The Healing Process of Female Adult Incest Survivors: Constructing a Personal Residence Claire Burke Draucker
This study generated a descriptive theoretical framework of the healing process of adult survivors of incest based on the perceptions of 11 survivors who had experienced some degree of healing. The core variable that emerged from the data was labeled “constructing a personal residence” to reflect the participants’ descriptions of their experiences as laborious, active and constructive. The process of constructing a residence included three main elements: building a new relationship with the s e e regulating one’s relationships with others; and influencing the community in a meaningful way.
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V
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iolence within the family is a major national public health concern. The incestuous abuse of children is of particular concern due to the continuing and pemasive impact this experience often has on the mental health of the survivors. In a study involving a largecummunity sample of 930 women, Russell (1986) reported that 38 percent of those interviewed indicated that they had experienced sexual abuse prior to the age of 18. For 16percent of the sample, the abuse had been incestuous. The prevalence of incestuous abuse is thought to be even higher in the backgrounds of certain clinical populations, e.g., psychiatric patients, (Briere & Zaidi, 1989; Jacobson, 1989). The long-term effects resulting from the experience of incest have been well-documented and include later experiences with victimization, post-traumatic stress symptomatology, depression, sexual dysfunction, and disturbed interpersonal relationships (Edwards & Donaldson, 1989; Finkelhor, Hotaling, Lewis, & Smith, 1989; Harter, Alexander, & Neimeyer, 1988; Herman, Russell, & Trocki, 1986). The treatment of adult survivors is an important clinical concern to nurses and mental health professionals because of the prevalence of childhood sexual abuse in society and the frequency, severity and diversity of long-term effects. Because the incest experience involves elements not necessarily found in other abuse, it was anticipated that the needs and concerns of incest survivors are unique. For example, incest involves the betrayal of a significant other, most typically during an early 4
developmental period, and often occurs over an extended period.
In addition, incest involves behavior that is considered taboo by society.
Review of Literature Several theories of victimization outline the processes survivors of trauma experience during recovery. Hypotheses from some of these theories have been applied to incest survivors. Taylor (1983), for example, identified three themes, or cognitive tasks, employed by individuals adjusting to threatening events. These tasks are “a search for meaning in the experience, an attempt to regain mastery over the event in particular and over one’s life more generally, and an effort to enhance one’s selfesteem - to feel good about oneself again despite the personal setback” (p. 1161). In a study of female incest survivors, Draucker (1989) reported that the degrees of accomplishment of the three tasks identified by Taylor were significantly related to several indices of adult functioning. Similarly, Silver, Booc, and Stones (1983) found that incest survivors who were able to make sense of the incest experience reported better psychological adjustment as adults. The aftermath of a victimizing experience also has been explained by attribution theory. Based on the reformulated learned-helplessness model, Peterson and Seligman (1983) suggested that the types of causal attributions a survivor makes regarding the victimizing experience may explain the survivor’s reaction to the situation. As predicted by this model, Gold (1986) discovered a relationship between depressive attributional style for negative events and psychological distress in a sample of incest survivors.
Claire Burke Draucker, RN, PhD, Delta Xi, is Assistant Professor, Kent State University. The author gratefully acknowledges Kathleen V. Cowles, RN,
~
1
PhD for consultation for this study as well as for her critique of the original manuscript. Preparation of this article was supported in part by the Peg Schiltz Memorial Fund administered by Delta X i Chapter, Sigma Theta Tau. Correspondence to School of Nursing, Kent State University, Kent, OH 44242. Accepted for publication May 24, 1991.
I
IMAGE: Journal of Nursing Scholarship
-The
The clinical literature, which addresses treatment goals and stages of recovery, also suggests processes leading to effective coping with the abuse experience. These processes include acknowledging,accepting and recounting the experience of incest (Courtois, 1988); constructively expressing feelings of anger, guilt, fear, grief and shame (Cowtois, 1988; Faria & Belohlavek, 1984; Forward & Buck, 1978; Goodman & Nowak-Schivelli, 1985;); abdicating responsibility for the abuse (Courtois, 1988; Faria & Belohlavek, 1984; Forward & Buck, 1978; Gordy, 1983); decreasing isolation (Courtois, 1988; Gordy, 1983); and gaining control over one’s life as an adult (Faria & Belohlavek, 1984). However, the life experiences of healing from incest from the perspective of the survivors have not been studied systematically. Theoretical formulations based on survivors’ descriptions of their own healing, rather than on assumptionsdrawn from only partially relevant theories of victimization or from clinicians’ perceptions, are essential to understanding the process of recovery from the trauma of incest. Such formulations may guide interventions appropriate to the needs of this unique population. The purpose of this study was to generate a descriptivetheoretical framework of the healing process of female adult survivors of incest based on the perceptions of those who had experienced some degree of healing.
