appropriate and nonabusive). The abuse becomes interpreted by the victim as a delusion or as an appropriate response to one’s own “badThe anger adult survivors often direct ness.” against themselves can then be understood as a repetitive reenactment of real events with the expression of affect from the past removed from its context. Without this understanding, such affect and associated behaviors appear irrational to survivors and to observers. According to Carmen and Rieker (1989), the accommodations that permitted the child victim to maintain connection with family members and retain some sense of safety and protection are not functional in the world in which the adult survivor lives. In the context of adult life, such accommodations may appear as dissociative symptoms, delusions, depression, self-destructiveness, irrational anxiety, paranoia, and interpersonal problems. What helped the child victim feel connected to the family may cause the adult to feel isolated and alone in the very different nonfamilial context. Thus, the symptoms that result in the victim’s becoming a patient represent a reaction to childhood sexual trauma within a context of familial disconformation, a familial response that is even stronger when sexual abuse is involved. An example of this process is found in the following personal account by Dianne Jennings Walker as quoted in Chamberlin (1978, p. 113). For once I feel that my mind, soul and body are mine. I was lied to for so many years that I still fear the feeling of being split apart from my body. This so-called symptom of schizophrenia is what happens to us when the perceptions
we have of our environment arc attacked and ignored and denied over and over again. Ironically, our perceptions are accurate. Even after we are terrorized, drugged or socialized out of expressing ourselves directly we do it symbolically and the feelings are right. I believed as a child that my soul had been stolen from its rightful body, that my parents lived on a satellite of Betelgeuse. That was not an insane delusion. It was a poetic and actually logical way to handle the unliveable environment that I had the ill fate to bc born into. In my late teens I discovered psychology and psychiatry, which I believed for many years were my salvation. “Oh wonderful: I’m not from another planet I’m simply crazy!“.
THE CLINICAL
RESPONSE
The substantial percentage of patients presenting with symptoms relating to childhood sexual assault has often gone unrecognized. Many patients do not volunteer the information that they have experienced childhood sexual abuse or deny the history if asked (Jacobson & Richardson, 1987; Summit, 1989). Summit (1989, p. 421) writes of the “survival imperative to act as if nothing has happened.” Many are not asked, or (if it is disclosed) the information is not believed or judged important enough for charting (Briere & Zaidi, 1989). Thus, any statistics regarding prevalence are likely to be underestimates even if patients are asked about their history directly. However, the underestimate becomes extreme if the data are based only on chart review and subjects are not directly questioned. A chart review study showing prevalence of physical/sexual child/ adult assault experiences of 43% in a female patient population (Carmen et al., 1984) stands in contrast to a finding of 72% (Bryer et al., 1987) or 81% (Jacobson & Richardson, 1987) when patients were questioned directly about assault experiences. Jacobson and Herald (1990) found that 56% of directly questioned inpatients who stated they had been sexually abused in childhood also stated that they had never disclosed the information to caregivers before that time. Jacobson (1989) found a rate of 71% in a similar study involving outpatients. Briere and Zaidi (1989) discovered a sexual abuse rate of only 6% among female psychiatric emergency department patients by chart review but 70% when patients were specifically asked. Many of the state hospital patients studied by Craine et al. (1988) stated that they had never previously revealed their abuse histories to clinicians because they had never been asked.
FEMALE SEXUAL
ABUSE SURVIVORS
AS PATIENTS
In ignoring or denying the existence and impact of childhood sexual abuse, professionals, families, and patients collude in a negative hallucination and maintain the myth of a nurturing family, a safe world, and a guilty patient (Carmen & Rieker, 1989; Chu & Dill, 1990). The patient’s sanity, the patient’s fragments of accurate memory and expected response to trauma (anger and fear) in a world unwilling to accept such reality, is viewed as insanity. The adult patient’s accommodation (labeled dissociative, psychotic, affectively disordered, inappropriately distrustful, etc.) appears pathological in a world that responds with blindness to the abuse experience but not to the survivor’s accommodation. Professional failure to initiate discussion of sexual abuse sends a message to patients that such abuse does not occur or does not matter and confirms the patients’ belief in the need to deny the reality of the experience (Bryer et al., 1987). Likewise, misperceiving recollections as psychosis, characterological manipulations, or Oedipal fantasies colludes with the family’s denial of the occurrence and impact of abuse or with the patient’s sense of guilt and defectiveness (Chu & Dill, 1990; Ogata et al., 1990; Summit, 1989). Patients’ attempts to deal with the distress of real affective, physical, and cognitive memory, confronting their own and caregivers’ accommodation (e.g., flash backs), lead to the development of more severe and confusing symptoms (Bryer et al., 1987). “When these