Treatment Rationale

When families seek help for problems related to sexual abuse, do not overlook the needs of the nonoffending parent, usually the mother. These women typically require multiple treatment approaches that may include family therapy, mothers’ group therapy, couples therapy, and individual therapy. Because mothers of incest victims rarely seek treatment for themselves, do everything possible to ensure that they receive assistance. Those who do receive therapy may be pressured by family members to withdraw from treatment. Therefore, support for these mothers must be consistent and focused on helping them with everyday challenges that could overwhelm someone unskilled in problem-solving.

According to Sgroi and Dana (1984), an effective treatment approach for mothers of incest victims must include individual therapy even if they are already in family or group treatment. Also, if you decide to use other treatment approaches, such as a victims’ mothers’ group, introduce this activity early as part of the overall treatment. Otherwise, the mother may resist the other treatment approaches. 

The behavior patterns of the mothers should help you determine appropriate treatment approaches. These patterns are often consistent with two types of husband-wife interaction described by Groth (1982) —dominant husband or dependent husband.

Dominant Husband

In relationships where the husband plays a dominant role, the wives often have low self-esteem and limited social skills. They are often very dependent and unable to break out of the passive role they have adopted in the family. This extreme dependency may be accompanied by an unrealistic fear of’ the threats and demands of the world. This fear reinforces their tendency to remain isolated and to rarely venture outside the dysfunctional family circle.

Mothers of incest victims who are married to dominant husbands commonly complain that “he makes me feel more like a child than a wife.” Husbands tend to be very critical, referring to their wives as stupid, ridiculous, or silly. While being contemptuous of their wives’ lack of independence and assertive behavior, these dominant husbands aggressively relegate their spouses to subservient positions.

Dependent Husband

According to Sgroi and Dana (1984), wives of dependent husbands may choose to turn away from the dissatisfying marriage relationship and seek fulfillment through occupational or social pursuits outside the home. These women typically complain that “he wants me to be his mother.” In spite of this complaint, they still accept their spouses’ dependent, juvenile behavior and actually foster it by their own caretaking or controlling behavior. The husbands, in turn, describe their wives as cold, unforgiving, and heartless. 

Treatment Suggestions

When treating the mother of a victim, first make sure that basic needs are being met. These include security for the mother, the victim, and other family members; food; clothing; and shelter. The discovery of incest often threatens the family with loss of economic stability. A restraining order against the offender, protective custody for the children, and welfare assistance for all family members may be necessary. Also obtain a thorough assessment of the client’s physical, mental, emotional, and social health. Psychological testing may be required. Refer the client for a medical or psychiatric evaluation if necessary. 

Sgroi and Dana (1984) have identified several issues that should be addressed in treatment of mothers of incest victims. These include the following:

1. Inability to trust

2. Impaired sell-image 3. Depression

4. Denial

5. Unreasonable expectations of husband and children

6. Failure to establish and enforce limits

7. Anger

8. Need for environmental intervention

Inability to Trust 

Many mothers of incest victims were abused as children. Because they did not receive necessary emotional and psychological nurturance during childhood, they carry a feeling of betrayal into their marriages. If their husband abuses a daughter, the cycle of betrayal is completed. This feeling of betrayal affects other relationships, which are weakened by suspicion, hostility, frequent withdrawal, and ambivalence. 

One of the most important things you must do in therapy is help the client learn to trust. Be warm, genuinely friendly, respectful, and absolutely consistent. Clients will tend to test you. They may vacillate between wanting to be taken care of and refusing any help at all. You must be able to set limits, while sometimes being supportive and sometimes withholding support. 

Because you may be one of the few people whom your client trusts, the relationship you have with her can become the basis for helping her develop trust in others. Your relationship with her can help you understand her basic attitudes and ways of relating to people. Use the thoughts and feelings you observe in this relationship to help the client understand how she can establish better relationships with others

Impaired Self-image

The client may have low self-esteem and a poor sell-image that will need to be addressed in treatment. Mothers of victims suffer emotionally and often have physical complaints as well. It is important to remember that clients will not necessarily present themselves as having a poor self-image. Many women who appear attractive, well-dressed, and confident may still be suffering from an impaired sell-image.

When dealing with this issue, consider the following:

• History. Many of these women have a history of abuse. They may feel ugly, worthless, or unattractive. They may fall prey to sell-fulfilling prophecies, believing in the image of themselves that resulted from abuse and treating themselves accordingly.

• Body awareness. Mothers of incest victims may have limited body awareness. This limited awareness is related to a negative self-image and denial of their sexual identity. They may withhold affection from family members and avoid sexual relations with their husbands. Consciously or unconsciously, some mothers increase the risk that their daughters will be required to fill the marital, sexual role that they have vacated.

• Failure. Failure is a common characteristic of people with low sell-esteem and poor sell-image. Many mothers of incest victims find little opportunity for success, particularly in the home. Many of their achievements are met with indifference or hostility. Consequently, they have little incentive to perform well. Failure becomes their standard, ensuring failure in the future. 