A description of the study was sent to professionals who specialize in working with incest survivors or women’s issues in the researcher’s community,a small midwestern city. They were asked to describe the study to any adult female survivorsof incest the professionals knew had experienced some healing and to invite their participation. In addition, women who identified themselves as incest survivors and who had shared their own healing experiences in some public context e.g., public media, educational setting, were contacted directly by the investigator to request their participation. Only women were included in the present sample due to evidence that male and female responses to incest differ in some significant ways (Marten, 1985), indicating that a separate theoretical framework for each group would be appropriate. Eleven survivors, who ranged from 20 to 64 years, participated in the study. Ten participants were Caucasian and one declined to specify her race. Five participants were single, three were divorced or separated, three were married and three had children. Five were students and the rest were in professional occupations such as teaching, nursing and telecommunications. All had experienced sexual abuse as a child by a family member or significant caretaker. The characteristics of the abuse situation, such as the age of the survivor at the time of the abuse, the duration of the incest, and the type of sexual activity involved, varied greatly among the participants. They had all sought professional or peer counselingas an adult for a variety of reasons including relationship problems, substance abuse problems and depression. A formal, unstructured in-depth interview was conducted with each participant. Prior to the interview, the study was explained to the participants, informed consent obtained, and Volume 24, Number 1, Spring 1992
Healing Process of Female Adult Incest Survivors: Constructing a Personal Residence
each participant filled out a brief demographic data sheet. The investigator developed an interview guide consisting of openended questions designed to encourage the participants to discuss freely their healing experiences including the causes, circumstances and consequences of those experiences. Each interview was tape-recorded. The interviews, which lasted an average of one and 112 hours, provided sufficient data to achieve the saturation of categories necessary for the development of a substantive theoretical framework. Data analysis was based on techniquesfrom grounded theory methodology (Glaser & Strauss, 1967). Open substantivecoding, abstracting each fact or incident described by the participants as a code word, was conducted directly on the interview transcripts. The substance of the data was examined and compared and theoretical groups or categories were identified and labeled. Large spread sheets were used to organize the codes into the identified categories and facilitate the on-going constant comparison and analysis of data. A core variable (Glaser, 1978) that accounted for much of the variation in the data and served to conceptually link the major categories into a descriptive framework was identified and was labeled “constructing a personal residence.” The data were compared and categorized into a substantively dense theoretical framework. To enhance the credibility of the study, the investigator discussed the data with a research consultant for the purpose of peer debriefing. Peer debriefing is described by Lincoln and Guba (1985) as “exposing oneself to a disinterested peer . . . for the purpose of exploring aspects of inquiry that might otherwise remain only implicit within the inquirer’s mind” (p. 308). In addition, a member check, the validation of reconstructions with the participants (Lincoln & Guba, 1985), was accomplished by follow-up contacts with the survivors. Eight of the original participants were located and sent a summary of the results. They were asked to share their reactions with the researcher. All those who participated in the member check indicated that the core variable accurately described their experience and that the theoretical framework was comprehensive in addressing the important aspects of the healing process. Constructing a Personal Residence: A Descriptive Framework The incest survivors who participated in this study described the healing process as one that involved building a new place for themselves in the world (Figure 1). Therefore, the metaphor of constructing a new residence was used to reflect the process as it was explained by the survivors. When discussing the healing process as a whole, the participants described it as an active, on-going, complex and timeconsuming experience involving “hard work.” The tasks of healing were often described with terms that implied accepting a challenge, e.g., facing, confronting; working to overcome odds encountered in the environment, e.g., digging away, struggling against, overcoming; and building something new; e.g., creating, designing. The metaphor of construction reflects the hard work of healing and captures its active, rather than passive, and constructive, rather than destructive,elements. When discussing their experiences, the survivors frequently used “construction”
5
The Healing Process of Female Adult Incest Survivors: Constructing a Personal Residence
metaphors themselves. They spoke of building walls, securing boundaries, opening doors, constructing bridges and mending fences. Deciding to Build For the survivors in this study, the decision to build a new place in their world was often preceded by a feeling that something was “not right,” although this feeling was not necessarily associated with their incest, at least initially. The survivors frequently discussed feeling depressed or anxious, being physically ill, or experiencing relationship problems that they did not understand. The determination that something was wrong occurred for several participants when they experienced intense and puzzling responses to certain events, which were frequently related to vicarious or threatened experiences with victimization. One survivor discussed watching a puppy getting hurt: “. . . he stepped on her and she yipped and he hauled off and kicked her about from here to that wall. A big construction worker. I just punched the s... out of him. And I’ve never done that before, I’ve never been physical. I walked back into my office and I shut the door, and I sat down and I though oh boy, we’ve got a problem here.” Connecting present distress with the abuse, something many participants had not previously done, was described as important in the decision to build. The survivors also discussed the importance of ceasing to minimize the abuse. They spoke of needing to come to believe that the incest was a “major problem,” that it “cost” them, or that it had a “profound effect” on them. Having the scope of the problem validated by others was helpful in thisprocess. The survivors often described experiencing intense emotions, such as anxiety and sadness, in response to making the connection between their present experiences and the abuse. One survivor spoke of someone “pulling the cork,” while another stated that the experience was like “opening the floodgates.” However, many also described the experience as freeing because they could begin to give meaning to their current problems. Once they had connected their present experiences to the abuse and allowed themselves to appreciate the impact of the incest on their lives, many participants described making an active and conscious decision to devote their time and energy to recovering from their abuse. Several stated that the decision was often based on having a “bridge” or connection to another who would support the healing process. Constructing the Residence The healing process, as described by the participants, included three main elements: building a new relationship with the self to provide nurturing and security; regulating one’s relationships with others; and influencing the community in a meaningful way. These elements are similar to those things a home can provide. A residence provides the means for persons to care for themselves and provide for their safety, a place to regulate their interactions with others, and a base from which they can act as involved community members. In this study, the survivors described being not only the builders of their own places, but the architects was well. As one survivor concluded: “I really feel good. I’m very happy with my life. I’ve designed it so it works for me.” 6
Constructing a New Relationship with the Self Participants emphasized that healing involves not just feeling differently about oneself, but actually treating oneself differently. Constructing a new residence, or place in their world, therefore, included a process of building a new relationship with themselves. The new relationship typically involved no longer treating themselves with criticism and neglect, but rather, with acceptance and caring. Attributing responsibility for the abuse to the offender (or to the family or society), rather than to oneself, was considered by participants to be an important part of healing. They could then stop criticizing themselves and begin to nurture and protect themselves instead. They spoke of taking care of their health, attending to their appearance, providing for their pleasure and happiness, developing a sense of humor, and being able to protect themselves and ensure their safety. The ability and the desire to provide self-care is exemplified in the following vignette: “Before I go to bed at night maybe I’ll fall into bed and I’ll think - ‘Well, wait, you forgot to brush your teeth and wash your face. Get up and do it.’ Whereas before I’d lay in bed and say ‘Well, so what? You’ll get a cavity; so maybe your face will break out tomorrow.” Regulating Boundaries Another function of a residence is to provide a structure that separates the inhabitants from the environment while allowing them to control access to their private lives. Residences have walls, doors, locks and fences that allow others in, keep them out, or regulate their physical distance from the inhabitants of the residence. A central task of all the survivors in this study seemed to be regulating their relationships with others. They discussed bringing others into or excluding them from their lives, redefining or regulating the parameters of their interactions with others, and actively monitoring the progress of their relationships. Constructing walls, or limiting access to oneself, was a primary task discussed by many of the survivors. Most of them described breaking off contact, at least initially, with the offender or family of origin during the healing process. This was especially necessary if their families continued to engage in behaviors such as blaming and denial that were deleterious to the survivors’ healing. The participants also discussed constructing “doors.” In many instances they did allow the significant others back into their lives, but often only on the survivors’terms. These terms were, for the most part, specific and definite. For example, one survivor re-established contact with her mother under the following conditions: “[I] do things that are going to benefit me, like this thing with my mom now. I am making another attempt at it, but if it becomes hurtful and destructive, I’m not going to be in the relationship anymore.” In designing boundaries, the process of allowing entrance to the survivors’ worlds seemed as important as did initiating exclusion. New ways of involving others in their lives, which they described as “opening doors,” included learning to reach out to others directly, decreasing isolation by making themselves more available to social contacts, allowing others to care about them, and asking for help. IMAGE: Journal of Nursing Scholarship
The Healing Process of Female Adult Incest Survivors: Constructing a Personal Residence
The survivors also described an active process of redefining their relationships with others outside the family of origin. This involved reevaluating their present significant relationships, ending destructive relationships, coming to appreciate female relationships, making new friends or creating a surrogate family. One survivor, a teacher, stated: “And it [her work] helps me get through the situation . . . not having my family; my kids [pupils] were like family .