behavioral reenactments are unrecognized, the psychotherapy situation can become a destructive repetition of the trauma in which the patient is again disconfirmed and left alone with her or his pain” (Carmen & Rieker, 1989, p. 440). Briere (1989) refers to the “psychiatric redefinition of post-sexual-abuse trauma” as the process that occurs when adult survivors are diagnosed without appreciating the impact of the abuse experience. Diagnoses that do not recognize the possible role of experience in the development of symptoms may invalidate the survivors’ perceptions by releasing their families from responsibility for their pain. The disorder is conceived as intrinsic to the patients themselves rather than as having external roots. Pharmacological treatment without an abuse-related conceptualization may reinforce this message (Ogata et al., 1990). Again, the victim is blamed. Given the characteristics predictive of childhood
249
sexual abuse histories in adult female psychiatric patients, it is not surprising that borderline personality disorder is diagnosed significantly more often in these patients than in nonabused patients (Briere & Zaidi, 1989; Bryer et al., 1987) and that abused patients are overrepresented within that diagnosis (Ogata et al., 1990). Although childhood sexual abuse may not by itself cause this constellation of symptoms, it does appear to predispose individuals to behavior that satisfies the Diagnostic & Statistical Manual, 3rd edition (DSM-III) criteria for borderline personality disorder while not satisfying the standard etiological theories for the development of that disorder (Briere, 1989). Dissociative symptoms are associated with borderline personality disorder but also with posttraumatic stress disorder and with dissociative disorders. Additionally, dissociation can appear similar to psychotic processes and may be mistaken for hallucinations or other Schneiderian first-rank symptoms and result in a misdiagnosis of schizophrenia (Beahrs, 1982; Bryer et al., 1987; Chu & Dill, 1990, Kluft, 1985). Craine et al. (1988) found that 66% of their sample of state hospital patients met the DSM-Ill criteria for a diagnosis of posttraumatic stress disorder, but none had received this diagnosis. Several researchers have argued that adult survivors should receive diagnoses such as posttraumatic stress disorder or a dissociative disorder, which not only characterize their symptoms but also correctly recognize the etiology. Abuse-related diagnoses would justify abuse-related treatment, which can be highly productive (Beahrs, 1982; Briere, 1989; Bryer et al., 1987; Chu & Dill, 1990; Craine et al.. 1988; Jacobson & Herald, 1990; Summit, 1989; Surrey et al., 1990). In addition to denial and disconfirmation of the abuse experience during diagnosis and treatment, there are numerous other ways treatment within the mental health system can recreate the context of familial childhood sexual abuse (Sonn, 1977). Even in physical illness. opinions of patients are usually discounted. The whole person is often invalidated because a part of him/her is sick. This invalidation is even more true in psychiatry in which statements are not taken at face value and everything a patient says is open to the interpretation of hidden messages. Patients who were assaulted in childhood by parents or other adults in authority have experienced a hierarchical relationship that was supposed
250
to be nurturing but instead was subverted to serve the aggressive or sexual needs of the adult (Jacobson & Richardson, 1987). Therefore, they enter a treatment relationship, which is also hierarchical, suspecting that any trust they develop will be used to hurt them. Knowledge of a patient’s sexual abuse history can form the basis of a different understanding of the patient’s difficulty in establishing a therapeutic alliance. Difficulty is expected rather then indicative that the patient is untreatable (Jacobson & Herald, 1990; Jacobson & Richardson, 1987). Survivors may repeatedly seek treatment that has victimized them previously either because that is all that is available or because of a compulsion to repeat trauma (van der Kolk, 1989). This persistence can lead to increasingly destructive cycles in which the survivor repeatedly seeks treatment that restimulates symptoms and the system (becoming frustrated by the patient’s poor response) treats the patient with increasingly punitive measures. The cycle often ends with the system severely limiting its offer of treatment (e.g., Diamond, Alexander, & Marshall, 1985). “Ignoring the [traumatic] cause of the patient’s distress is likely to result in increasingly hostile demands on the part of the patient, and equally firm rejections on the part of the care-givers” (van der Kolk, 1987, p. 22). However, labeling these patients as untreatable is premature (Chu & Dill, 1990). A better altemative to no treatment or treatment that only seems to hurt patients (Aronson, 1989) may be treatment within a trauma-related conceptual framework. Such treatment acknowledges not only the abuse history but the context that caused accommodation to occur (i.e., the centrality of past and continued victimization in the lives of these patients) and is effective (Braun, 1989; Briere, 1989; Chu & Dill, 1990; Carmen et al., 1984; Jacobson & Richardson, 1987; Kluft, 1984; Ogata et al., 1990; Summit, 1989). Effective treatment confirms the recollections of abuse and helps the patient acknowledge and recontextualize the trauma (Carmen & Rieker, 1989). Summit (1989) argues that “in the absence of a trauma-centered conceptual framework and specific therapeutic interaction, the radical prospect of recovery and normality for survivors remains unrecognized” (p. 4 13) and “every patient whose identity was founded on assault, betrayal, abandonment, shame, and alienation de-