Depression

The mother may feel severely depressed during the disclosure crisis. If she exhibits symptoms of depression, conduct a thorough depression assess­ment. Assess her precise level of functioning functioning and compare it with her mood and behavior during the crisis. If she has a history of depression preceding the incest disclosure, you may need to treat the anger and hurt she feels because she was abused as a child and her current feeling of being betrayed by her husband.

Depression generates feelings of helplessness and hopelessness. Identifying realistic tasks, developing plans, and creating a support system will give the client a sense of control over what was previously an uncontrollable situation. She may also need to consult a psychiatrist to obtain medication for depression.

Denial

Do not assume that women are aware of their husband’s child abuse. However, some mothers are conscious of the incestuous relationship to a greater or lesser degree but deny the problem when it is initially disclosed. This denial is related to their fundamental denial of feelings in an attempt to desensitize themselves to what is happening. The inability to face sexual abuse ranges from making empty promises such as “never letting Daddy be alone with you again,” to ignoring personal observations or concrete evidence. Many mothers submerge conscious awareness of the incestuous relationship.

To treat this denial of feelings, encourage the mother to talk about the reality of the sexual abuse to you, her stake president, her bishop, a close relative, or another trusted listener. It is extremely important that the client learn to face the reality of the abuse. Once she can do this, you can help her to express her feelings about the incest to the victim. She should ask the victim’s forgiveness if she knew or should have known about the abuse and failed to protect the child. 

A mother’s denial of incest is often part of a more pervasive and dysfunctional coping mechanism. The practice of avoiding psychological and emotional difficulties by denial must be uncovered and replaced with more positive methods of coping. 

Unreasonable Expectations of Husband and Children

Mothers of incest victims may have had unreasonable expectations of their husbands before the sexual abuse. Many of these women enter marriage assuming that their husbands will be able to compensate for the dysfunctional family in which they were raised. They may share with you their fantasies of the ideal marriage, their unrealistic expectations of married life, and descriptions of the nurturance and security they expected their husbands to provide.

Many mothers of incest victims are unable to recognize their own contributions to a problem marriage. They project their failings onto their spouses, blaming them for marital and familial difficulties. The disclosure of incest reinforces the mother’s allegations that the husband is entirely to blame.

Unrealistic expectations the mothers have for their children are equally problematic. Role reversal may be common. These expectations may be part of an intergenerational pattern extending back to the client’s mother.

Helping the client to develop reasonable expectations depends almost entirely upon increasing her self-esteem. She must substitute functional and appropriate methods of gratifying basic needs for dysfunctional behavior patterns. This substitution will require internal strength. She must take responsibility for her own behavior and adjust her expectations of others. It is useless to instruct a mother to stop demanding nurturance from her children when she is not strong enough to identify more legitimate ways of meeting her needs. Mothers’ groups may reinforce the concept that adults should not look to children to gratify needs. A group can also help the client develop greater emotional strength.

Failure to Establish and Enforce Limits

Establishing and enforcing role boundaries within the family are important parenting tasks. A woman is not responsible for the incestuous behavior of her husband. However, it is critical to help the client acknowledge her part in blurring the lines between family roles that may have contributed to the possibility for abuse. This is often extremely difficult. It is far easier for mothers of incest victims to see themselves as victims also. Blaming the husband for all problems relating to the abuse allows the mother to abdicate her own responsibility for the family’s problems.

The treatment for this issue is to help the client develop self-esteem and autonomy. When she is able to accept responsibility for her own behavior, she will have an increased sense of empowerment and sell-control. Even when mothers can verbally acknowledge their roles in allowing an environment in which abuse can take place, they tend to intellectualize the issue with little emotional investment. Group feedback may be more effective than individual therapy in helping with this issue because clients feel more accountable to one another.

Therapists are sometimes overly kind and supportive, protecting clients from dealing with their own pain. Pain is an agent for change. Allow the mother to experience appropriate pain as she comes to understand her responsibility in making the abuse possible. Help her see the relationship between incest, collusion, and pain. However, if she was clearly not aware of the abuse or collusion, do not hold her responsible for something beyond her control.

Anger

Mothers of incest victims are generally angry. This anger may begin in childhood as the result of abuse and the absence of emotional and psychological nurturance. It may be exacerbated by a dissatisfying and even abusive marriage. The incest itself fuels the anger. The mother may even feel anger toward those who are trying to help her, as doctors, mental health professionals, and law enforcement personnel separate the family and disrupt her life.

Mothers may be angry at their children for participating in the incestuous relationship. They may feel rivalry, competition, and jealousy. Finally, mothers of victims are profoundly angry at themselves. Their anger is caused by feelings of frustration, betrayal, inadequacy, dissatisfaction, and impotence.