. . . They were my
family for a long time.”
Many participants allowed others into their world through the process of disclosing the abuse experience. Having others know of the experience was, for some survivors, a prerequisite to closeness. For the most part, the participants described positive, or supportive, responses to their initial disclosures. If, however, the response to the disclosure, or to the healing process more generally, was perceived by the survivor to be negative, or nonsupportive, the other was then typically excluded from the life of the survivor. Non-supportive responses were described as curiosity or inquisitiveness rather than concern, pressure to heal quickly, disparagement of counseling, pressure to forgive the offender, advice, anger and blaming the survivor for causing pain by “bringing it up,” and failing to acknowledge the significance of the abuse. Responses by therapists that indicated shock were perceived as particularly destructive. Many survivors specified that those who could get closest to them were those who had experienced abuse and therefore could truly understand their experiences. Part of constructing the new residence was recognizing and appreciating that there was a place in the residence where entry was determined by shared experience. As one survivor stated: “There’s a place, I think, in everyone that’s been abused where we go that no one else can go, and I think you need to understand that.”
In many instances, monitoring relationships involved not just exclusion/inclusion or closeness/distance issues but rather a redefinition of the “rules.” Often, survivors redefined their relationships in such a way that they became more active, assertive participants. They discussed setting limits on the behaviors of others and expressing their feelings, especially anger, openly and directly to others. Just as one typically feels more in control when in one’s own home, these individuals reported being more in control of their relationships. The importance of monitoring relationships with others and controlling access to the self is strikingly exemplified by an incident told by one survivor. Before she was married she had a power of attorney for health care drawn that stated if something happened to disable her, her fiance’s mother would be granted custody of her. She explained: “She would determine if the plug was pulled or not, not my brothers or sisters . . . because I would not trust them to not abuse me and I would be a helpless vegetable who really couldn’t do anything about it, and I wouldn’t do that.”
Influencing One’s Community
For many of the survivors, building their “residence” involved not only structuring a new relationship with themselves and others, but also structuring a new relationship with Volume 24, Number 1, Spring 1992
their community. An essential part of the healing process for many of the participants involved recognizing that they could have a positive impact on their world. One way survivors described influencing their “community” was by personally reaching out to other survivors of abuse. Many expressed wanting to share their healing by “passing it [the healing] on” and “pulling others [survivors] along.” The participants described sharing their abuse experiences with others, treating others with compassion and understanding, and providing guidance. Several survivors sought to have an impact by being an advocate for children and other victims of abuse by becoming involved in activities or programs aimed at abuse prevention. One woman discussed conducting incest awareness seminars and another discussed belonging to a rape prevention task force. One survivor discussed choosing to teach in an inner-city school because she was aware of what it was like to be poor, hungry and scared. Having an impact on one’s community thus seemed to be an important step in building one’s personal residence.
Conclusions and Implications Many of the elements of the theoretical framework are consistent with descriptions of the healing process of survivors discussed in the literature. With respect to the victimization theories, for example, the framework addresses the process of attribution (Peterson & Seligman, 1983) and elements of Taylor’s (1983) three tasks, e.g., finding meaning by helping others, gaining mastery in relationships. Similarly, the framework includes several processes that have been discussed in the clinical literature including acknowledging and accepting the reality of the abuse (Courtois, 1988); validating memories (Herman & Schatzow, 1987); and attributing responsibility for the abuse to the offender (Courtois, 1988; Faria & Belohlavek, 1984; Forward & Buck, 1978; Gordy, 1983). However, while much of the literature emphasizes internal cognitive processes, the theoretical framework described here focuses more on activities that have an impact on the environment or on the self. The participants described not only feeling good about themselves but actually treating themselves differently. They not only stopped blaming themselves for the abuse, they also worked to prevent the abuse of others. Although internal cognitive processes and behavioral changes are closely interrelated, the participants of this study perceived actively building a new world for themselves as the most salient aspect of the healing process. Wynne (1987), an incest survivor, wrote a book describing her recovery and healing, That Looks Like a Nice House. Her story supports the metaphorical basis of the theoretical framework of this study. She described a house that looked like a nice house on the outside but that had been badly damaged by an invasion of ants on the inside, resulting in its being abandoned by the child who lived there. It was only when the house allowed a carpenter in and agreed to “major repairs,” including new windows, a new beam, and a new floor, that the ants were eliminated and the child returned. Theoretical frameworksthat are generated from and grounded in the data, while not generalizable in the traditional sense, do offer unique insights into the concerns and needs of others as they I
The Healing Process of Female Adult Incest Survivors: Constructing a Personal Residence
experience a phenomenon, and thus can guide clinicians in planning interventions. For example, the processes involved in constructing a personal residence, as described by the participants, have potential treatment implications for nurse therapists. These survivors experienced healing as an active, constructive, and complicated process that seemed to be facilitated if the survivor had a significant “bridgk“ or connection to another person, often a therapist. The results of the study suggest that being this “bridge” begins with a supportive response to disclosure. Also, assisting survivors to become more aware of the impact the incest has had on their lives and confronting their tendency to minimize the experience were described as essential therapist tasks. Further, therapeutic interventions aimed at increasing the survivors’ ability to care for themselves might be helpful early in the healing process, so that survivors can nurture and protect themselves while they experience some of the more painful aspects of healing. Nursing interventions may also facilitate the process of regulating boundaries. For example, survivors may need the support of the therapist to gain distance, at least temporarily, from their family of origin while exploring ways to include others in their lives who can support the healing process. After survivors experience progress in their own healing, therapy can be used to explore avenues through which they might then influence their community in a meaningful way. Further development of the theoretical framework derived from this study is indicated. The participants were similar in terms of race, social class and treatment involvement. Additional research should explore how the effects of these variables, as well
I.