DEBORAH DO06
serves the benefit of active therapeutic resolution of post-traumatic pain” (page 425). In summary, researchers have found that diagnosis and treatment within the mental health system has often continued the denial and disconfirmation that first confronted the patient during childhood and resulted in the accommodations that became symptoms in adulthood. Such diagnosis and treatment may restimulate symptoms and cause abuse survivors to appear very ill and untreatable. Diagnosis and treatment within a posttraumatic framework provides the possibility of an optimistic outcome. IMPLICATIONS FOR NURSING
Childhood sexual abuse survivors compose a substantial proportion of our patient population either as new patients or as those with extensive treatment histories. Nurses have an enormous opportunity to make a difference in the treatment of survivors, a difference that may ultimately result in healing and the prevention of chronicity. By recognizing childhood sexual abuse and its impact on adult patients and by understanding dysfunctional behaviors as accommodations to childhood familial realities, nursing can help other caregivers and patients gain a treatment perspective that is effective rather than continue the pattern of denial that served as the basis for later symptom development. Informed nursing can influence diagnostic and treatment decisions toward more effective approaches, alter staff attitudes so that destructive interactions similar to those of childhood are not recreated during treatment, and work with patients to alter their often revictimizing attitudes toward themselves. With patients who already have extensive treatment histories, nurses should be alert to the characteristic pattern of symptoms showed by survivors of childhood sexual abuse and should note any indication of abuse history in the previous records. Such observations may warrant advocating for the consideration of diagnostic and treatment alternatives by the treatment team. A posttraumatic perspective may suggest changes in the way patient behaviors are understood and responded to by the nursing staff. We may thus develop more effective treatment approaches that will enable the persons we once saw regularly on our hospital units to transition permanently into mainstream society.
FEMALE SEXUAL
ABUSE SURVIVORS
AS PATIENTS
REFERENCES Aronson, T.A. (1989). A critical review of psychotherapeutic treatments of the borderline personality: Historical trends and future directions. Journal of Nervous and Mental Disease. 177, 51 l-528. Beahrs. J.O. (1982). Unity and multiplicity: Multilevel consciousness oj. self in hypnosis. psychiatric disorder and mental health. New York: Brunner/Mazel. Beck, J.C.. & van der Kolk, B. (1987). Reports of childhood incest and current behavior of chronically hospitalized psychotic women. American Journal of Psychiatry, 144. 14741476. Braun, B.G. (1989). Psychotherapy of the survivor of incest with a dissociative disorder. Psychiatric Clinics of North America. 12. 307-324. Briere. J. (1989). Therapy for adults molested as children: Beyond survival. New York: Springer. Briere. J., & Zaidi, L.Y. (1989). Sexual abuse histories and sequelae in female psychiatric emergency room patients. American Journal of Psychiatry, 146, 16021606. Browne, A.. & Finkelhor. D. (1986). Impact of child sexual abuse: A review of the research. Psychological Bulletin. 99. 66-77. Bryer. J.B.. Nelson, B.A., Miller, J.B., & Krol, P.A. (1987). Childhood sexual and physical abuse as factors in adult psychiatric illness. American Journal of Psychiarry. 144, 1426-1430. E.H., & Rieker, P.P. (1989). A psychosocial model of the victim-to-patient process. Psychiatric Clinics of North America, 12. 431-443. Carmen, E.H., Rieker, P.P., & Mills, T. (1984). Victims of violence and psychiatric illness. American Journal of Psychiatry, 141, 378-383. Chamberlin, J. (1978). On our own: Patient-controlled alternatives to the mental health system. New York: McGraw-Hill. Chu. J.A.. & Dill, D.L. (1990). Dissociative symptoms in relation to childhood physical and sexual abuse. American Journal of Psychiatry, 147, 887-892.
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Diamond, R.J., Alexander, A.A.. & Marshall, J.R. (1985). A chronic psychiatric patient in an HMO. Hospital and Community Psychiatry, 36, 239-241. Herman, J.. Russell, D.. & Trocki, K. (1986). Long-term effects of incestuous abuse in childhood. American Journal of Psychiatry. 143, 1293-1296. Jacobson, A. (1989). Physical and sexual assault histories among psychiatric outpatients. American Journal of Psychiatry. 146, 755-758. Jacobson. A., & Herald, C. (1990). The relevance of childhood sexual abuse to adult psychiatric inpatient care. Hospital and Community Psychiatry, 41. 154-158. Jacobson. A., &Richardson, B. (1987). Assault experiences of 100 psychiatric inpatients: Evidence of the need for routine inquiry. American Journal of Psychiatry, 144, 908913. Kluft. R.P. (1984). Treatment of multiple personality disorder. Psychiatric Clinics of North America, 7. 9-29. Kluft, R.P. (1985). The natural history of multiple personality disorder. In R.P. Kluft (Ed.), Childhood antecedents af multiple personality (pp. 198-238). Washington, DC: American Psychiatric Press. Ogata.
Sonn. M.
i 1977). Patients’ subjective experiences of psychiat-
ric hospitalization. In T.C. Manschieck & A.M. Kleinman (Eds.), Renewal in Psychiatry: A Critical Rational Perspective (pp. 245-264). New York: John Wiley & Sons.
Carmen,
Craine. L.S., Henson, C.E., Colliver, J.A., & MacLean, D.G. (1988). Prevalence of a history of sexual abuse among female psychiatric patients in a state hospital system. Hospital and Community Psychiatry, 39, 300-304. Curry. J.L. (1990). Childhood sexual abuse. Hospital and Community Psychiatry. 4 I, 807,
S.N., Silk, K.R., Goodrich, S., Lohr. N.E., Westen. D.. & Hill, E.M. (1990). Childhood sexual and physical abuse in adult patients with borderline personality disorder. American Journal of Psychiatry, 147. 1008. 1013.
Summit.
R.C. (1989). The centrality of victimization. atric Clinics ofNorth America, 12, 413-429.
Psychi-
Surrey. J.. Swett, Jr., C.. Michaels, A.. & Levin. S. (1990). Reported history of physical and sexual abuse and severity of symptomatology in women psychiatric outpatients. American Journal of Orthopsychiatry. 60. II 2. 417. van der Kolk, B.A. ( 1987). The psychological consequences of overwhelming life experiences. In B.A. van der Kolk (Ed.), Psychological Trauma (pp. l-30). Washington, DC: American Psychiatric Press. van der Kolk, B.A. (1989). The compulsion to repeat the trauma: Re-enactment, revictimization, and masochism. Psychiatric Clinics of North America, I?, 389-411.
The literature on adult female psychiatric patients who are survivors of childhood sexual abuse is reviewed. This literature shows both high rates of such abuse and a characteristic pattern of symptoms that distinguishes these survivors from other patients. A theoretical framework is discussed which explains how psychiatric symptoms may develop after childhood sexual abuse and how diagnosis and treatment may serve to maintain or intensify such symptoms. Viewing patients from a posttraumatic treatment perspective is advocated as a strategy for nursing to effectively help these patients with the healing process.
Copyright
A
0 1992 by W.B. Saunders
SIGNIFICANT percentage of adult female psychiatric patients are survivors of incest and show a pattern of symptoms believed to be related to the experience of childhood sexual abuse (Bryer, Nelson, Miller, & Krol, 1987; Craine, Henson, Colliver, & MacLean, 1988; Jacobson & Herald, 1990; Surrey, Swett, Michaels, & Levin, 1990). When treatment is directed toward resolving the emotional and psychiatric sequelae of incest, the prognosis for these patients is good (Beahrs, 1982; Braun, 1989; Briere, 1989; Carmen & Rieker, 1989; Kluft, 1984; Summit, 1989). However, when the posttraumatic nature of the symptoms is disregarded in diagnosis and treatment, the professional response mimics the context of the original abuse and the prognosis is generally poor (Bryer et al., 1987; Carmen & Rieker, 1989; Carmen, Rieker, & Mills, 1984; Chu & Dill, 1990; Jacobson & Herald, 1990; Jacobson & Richardson, 1987; Ogata, Silk, Goodrich, Lohr, Westen, & Hill, 1990; Summit, 1989). In fact, it is increasingly apparent that there may be substantial numbers of incest survivors among the population of chronically mentally ill patients (Beck & van der Kolk, 1987). To foster healing instead of intensification and maintenance of symptoms, it is essential that psychiatric nurses recognize the persistent effects of abuse experiences and understand the particular treatment sensitivities that survivors may have. An unintentional attitude of denial recreates the context of childhood experiences when survivors may
Company
have been blamed for their victimization and when their suffering was ignored. The literature summarized in this review examines the prevalence of childhood sexual abuse among adult female psychiatric patients and the characteristic pattern of symptoms that distinguishes them from other patients. A theoretical framework is discussed for conceptualizing how psychiatric symptoms may develop after childhood sexual abuse. Also described are some ways in which diagnosis and treatment may recreate the past abuse context and result in intensified symptoms and chronicity. Instead, approaching the treatment of these patients from an abuse perspective may offer real hope of healing. PREVALENCE OF CHILDHOOD SEXUAL ABUSE AMONG ADULT FEMALE PSYCHIATRIC PATIENTS
In a study based on chart review, Carmen et al. (1984) reported a 43% prevalence of physical and/ or sexual assault histories among adult and adolescent male and female psychiatric inpatients. The rate of combined child and adult sexual victimiza-
From the School of Nursing, University of Wisconsin, Madison, WI. Address reprint requests to Deborah Doob, B.S., B.S.N., R.N., 844 Hughes Place, Madison, WI 53713. Copyright 0 1992 by W.B. Saunders Company 0883~9417/92lO604-0009$3.0000/0
Archives of Psychiatric Nursing, Vol. VI, No. 4 (August), 1992: pp. 245-251
245
DEBORAH DOOB
tion was 20%. Since then, the prevalence of assault experiences revealed by direct questioning of patients has been found to be approximately twice the earlier chart review figures (Bryer et al., 1987; Chu & Dill, 1990; Jacobson, 1989; Jacobson & Richardson, 1987; Surrey et al., 1990). Among adult female psychiatric patients, the prevalence of childhood sexual abuse, defined as genital contact between a child and a significantly older person, was documented as between 20% and 40% (Table 1). Only a few studies reported the prevalence of incestuous abuse (child abuse, as defined above, perpetrated by family members). Incest was found in 14% to 23% of female psychiatric inpatients in acute-care facilities or outpatient settings (Bryer et al., 1987; Jacobson & Herald, 1990; Surrey et al., 1990). The rate of incest reported by female patients in a state psychiatric hospital system (including short-term and long-term adolescent and adult patients) was 42% (Craine et al., 1988). The rate of incest reported by caregivers or recorded in the charts of female long-term patients in a different state hospital was 46% (Beck & van der Kolk, 1987). The highest rate of incest (52%) was found among patients admitted to a major urban psychiatric emergency department (Briere & Zaidi, 1989). Reported prevalence rates are difficult to compare across studies because of differences in population, sampling method, and definition of abuse.