Deciding to “build” rather than “ ‘ r e d 1 A. A feeling that something is ‘hot right” B. Connecting present distress with the abuse C. Ceasing to minimize the impact of the abuse LI. Constructing the residence A. Constructing a new relationship with the self I . Abdicating responsibility for the abuse 2. Self-acceptance 3. Providing a structure within which to provide for
one’s self-care and safety. B. Regulating boundaries 1. Limiting access to oneself (“building walls”) 2. Allowing entrance of supportive others into one’s world (“building doors”) 3. Redefining interpersod relationships 4.Maintaining conml in interpersonal relationships (“building gates”) C. Influencing one’s community (“establishing residency”) 1. Assisting other survivors 2. Involvement in abuse prevention
Agum 1: Constmctlflg a Personal Residsncs: ADeecrlptlve Framework
8
as gender and the characteristics of the abuse situation, e.g., age, duration, and relationship to the offender, might influence the process of constructing a personal residence. Adult incest survivors constitute a relatively large portion of women who seek therapy and their clinical needs are unique and complex. The theoretical framework described provides a beginning understanding of the healing experiences of survivors and some insights into possible nursing interventions for this special client population. @Q
References Briere, J. & Zaidi, L. Y. (1989). Sexual abuse histories and sequelae in female psychiatric emergency room patients. AmericanJournal of Psychiatry, 146, 1602- 1606. Courtois, C. A. (1988). Healing the incest wound. New York W. W. Norton & Company. Draucker, C. B. (1989).The cognitive adaptation of female incest survivors. Journal of Clinical and Consulting Psychology, 57,668-670. Edwards, P. W., & Donaldson, M. A. (1989). Assessment of symptoms in adult survivors of incest: A factor analytic study of the responses to Childhood Incest Questionnaire. Child Ahuse and Neglect, 13,101-110. Faria, G., & Belohlavek, N. (1984). Treating female adult survivors of incest. Social Casework, 65,465-47 1. Finkelhor,D.,Hotaling,G. T.,Lewis,I.A., & Smith, C. (1989).Sexualabuseand its relationshipto later sexual satisfaction, marital status, religion and attitudes. Journal of Interpersonal Violence, 4,379-399. Forward, S., & Buck, C. (1978). Betrayal of innocence: Incest and its devastation. Los Angeles: J. P. Archer. Glaser, B. G. (1978). Theoretical sensitivity: Advances in the methodology of grounded theory. Mill Valley, Ca: The Sociology Press. Glaser, B. G., & Straws, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research. Chicago: Aldine. Gold, E. R. (1986). Long-term effects of sexual victimization in childhood: An attributional approach. Journal of Consulting and Clinical Psychology, 4, 47 1-475. Goodman, B., & Nowak-Scibelli, D. (1985).Group treatment for women incestuously abused as children. InternationalJournal of Group Psychotherapy, 34,531-544. Gordy, P. L. (1983). Group work that supports adult victims of childhood incest. Social Casework, 64,300-307. Harter S., Alexander, P. C., & Neimeyer, R. A. (1988). Long-term effects of incestuous child abuse in college women: Social adjustment, social cognition, and family characteristics.Journal of Consulting and Clinical Psychology, 56,5-8. Herman, J., Russell, D., & Trocki, K. (1986). Long-term effects of incestuous abuse in childhood. American Journal of Psychiatry, 143,1293-1296. Herman,J. L., & Schatzow, E. (1987).Recovery and verification of memories of childhood sexual trauma. Psychoanalytic Psychology, 4,l-14. Jacobson, A. (1989). Physical and sexual assault histories among psychiatric outpatients. American Journal of Psychiatry, 146,755-758. Lincoln, Y. S., & Guba, E. G. (1985). Naturalisticinquiry. Newbury Park Sage. Marten, L. M. (1985). Gender-specific reactions to incest (Doctoral dissertation, North Texas State University). Dissertations Abstracts International, 46, 1671-B. Peterson, C., & Seligman, M. E. P. (1983). Learned helplessness and victimization. Journal of Social Issues, 39, 103-116. Russell, D. (1986).The secret trauma: Incest in the lives of girls and women. New York Basic Books. Silver, R. L., Boon, C., & Stones, M. H. (1983). Searching for meaning in misfortune: Making sense of incest. Journal of Social Issues, 39(2), 81-101. Taylor, S. E. (1983). Adjustment to threatening events: A theory of cognitive adaptation. American Psychologist, 38,1161-1 173. Wynne, C. W. (1987). That looks like a nice house. Walnut Creek, C A Launch Press. IMAGE:Journal of Nursing Scholarship
This study generated a descriptive theoretical framework of the healing process of adult survivors of incest based on the perceptions of 11 survivors who had experienced some degree of healing. The core variable that emerged from the data was labeled “constructing a personal residence” to reflect the participants’ descriptions of their experiences as laborious, active and constructive. The process of constructing a residence included three main elements: building a new relationship with the s e e regulating one’s relationships with others; and influencing the community in a meaningful way.