Table 1. Rates of Child Sexual Abuse in Female Patient Populations Revealed by Direct Questioning
of Patients Abuse WI
A
6
C
Inpatient
54
20
14
Surrey et al. (1990)
Outpatient
15
Inpatient
-
33
Chu and Dill (1990)
36
-
Jacobson (1969)
Outpatient
-
Inpatient
-
42
Bryer et al. (1987)
44
23
Craine et al. (1988)
Inpatient
51
46
42
Currey (1990)
Outpatient
57
-
-
Briere and Zaidi
Psychiatric
-
70
52
Study
Jacobson and Herald
Population
(1990)
(1989)
emergency department
NOTE. Abuse A is defined as sexual abuse with or without genital contact, Abuse B is defined as abuse involving genital contact. Abuse C is defined as genital contact with a family member (incest).
In summary, regardless of wide variations in incidence rates, the literature shows that substantial numbers of adult psychiatric patients report histories of incest or other childhood sexual abuse. These numbers are probably understated. Survivors of childhood sexual abuse often do not recall or disclose this history (Briere, 1989; Bryer et al., 1987; Chu & Dill, 1990; Summit, 1989). Most patients view childhood sexual abuse as shameful and stigmatizing (Briere, 1989; Briere & Zaidi, 1989; Browne & Finkelhor, 1986). Therefore, underreporting is far more likely than fabrication and overreporting. In addition, the researchers excluded from their studies the most disturbed patients and those who were otherwise unable or unwilling to give informed consent. Although this exclusion would avoid purely delusionally based responses, it may also have lowered the reported prevalence because there is evidence that the more severely disturbed patients on a unit are more likely to have been abused during childhood (Bryer et al., 1987). However, it appears clear that sizable subgroups of populations of adult female psychiatric patients are survivors of childhood sexual abuse. CHILDHOOD SEXUAL ABUSE AND PSYCHIATRIC SYMPTOMATOLOGY
It is generally recognized that adult psychiatric patients with histories of childhood sexual abuse show a characteristic pattern of symptoms (Browne & Finkelhor, 1986). In their study of psychiatric inpatients, Carmen et al. (1984) found that victims of physical and sexual assault had extreme difficulties with anger and aggression, self-image, and trust. Adult survivors tend to blame themselves for their victimization, explaining that they were abused because of their essential “badness.” The women directed their hatred and aggression against themselves in ways ranging from depression to repeated episodes of self-mutilation and suicide attempts. They had more treatment difficulties, possibly as a result of their inability to trust (impacting negatively on therapeutic alliance), impaired self-esteem (feeling undeserving of treatment), and difficulty coping with aggression (directing anger against the self or others). Bryer et al. (1987) claimed that both clinical experience and research data suggest that the most distressed patients in the hospital may have been abused as
FEMALE SEXUAL ABUSE SURVIVORS
247
AS PATIENTS
children. Surrey et al. (1990) also found that the abuse survivors in his sample of outpatients showed the most severe symptomatology. Several other studies also found a preponderance of certain symptoms in patients who reported sexual abuse during childhood. Persistent symptoms of anxiety and distrust, hostility, interpersonal sensitivity, negative self-esteem, depression, and sexual problems were reported by Herman, Russell, and Trocki ( 1986) and Surrey et al. (1990) in their sexually abused adult populations. An emergency department sample of women reporting childhood sexual abuse was significantly different from the nonabused sexually comparison group in having histories of self-mutilation, suicidal ideation, suicide attempts, drug use. and in having acquired more psychiatric diagnoses (Briere & Zaidi, 1989). The sexually abused group studied by Bryer et al. (1987) also differed significantly from the comparison nonabused group by showing more severe and possibly psychotic or psychoticlike acute symptoms, by having more suicidal symptoms, and by receiving pharmacological treatment more often. Chu and Dill (1990) investigated the relationship between dissociative symptoms and a history of childhood sexual abuse in a sample of adult female psychiatric hospital patients. Compared with other major symptoms, they found that only dissociation was predicted significantly by such history. Furthermore, survivors of incest reported more dissociative symptoms and were more likely to have auditory hallucinations, numerous diagnoses, and repeated hospitalizations than survivors with histories of nonfamilial abuse. These findings are similar to those of Ogata et al. (1990), who reported that chronic dysphoria (manifested by feelings of emptyness, loneliness, and boredom) and derealization (a dissociative symptom) each separately or together predicted childhood sexual abuse among hospitalized women with diagnoses of depression alone or borderline personality disorder. In summary, the pattern of characteristics expected of adult female patient survivors of childhood sexual abuse include symptoms that appear more severe than those of nonabused patients, more self-destructive behaviors, chronic dysphoria, depression, dissociative symptoms including psychotic-like symptoms, history of substance
abuse, anxiety, hostility, interpersonal problems, and lack of diagnostic clarity. The symptoms may be particularly severe in survivors of incest. ACCOMMODATION: VICTIMIZATION
A LINK BETWEEN
AND SYMPTOMATOLOGY
Carmen et al. (1984) stated that although the psychosocial consequences of abuse are known, the process whereby a victim becomes a patient has not been appreciated by clinicians or adequately conceptualized by researchers. They developed a psychosocial model of the victim-topatient process to explain how chronic abuse damages the self and sets into motion psychological processes that may evolve into various forms of mental illness (Carmen & Rieker, 1989). According to Carmen and Rieker ( 1989), the victim accommodates to the interplay between the abuse events, family relationships, and other life contexts. These accommodations, originally adaptive survival strategies, later form the core of the survivor’s psychopathology. After abuse occurs, the victim must accommodate to the judgments of others about the abuse. This accommodation takes the form of denying the occurrence of the abuse, altering the affective responses to the abuse, and denying the importance of the abuse by disconfirmation and transformation. Carmen and Rieker assert that the victim of familial child abuse is in a situation in which acknowledging the abuse means acknowledging that the world is dangerous and that those who are supposed to protect and nurture instead failed to protect or caused harm. Reports of abuse are often denied or discounted by family and society. Thus, victims have the negative choices of revealing the abuse (acknowledging lack of safety and nurturing, being disbelieved or discounted) or denying and discounting the abuse, altering their affective response and transforming the abuse. In a sense, victims choose between revealing the abuse at the time (being discredited or discounted and punished) and transforming the abuse and the normal response to it (developing strategies that will become pathological as an adult). The victim can transform the abuse by assuming responsibility for the abuse, thereby suffering guilt but restoring an illusion of control, or by redefining the trauma as not abusive, thereby denying cognitive and affec-
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DEBORAH DOOB
tive experience but restoring the illusion of a safe world. By accommodating to the judgments of others, the victim is denied an acknowledgment of the accurate abuse experience, the true feelings connected with the abuse, and an understanding of the meaning of the abuse (Carmen & Rieker, 1989). There is a profound disconfirmation of the victim’s reality. The normal affective response to abuse is fear, anxiety, helplessness, and rage, but these feelings must be distorted or suppressed to conform to the abusive family’s delusion of safety and nurturing. Therefore, victims must deny reality and alter their thoughts, feelings, and behaviors to conform to their family norms and expectations. Victims ultimately transform the meaning of the abuse to the familial explanation (either nonoccurrence or appropriate and nonabusive). The abuse becomes interpreted by the victim as a delusion or as an appropriate response to one’s own “badThe anger adult survivors often direct ness.” against themselves can then be understood as a repetitive reenactment of real events with the expression of affect from the past removed from its context. Without this understanding, such affect and associated behaviors appear irrational to survivors and to observers. According to Carmen and Rieker (1989), the accommodations that permitted the child victim to maintain connection with family members and retain some sense of safety and protection are not functional in the world in which the adult survivor lives. In the context of adult life, such accommodations may appear as dissociative symptoms, delusions, depression, self-destructiveness, irrational anxiety, paranoia, and interpersonal problems. What helped the child victim feel connected to the family may cause the adult to feel isolated and alone in the very different nonfamilial context. Thus, the symptoms that result in the victim’s becoming a patient represent a reaction to childhood sexual trauma within a context of familial disconformation, a familial response that is even stronger when sexual abuse is involved. An example of this process is found in the following personal account by Dianne Jennings Walker as quoted in Chamberlin (1978, p. 113). For once I feel that my mind, soul and body are mine. I was lied to for so many years that I still fear the feeling of being split apart from my body. This so-called symptom of schizophrenia is what happens to us when the perceptions
we have of our environment arc attacked and ignored and denied over and over again. Ironically, our perceptions are accurate. Even after we are terrorized, drugged or socialized out of expressing ourselves directly we do it symbolically and the feelings are right. I believed as a child that my soul had been stolen from its rightful body, that my parents lived on a satellite of Betelgeuse. That was not an insane delusion. It was a poetic and actually logical way to handle the unliveable environment that I had the ill fate to bc born into. In my late teens I discovered psychology and psychiatry, which I believed for many years were my salvation. “Oh wonderful: I’m not from another planet I’m simply crazy!“.