*
V
*
*
iolence within the family is a major national public health concern. The incestuous abuse of children is of particular concern due to the continuing and pemasive impact this experience often has on the mental health of the survivors. In a study involving a largecummunity sample of 930 women, Russell (1986) reported that 38 percent of those interviewed indicated that they had experienced sexual abuse prior to the age of 18. For 16percent of the sample, the abuse had been incestuous. The prevalence of incestuous abuse is thought to be even higher in the backgrounds of certain clinical populations, e.g., psychiatric patients, (Briere & Zaidi, 1989; Jacobson, 1989). The long-term effects resulting from the experience of incest have been well-documented and include later experiences with victimization, post-traumatic stress symptomatology, depression, sexual dysfunction, and disturbed interpersonal relationships (Edwards & Donaldson, 1989; Finkelhor, Hotaling, Lewis, & Smith, 1989; Harter, Alexander, & Neimeyer, 1988; Herman, Russell, & Trocki, 1986). The treatment of adult survivors is an important clinical concern to nurses and mental health professionals because of the prevalence of childhood sexual abuse in society and the frequency, severity and diversity of long-term effects. Because the incest experience involves elements not necessarily found in other abuse, it was anticipated that the needs and concerns of incest survivors are unique. For example, incest involves the betrayal of a significant other, most typically during an early 4
developmental period, and often occurs over an extended period.
In addition, incest involves behavior that is considered taboo by society.
Review of Literature Several theories of victimization outline the processes survivors of trauma experience during recovery. Hypotheses from some of these theories have been applied to incest survivors. Taylor (1983), for example, identified three themes, or cognitive tasks, employed by individuals adjusting to threatening events. These tasks are “a search for meaning in the experience, an attempt to regain mastery over the event in particular and over one’s life more generally, and an effort to enhance one’s selfesteem - to feel good about oneself again despite the personal setback” (p. 1161). In a study of female incest survivors, Draucker (1989) reported that the degrees of accomplishment of the three tasks identified by Taylor were significantly related to several indices of adult functioning. Similarly, Silver, Booc, and Stones (1983) found that incest survivors who were able to make sense of the incest experience reported better psychological adjustment as adults. The aftermath of a victimizing experience also has been explained by attribution theory. Based on the reformulated learned-helplessness model, Peterson and Seligman (1983) suggested that the types of causal attributions a survivor makes regarding the victimizing experience may explain the survivor’s reaction to the situation. As predicted by this model, Gold (1986) discovered a relationship between depressive attributional style for negative events and psychological distress in a sample of incest survivors.
Claire Burke Draucker, RN, PhD, Delta Xi, is Assistant Professor, Kent State University. The author gratefully acknowledges Kathleen V. Cowles, RN,
~
1
PhD for consultation for this study as well as for her critique of the original manuscript. Preparation of this article was supported in part by the Peg Schiltz Memorial Fund administered by Delta X i Chapter, Sigma Theta Tau. Correspondence to School of Nursing, Kent State University, Kent, OH 44242. Accepted for publication May 24, 1991.
I
IMAGE: Journal of Nursing Scholarship
-The
The clinical literature, which addresses treatment goals and stages of recovery, also suggests processes leading to effective coping with the abuse experience. These processes include acknowledging,accepting and recounting the experience of incest (Courtois, 1988); constructively expressing feelings of anger, guilt, fear, grief and shame (Cowtois, 1988; Faria & Belohlavek, 1984; Forward & Buck, 1978; Goodman & Nowak-Schivelli, 1985;); abdicating responsibility for the abuse (Courtois, 1988; Faria & Belohlavek, 1984; Forward & Buck, 1978; Gordy, 1983); decreasing isolation (Courtois, 1988; Gordy, 1983); and gaining control over one’s life as an adult (Faria & Belohlavek, 1984). However, the life experiences of healing from incest from the perspective of the survivors have not been studied systematically. Theoretical formulations based on survivors’ descriptions of their own healing, rather than on assumptionsdrawn from only partially relevant theories of victimization or from clinicians’ perceptions, are essential to understanding the process of recovery from the trauma of incest. Such formulations may guide interventions appropriate to the needs of this unique population. The purpose of this study was to generate a descriptivetheoretical framework of the healing process of female adult survivors of incest based on the perceptions of those who had experienced some degree of healing.