THE CLINICAL
RESPONSE
The substantial percentage of patients presenting with symptoms relating to childhood sexual assault has often gone unrecognized. Many patients do not volunteer the information that they have experienced childhood sexual abuse or deny the history if asked (Jacobson & Richardson, 1987; Summit, 1989). Summit (1989, p. 421) writes of the “survival imperative to act as if nothing has happened.” Many are not asked, or (if it is disclosed) the information is not believed or judged important enough for charting (Briere & Zaidi, 1989). Thus, any statistics regarding prevalence are likely to be underestimates even if patients are asked about their history directly. However, the underestimate becomes extreme if the data are based only on chart review and subjects are not directly questioned. A chart review study showing prevalence of physical/sexual child/ adult assault experiences of 43% in a female patient population (Carmen et al., 1984) stands in contrast to a finding of 72% (Bryer et al., 1987) or 81% (Jacobson & Richardson, 1987) when patients were questioned directly about assault experiences. Jacobson and Herald (1990) found that 56% of directly questioned inpatients who stated they had been sexually abused in childhood also stated that they had never disclosed the information to caregivers before that time. Jacobson (1989) found a rate of 71% in a similar study involving outpatients. Briere and Zaidi (1989) discovered a sexual abuse rate of only 6% among female psychiatric emergency department patients by chart review but 70% when patients were specifically asked. Many of the state hospital patients studied by Craine et al. (1988) stated that they had never previously revealed their abuse histories to clinicians because they had never been asked.
FEMALE SEXUAL
ABUSE SURVIVORS
AS PATIENTS
In ignoring or denying the existence and impact of childhood sexual abuse, professionals, families, and patients collude in a negative hallucination and maintain the myth of a nurturing family, a safe world, and a guilty patient (Carmen & Rieker, 1989; Chu & Dill, 1990). The patient’s sanity, the patient’s fragments of accurate memory and expected response to trauma (anger and fear) in a world unwilling to accept such reality, is viewed as insanity. The adult patient’s accommodation (labeled dissociative, psychotic, affectively disordered, inappropriately distrustful, etc.) appears pathological in a world that responds with blindness to the abuse experience but not to the survivor’s accommodation. Professional failure to initiate discussion of sexual abuse sends a message to patients that such abuse does not occur or does not matter and confirms the patients’ belief in the need to deny the reality of the experience (Bryer et al., 1987). Likewise, misperceiving recollections as psychosis, characterological manipulations, or Oedipal fantasies colludes with the family’s denial of the occurrence and impact of abuse or with the patient’s sense of guilt and defectiveness (Chu & Dill, 1990; Ogata et al., 1990; Summit, 1989). Patients’ attempts to deal with the distress of real affective, physical, and cognitive memory, confronting their own and caregivers’ accommodation (e.g., flash backs), lead to the development of more severe and confusing symptoms (Bryer et al., 1987). “When these behavioral reenactments are unrecognized, the psychotherapy situation can become a destructive repetition of the trauma in which the patient is again disconfirmed and left alone with her or his pain” (Carmen & Rieker, 1989, p. 440). Briere (1989) refers to the “psychiatric redefinition of post-sexual-abuse trauma” as the process that occurs when adult survivors are diagnosed without appreciating the impact of the abuse experience. Diagnoses that do not recognize the possible role of experience in the development of symptoms may invalidate the survivors’ perceptions by releasing their families from responsibility for their pain. The disorder is conceived as intrinsic to the patients themselves rather than as having external roots. Pharmacological treatment without an abuse-related conceptualization may reinforce this message (Ogata et al., 1990). Again, the victim is blamed. Given the characteristics predictive of childhood
249
sexual abuse histories in adult female psychiatric patients, it is not surprising that borderline personality disorder is diagnosed significantly more often in these patients than in nonabused patients (Briere & Zaidi, 1989; Bryer et al., 1987) and that abused patients are overrepresented within that diagnosis (Ogata et al., 1990). Although childhood sexual abuse may not by itself cause this constellation of symptoms, it does appear to predispose individuals to behavior that satisfies the Diagnostic & Statistical Manual, 3rd edition (DSM-III) criteria for borderline personality disorder while not satisfying the standard etiological theories for the development of that disorder (Briere, 1989). Dissociative symptoms are associated with borderline personality disorder but also with posttraumatic stress disorder and with dissociative disorders. Additionally, dissociation can appear similar to psychotic processes and may be mistaken for hallucinations or other Schneiderian first-rank symptoms and result in a misdiagnosis of schizophrenia (Beahrs, 1982; Bryer et al., 1987; Chu & Dill, 1990, Kluft, 1985). Craine et al. (1988) found that 66% of their sample of state hospital patients met the DSM-Ill criteria for a diagnosis of posttraumatic stress disorder, but none had received this diagnosis. Several researchers have argued that adult survivors should receive diagnoses such as posttraumatic stress disorder or a dissociative disorder, which not only characterize their symptoms but also correctly recognize the etiology. Abuse-related diagnoses would justify abuse-related treatment, which can be highly productive (Beahrs, 1982; Briere, 1989; Bryer et al., 1987; Chu & Dill, 1990; Craine et al.. 1988; Jacobson & Herald, 1990; Summit, 1989; Surrey et al., 1990). In addition to denial and disconfirmation of the abuse experience during diagnosis and treatment, there are numerous other ways treatment within the mental health system can recreate the context of familial childhood sexual abuse (Sonn, 1977). Even in physical illness. opinions of patients are usually discounted. The whole person is often invalidated because a part of him/her is sick. This invalidation is even more true in psychiatry in which statements are not taken at face value and everything a patient says is open to the interpretation of hidden messages. Patients who were assaulted in childhood by parents or other adults in authority have experienced a hierarchical relationship that was supposed
250
to be nurturing but instead was subverted to serve the aggressive or sexual needs of the adult (Jacobson & Richardson, 1987). Therefore, they enter a treatment relationship, which is also hierarchical, suspecting that any trust they develop will be used to hurt them. Knowledge of a patient’s sexual abuse history can form the basis of a different understanding of the patient’s difficulty in establishing a therapeutic alliance. Difficulty is expected rather then indicative that the patient is untreatable (Jacobson & Herald, 1990; Jacobson & Richardson, 1987). Survivors may repeatedly seek treatment that has victimized them previously either because that is all that is available or because of a compulsion to repeat trauma (van der Kolk, 1989). This persistence can lead to increasingly destructive cycles in which the survivor repeatedly seeks treatment that restimulates symptoms and the system (becoming frustrated by the patient’s poor response) treats the patient with increasingly punitive measures. The cycle often ends with the system severely limiting its offer of treatment (e.g., Diamond, Alexander, & Marshall, 1985). “Ignoring the [traumatic] cause of the patient’s distress is likely to result in increasingly hostile demands on the part of the patient, and equally firm rejections on the part of the care-givers” (van der Kolk, 1987, p. 22). However, labeling these patients as untreatable is premature (Chu & Dill, 1990). A better altemative to no treatment or treatment that only seems to hurt patients (Aronson, 1989) may be treatment within a trauma-related conceptual framework. Such treatment acknowledges not only the abuse history but the context that caused accommodation to occur (i.e., the centrality of past and continued victimization in the lives of these patients) and is effective (Braun, 1989; Briere, 1989; Chu & Dill, 1990; Carmen et al., 1984; Jacobson & Richardson, 1987; Kluft, 1984; Ogata et al., 1990; Summit, 1989). Effective treatment confirms the recollections of abuse and helps the patient acknowledge and recontextualize the trauma (Carmen & Rieker, 1989). Summit (1989) argues that “in the absence of a trauma-centered conceptual framework and specific therapeutic interaction, the radical prospect of recovery and normality for survivors remains unrecognized” (p. 4 13) and “every patient whose identity was founded on assault, betrayal, abandonment, shame, and alienation de-
DEBORAH DO06
serves the benefit of active therapeutic resolution of post-traumatic pain” (page 425). In summary, researchers have found that diagnosis and treatment within the mental health system has often continued the denial and disconfirmation that first confronted the patient during childhood and resulted in the accommodations that became symptoms in adulthood. Such diagnosis and treatment may restimulate symptoms and cause abuse survivors to appear very ill and untreatable. Diagnosis and treatment within a posttraumatic framework provides the possibility of an optimistic outcome. IMPLICATIONS FOR NURSING
Childhood sexual abuse survivors compose a substantial proportion of our patient population either as new patients or as those with extensive treatment histories. Nurses have an enormous opportunity to make a difference in the treatment of survivors, a difference that may ultimately result in healing and the prevention of chronicity. By recognizing childhood sexual abuse and its impact on adult patients and by understanding dysfunctional behaviors as accommodations to childhood familial realities, nursing can help other caregivers and patients gain a treatment perspective that is effective rather than continue the pattern of denial that served as the basis for later symptom development. Informed nursing can influence diagnostic and treatment decisions toward more effective approaches, alter staff attitudes so that destructive interactions similar to those of childhood are not recreated during treatment, and work with patients to alter their often revictimizing attitudes toward themselves. With patients who already have extensive treatment histories, nurses should be alert to the characteristic pattern of symptoms showed by survivors of childhood sexual abuse and should note any indication of abuse history in the previous records. Such observations may warrant advocating for the consideration of diagnostic and treatment alternatives by the treatment team. A posttraumatic perspective may suggest changes in the way patient behaviors are understood and responded to by the nursing staff. We may thus develop more effective treatment approaches that will enable the persons we once saw regularly on our hospital units to transition permanently into mainstream society.
FEMALE SEXUAL
ABUSE SURVIVORS
AS PATIENTS
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