A description of the study was sent to professionals who specialize in working with incest survivors or women’s issues in the researcher’s community,a small midwestern city. They were asked to describe the study to any adult female survivorsof incest the professionals knew had experienced some healing and to invite their participation. In addition, women who identified themselves as incest survivors and who had shared their own healing experiences in some public context e.g., public media, educational setting, were contacted directly by the investigator to request their participation. Only women were included in the present sample due to evidence that male and female responses to incest differ in some significant ways (Marten, 1985), indicating that a separate theoretical framework for each group would be appropriate. Eleven survivors, who ranged from 20 to 64 years, participated in the study. Ten participants were Caucasian and one declined to specify her race. Five participants were single, three were divorced or separated, three were married and three had children. Five were students and the rest were in professional occupations such as teaching, nursing and telecommunications. All had experienced sexual abuse as a child by a family member or significant caretaker. The characteristics of the abuse situation, such as the age of the survivor at the time of the abuse, the duration of the incest, and the type of sexual activity involved, varied greatly among the participants. They had all sought professional or peer counselingas an adult for a variety of reasons including relationship problems, substance abuse problems and depression. A formal, unstructured in-depth interview was conducted with each participant. Prior to the interview, the study was explained to the participants, informed consent obtained, and Volume 24, Number 1, Spring 1992
Healing Process of Female Adult Incest Survivors: Constructing a Personal Residence
each participant filled out a brief demographic data sheet. The investigator developed an interview guide consisting of openended questions designed to encourage the participants to discuss freely their healing experiences including the causes, circumstances and consequences of those experiences. Each interview was tape-recorded. The interviews, which lasted an average of one and 112 hours, provided sufficient data to achieve the saturation of categories necessary for the development of a substantive theoretical framework. Data analysis was based on techniquesfrom grounded theory methodology (Glaser & Strauss, 1967). Open substantivecoding, abstracting each fact or incident described by the participants as a code word, was conducted directly on the interview transcripts. The substance of the data was examined and compared and theoretical groups or categories were identified and labeled. Large spread sheets were used to organize the codes into the identified categories and facilitate the on-going constant comparison and analysis of data. A core variable (Glaser, 1978) that accounted for much of the variation in the data and served to conceptually link the major categories into a descriptive framework was identified and was labeled “constructing a personal residence.” The data were compared and categorized into a substantively dense theoretical framework. To enhance the credibility of the study, the investigator discussed the data with a research consultant for the purpose of peer debriefing. Peer debriefing is described by Lincoln and Guba (1985) as “exposing oneself to a disinterested peer . . . for the purpose of exploring aspects of inquiry that might otherwise remain only implicit within the inquirer’s mind” (p. 308). In addition, a member check, the validation of reconstructions with the participants (Lincoln & Guba, 1985), was accomplished by follow-up contacts with the survivors. Eight of the original participants were located and sent a summary of the results. They were asked to share their reactions with the researcher. All those who participated in the member check indicated that the core variable accurately described their experience and that the theoretical framework was comprehensive in addressing the important aspects of the healing process. Constructing a Personal Residence: A Descriptive Framework The incest survivors who participated in this study described the healing process as one that involved building a new place for themselves in the world (Figure 1). Therefore, the metaphor of constructing a new residence was used to reflect the process as it was explained by the survivors. When discussing the healing process as a whole, the participants described it as an active, on-going, complex and timeconsuming experience involving “hard work.” The tasks of healing were often described with terms that implied accepting a challenge, e.g., facing, confronting; working to overcome odds encountered in the environment, e.g., digging away, struggling against, overcoming; and building something new; e.g., creating, designing. The metaphor of construction reflects the hard work of healing and captures its active, rather than passive, and constructive, rather than destructive,elements. When discussing their experiences, the survivors frequently used “construction”
5
The Healing Process of Female Adult Incest Survivors: Constructing a Personal Residence
metaphors themselves. They spoke of building walls, securing boundaries, opening doors, constructing bridges and mending fences. Deciding to Build For the survivors in this study, the decision to build a new place in their world was often preceded by a feeling that something was “not right,” although this feeling was not necessarily associated with their incest, at least initially. The survivors frequently discussed feeling depressed or anxious, being physically ill, or experiencing relationship problems that they did not understand. The determination that something was wrong occurred for several participants when they experienced intense and puzzling responses to certain events, which were frequently related to vicarious or threatened experiences with victimization. One survivor discussed watching a puppy getting hurt: “. . . he stepped on her and she yipped and he hauled off and kicked her about from here to that wall. A big construction worker. I just punched the s... out of him. And I’ve never done that before, I’ve never been physical. I walked back into my office and I shut the door, and I sat down and I though oh boy, we’ve got a problem here.” Connecting present distress with the abuse, something many participants had not previously done, was described as important in the decision to build. The survivors also discussed the importance of ceasing to minimize the abuse. They spoke of needing to come to believe that the incest was a “major problem,” that it “cost” them, or that it had a “profound effect” on them. Having the scope of the problem validated by others was helpful in thisprocess. The survivors often described experiencing intense emotions, such as anxiety and sadness, in response to making the connection between their present experiences and the abuse. One survivor spoke of someone “pulling the cork,” while another stated that the experience was like “opening the floodgates.” However, many also described the experience as freeing because they could begin to give meaning to their current problems. Once they had connected their present experiences to the abuse and allowed themselves to appreciate the impact of the incest on their lives, many participants described making an active and conscious decision to devote their time and energy to recovering from their abuse. Several stated that the decision was often based on having a “bridge” or connection to another who would support the healing process. Constructing the Residence The healing process, as described by the participants, included three main elements: building a new relationship with the self to provide nurturing and security; regulating one’s relationships with others; and influencing the community in a meaningful way. These elements are similar to those things a home can provide. A residence provides the means for persons to care for themselves and provide for their safety, a place to regulate their interactions with others, and a base from which they can act as involved community members. In this study, the survivors described being not only the builders of their own places, but the architects was well. As one survivor concluded: “I really feel good. I’m very happy with my life. I’ve designed it so it works for me.” 6
Constructing a New Relationship with the Self Participants emphasized that healing involves not just feeling differently about oneself, but actually treating oneself differently. Constructing a new residence, or place in their world, therefore, included a process of building a new relationship with themselves. The new relationship typically involved no longer treating themselves with criticism and neglect, but rather, with acceptance and caring. Attributing responsibility for the abuse to the offender (or to the family or society), rather than to oneself, was considered by participants to be an important part of healing. They could then stop criticizing themselves and begin to nurture and protect themselves instead. They spoke of taking care of their health, attending to their appearance, providing for their pleasure and happiness, developing a sense of humor, and being able to protect themselves and ensure their safety. The ability and the desire to provide self-care is exemplified in the following vignette: “Before I go to bed at night maybe I’ll fall into bed and I’ll think - ‘Well, wait, you forgot to brush your teeth and wash your face. Get up and do it.’ Whereas before I’d lay in bed and say ‘Well, so what? You’ll get a cavity; so maybe your face will break out tomorrow.” Regulating Boundaries Another function of a residence is to provide a structure that separates the inhabitants from the environment while allowing them to control access to their private lives. Residences have walls, doors, locks and fences that allow others in, keep them out, or regulate their physical distance from the inhabitants of the residence. A central task of all the survivors in this study seemed to be regulating their relationships with others. They discussed bringing others into or excluding them from their lives, redefining or regulating the parameters of their interactions with others, and actively monitoring the progress of their relationships. Constructing walls, or limiting access to oneself, was a primary task discussed by many of the survivors. Most of them described breaking off contact, at least initially, with the offender or family of origin during the healing process. This was especially necessary if their families continued to engage in behaviors such as blaming and denial that were deleterious to the survivors’ healing. The participants also discussed constructing “doors.” In many instances they did allow the significant others back into their lives, but often only on the survivors’terms. These terms were, for the most part, specific and definite. For example, one survivor re-established contact with her mother under the following conditions: “[I] do things that are going to benefit me, like this thing with my mom now. I am making another attempt at it, but if it becomes hurtful and destructive, I’m not going to be in the relationship anymore.” In designing boundaries, the process of allowing entrance to the survivors’ worlds seemed as important as did initiating exclusion. New ways of involving others in their lives, which they described as “opening doors,” included learning to reach out to others directly, decreasing isolation by making themselves more available to social contacts, allowing others to care about them, and asking for help. IMAGE: Journal of Nursing Scholarship
The Healing Process of Female Adult Incest Survivors: Constructing a Personal Residence
The survivors also described an active process of redefining their relationships with others outside the family of origin. This involved reevaluating their present significant relationships, ending destructive relationships, coming to appreciate female relationships, making new friends or creating a surrogate family. One survivor, a teacher, stated: “And it [her work] helps me get through the situation . . . not having my family; my kids [pupils] were like family .
. . . They were my
family for a long time.”
Many participants allowed others into their world through the process of disclosing the abuse experience. Having others know of the experience was, for some survivors, a prerequisite to closeness. For the most part, the participants described positive, or supportive, responses to their initial disclosures. If, however, the response to the disclosure, or to the healing process more generally, was perceived by the survivor to be negative, or nonsupportive, the other was then typically excluded from the life of the survivor. Non-supportive responses were described as curiosity or inquisitiveness rather than concern, pressure to heal quickly, disparagement of counseling, pressure to forgive the offender, advice, anger and blaming the survivor for causing pain by “bringing it up,” and failing to acknowledge the significance of the abuse. Responses by therapists that indicated shock were perceived as particularly destructive. Many survivors specified that those who could get closest to them were those who had experienced abuse and therefore could truly understand their experiences. Part of constructing the new residence was recognizing and appreciating that there was a place in the residence where entry was determined by shared experience. As one survivor stated: “There’s a place, I think, in everyone that’s been abused where we go that no one else can go, and I think you need to understand that.”
In many instances, monitoring relationships involved not just exclusion/inclusion or closeness/distance issues but rather a redefinition of the “rules.” Often, survivors redefined their relationships in such a way that they became more active, assertive participants. They discussed setting limits on the behaviors of others and expressing their feelings, especially anger, openly and directly to others. Just as one typically feels more in control when in one’s own home, these individuals reported being more in control of their relationships. The importance of monitoring relationships with others and controlling access to the self is strikingly exemplified by an incident told by one survivor. Before she was married she had a power of attorney for health care drawn that stated if something happened to disable her, her fiance’s mother would be granted custody of her. She explained: “She would determine if the plug was pulled or not, not my brothers or sisters . . . because I would not trust them to not abuse me and I would be a helpless vegetable who really couldn’t do anything about it, and I wouldn’t do that.”
Influencing One’s Community
For many of the survivors, building their “residence” involved not only structuring a new relationship with themselves and others, but also structuring a new relationship with Volume 24, Number 1, Spring 1992
their community. An essential part of the healing process for many of the participants involved recognizing that they could have a positive impact on their world. One way survivors described influencing their “community” was by personally reaching out to other survivors of abuse. Many expressed wanting to share their healing by “passing it [the healing] on” and “pulling others [survivors] along.” The participants described sharing their abuse experiences with others, treating others with compassion and understanding, and providing guidance. Several survivors sought to have an impact by being an advocate for children and other victims of abuse by becoming involved in activities or programs aimed at abuse prevention. One woman discussed conducting incest awareness seminars and another discussed belonging to a rape prevention task force. One survivor discussed choosing to teach in an inner-city school because she was aware of what it was like to be poor, hungry and scared. Having an impact on one’s community thus seemed to be an important step in building one’s personal residence.
Conclusions and Implications Many of the elements of the theoretical framework are consistent with descriptions of the healing process of survivors discussed in the literature. With respect to the victimization theories, for example, the framework addresses the process of attribution (Peterson & Seligman, 1983) and elements of Taylor’s (1983) three tasks, e.g., finding meaning by helping others, gaining mastery in relationships. Similarly, the framework includes several processes that have been discussed in the clinical literature including acknowledging and accepting the reality of the abuse (Courtois, 1988); validating memories (Herman & Schatzow, 1987); and attributing responsibility for the abuse to the offender (Courtois, 1988; Faria & Belohlavek, 1984; Forward & Buck, 1978; Gordy, 1983). However, while much of the literature emphasizes internal cognitive processes, the theoretical framework described here focuses more on activities that have an impact on the environment or on the self. The participants described not only feeling good about themselves but actually treating themselves differently. They not only stopped blaming themselves for the abuse, they also worked to prevent the abuse of others. Although internal cognitive processes and behavioral changes are closely interrelated, the participants of this study perceived actively building a new world for themselves as the most salient aspect of the healing process. Wynne (1987), an incest survivor, wrote a book describing her recovery and healing, That Looks Like a Nice House. Her story supports the metaphorical basis of the theoretical framework of this study. She described a house that looked like a nice house on the outside but that had been badly damaged by an invasion of ants on the inside, resulting in its being abandoned by the child who lived there. It was only when the house allowed a carpenter in and agreed to “major repairs,” including new windows, a new beam, and a new floor, that the ants were eliminated and the child returned. Theoretical frameworksthat are generated from and grounded in the data, while not generalizable in the traditional sense, do offer unique insights into the concerns and needs of others as they I
The Healing Process of Female Adult Incest Survivors: Constructing a Personal Residence
experience a phenomenon, and thus can guide clinicians in planning interventions. For example, the processes involved in constructing a personal residence, as described by the participants, have potential treatment implications for nurse therapists. These survivors experienced healing as an active, constructive, and complicated process that seemed to be facilitated if the survivor had a significant “bridgk“ or connection to another person, often a therapist. The results of the study suggest that being this “bridge” begins with a supportive response to disclosure. Also, assisting survivors to become more aware of the impact the incest has had on their lives and confronting their tendency to minimize the experience were described as essential therapist tasks. Further, therapeutic interventions aimed at increasing the survivors’ ability to care for themselves might be helpful early in the healing process, so that survivors can nurture and protect themselves while they experience some of the more painful aspects of healing. Nursing interventions may also facilitate the process of regulating boundaries. For example, survivors may need the support of the therapist to gain distance, at least temporarily, from their family of origin while exploring ways to include others in their lives who can support the healing process. After survivors experience progress in their own healing, therapy can be used to explore avenues through which they might then influence their community in a meaningful way. Further development of the theoretical framework derived from this study is indicated. The participants were similar in terms of race, social class and treatment involvement. Additional research should explore how the effects of these variables, as well
I.
Deciding to “build” rather than “ ‘ r e d 1 A. A feeling that something is ‘hot right” B. Connecting present distress with the abuse C. Ceasing to minimize the impact of the abuse LI. Constructing the residence A. Constructing a new relationship with the self I . Abdicating responsibility for the abuse 2. Self-acceptance 3. Providing a structure within which to provide for
one’s self-care and safety. B. Regulating boundaries 1. Limiting access to oneself (“building walls”) 2. Allowing entrance of supportive others into one’s world (“building doors”) 3. Redefining interpersod relationships 4.Maintaining conml in interpersonal relationships (“building gates”) C. Influencing one’s community (“establishing residency”) 1. Assisting other survivors 2. Involvement in abuse prevention
Agum 1: Constmctlflg a Personal Residsncs: ADeecrlptlve Framework
8
as gender and the characteristics of the abuse situation, e.g., age, duration, and relationship to the offender, might influence the process of constructing a personal residence. Adult incest survivors constitute a relatively large portion of women who seek therapy and their clinical needs are unique and complex. The theoretical framework described provides a beginning understanding of the healing experiences of survivors and some insights into possible nursing interventions for this special client population. @Q
References Briere, J. & Zaidi, L. Y. (1989). Sexual abuse histories and sequelae in female psychiatric emergency room patients. AmericanJournal of Psychiatry, 146, 1602- 1606. Courtois, C. A. (1988). Healing the incest wound. New York W. W. Norton & Company. Draucker, C. B. (1989).The cognitive adaptation of female incest survivors. Journal of Clinical and Consulting Psychology, 57,668-670. Edwards, P. W., & Donaldson, M. A. (1989). Assessment of symptoms in adult survivors of incest: A factor analytic study of the responses to Childhood Incest Questionnaire. Child Ahuse and Neglect, 13,101-110. Faria, G., & Belohlavek, N. (1984). Treating female adult survivors of incest. Social Casework, 65,465-47 1. Finkelhor,D.,Hotaling,G. T.,Lewis,I.A., & Smith, C. (1989).Sexualabuseand its relationshipto later sexual satisfaction, marital status, religion and attitudes. Journal of Interpersonal Violence, 4,379-399. Forward, S., & Buck, C. (1978). Betrayal of innocence: Incest and its devastation. Los Angeles: J. P. Archer. Glaser, B. G. (1978). Theoretical sensitivity: Advances in the methodology of grounded theory. Mill Valley, Ca: The Sociology Press. Glaser, B. G., & Straws, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research. Chicago: Aldine. Gold, E. R. (1986). Long-term effects of sexual victimization in childhood: An attributional approach. Journal of Consulting and Clinical Psychology, 4, 47 1-475. Goodman, B., & Nowak-Scibelli, D. (1985).Group treatment for women incestuously abused as children. InternationalJournal of Group Psychotherapy, 34,531-544. Gordy, P. L. (1983). Group work that supports adult victims of childhood incest. Social Casework, 64,300-307. Harter S., Alexander, P. C., & Neimeyer, R. A. (1988). Long-term effects of incestuous child abuse in college women: Social adjustment, social cognition, and family characteristics.Journal of Consulting and Clinical Psychology, 56,5-8. Herman, J., Russell, D., & Trocki, K. (1986). Long-term effects of incestuous abuse in childhood. American Journal of Psychiatry, 143,1293-1296. Herman,J. L., & Schatzow, E. (1987).Recovery and verification of memories of childhood sexual trauma. Psychoanalytic Psychology, 4,l-14. Jacobson, A. (1989). Physical and sexual assault histories among psychiatric outpatients. American Journal of Psychiatry, 146,755-758. Lincoln, Y. S., & Guba, E. G. (1985). Naturalisticinquiry. Newbury Park Sage. Marten, L. M. (1985). Gender-specific reactions to incest (Doctoral dissertation, North Texas State University). Dissertations Abstracts International, 46, 1671-B. Peterson, C., & Seligman, M. E. P. (1983). Learned helplessness and victimization. Journal of Social Issues, 39, 103-116. Russell, D. (1986).The secret trauma: Incest in the lives of girls and women. New York Basic Books. Silver, R. L., Boon, C., & Stones, M. H. (1983). Searching for meaning in misfortune: Making sense of incest. Journal of Social Issues, 39(2), 81-101. Taylor, S. E. (1983). Adjustment to threatening events: A theory of cognitive adaptation. American Psychologist, 38,1161-1 173. Wynne, C. W. (1987). That looks like a nice house. Walnut Creek, C A Launch Press. IMAGE:Journal of Nursing Scholarship