Help the client identify and understand the feelings that contribute to her anger, such as helplessness, betrayal, guilt, and inadequacy. As she allows herself to experience and express these feelings, she will better understand her anger and be able to control it. Anger appears to be an inevitable part of a mother’s initial reaction to the discovery of her child’s abuse; however, chronic, unresolved anger can be damaging. It prevents the person from freeing herself emotionally and mentally from the abuse and the abuser. She remains stuck in the past and unable to live her life fully in the present. For some, holding on to angry feelings and dwelling on past abuse becomes a defense against coping with challenges in the present. Work with the client on letting go of the anger. Prayer and spiritual counsel from her bishop, bibliotherapy (for example, Borysenko, 1990; Bradshaw, 1988, 19901. recording her feelings in a journal, and empty chair work can be helpful. 

You may need to help the client develop self-esteem and reduce her feelings of guilt and shame before dealing with the sensitive issue of her anger

Need for Environmental Intervention

Treating a client’s emotional dysfunction may be difficult when she is beset in her home by a multitude of problems clamoring for attention. The offending husband may no longer be in the home, and the mother may be required for the first time to act as the bead of the household. Responsibility for finances, child rearing, and restoring a disrupted family may rest solely upon her shoulders. Crisis intervention is critical at this point. According to Jed Ericksen, Crisis Coordinator at the University of Utah, it is imperative to help the individual in crisis do the following, 

• Gain a cognitive understanding of her problems. 

• Define, explain, and understand the external stressors affecting her. 

• Make constructive environmental changes. 

• Change internal forces that contribute to the crisis at hand.

Finally, it is important to help the client accept what she cannot change.

Additional Treatment Suggestions

Help the client resolve marital problems. Nonoffending spouses occasionally find that they must separate from the offender to protect the child, stabilize the family, and stop the sexual enmeshment process. Though LDS Social Services practitioners do not counsel couples to divorce, you should help them look realistically at problems and determine what is in the best interest of the nonoffending parent and the children. Work closely with the referring ecclesiastical leader as you help the couple evaluate and resolve relationship problems. 

When appropriate, see that clients receive help for problems with sexual functioning. The majority of nonoffending spouses have sexual problems, some of which may need to be treated through therapy or medical intervention. Sexual myths often reinforce sexual dysfunction. Clients need to be referred to therapists who are qualified to treat such problems.

TREATING THE PERPETRATOR

When you have completed part 710, you should be able to do the following:

Client Selection

Contrary to the beliefs of some therapists, many perpetrators respond favorably to therapy. For example, among families enrolled over a ten-year period in the Child Sexual Abuse Treatment Program of Santa Clara County, California, 90 percent of the children were reunited with their parents. Most cases involved father-daughter incest. The recidivism rate in families who completed treatment was less than 1. percent (Giarretto, 1982). Practitioners in the Salt Lake City office of LDS Social Services report that a high percentage of sexual offenders in their treatment program respond favorably to treatment. 

Among adult offenders, egodystonic (regressed) pedophiles are more likely to respond to short-term therapies than are egosyntomc (fixated) pedophiles. Before treatment is provided, distinguish between these two types of offenders. You should also assess the person’s motivation for seeking help (see part 5). 

Adolescent or preadolescent perpetrators may also respond to the short-term help you can provide Unless they are deeply entrenched in abusive behavior. Nearly half of sexual offenders become perpetrators during their teenage years. Most adolescent offenders fall into two types. The undersocialized-nonaggressive offender has low self-esteem and no friends and uses little or no force in the abuse. The socialized-aggressive offender is brighter, has an active social life, engages in antisocial behavior, is involved in drugs, and uses force or violence in the abuse. There is little evidence to suggest that one type is any easier to treat than the other. As with adults, however, accept individuals for treatment only after legal requirements have been met and after careful screening.

Treatment Rationale

The treatment of both extrafamilial and intrafarmlial sexual offenders often centers on moving them from denial, minimization, and rationalization to empathy and acceptance of responsibility for their behavior.

When first confronted with abuse, perpetrators often deny all allegations. Though most eventually relinquish this total denial during treatment, they may still deny certain aspects of the abuse. For example, they may refuse to say whether intercourse took place. At times an offender’s denial will be so adamant and seem so sincere that those working with him may be manipulated into believing him. Remember, a child seldom lies about being sexually abused. If anything, children minimize what took place. They realize very quickly that discovery leads to confusion and pain, not only for the offender, but for the victim and her family. That is why many children later recant abuse accusations.

Unfortunately, the nonoffending spouse and other family members often unwittingly encourage the victim to recant or even openly suggest that she do so.

In treating intrafamilial abuse, the ideal is for the offender, the nonoffending spouse, and the victim to each have his or her own therapist to act as an advocate. Therapy disrupts existing coping mechanisms in the family. The offender and his family may consciously or unconsciously try to subvert therapy and return family functioning to established, albeit disruptive and abusive, patterns of behavior.

Dyad treatment involving the victim and other family members is also important. For example, when the abusive father has acknowledged the abuse, it may be valuable to have him meet with each family member and openly take responsibility for the offense and the disruption in their lives. This is particularly important for the victim. In these meetings, be should state what he did to the victim in sufficient detail that everyone clearly understands that his sexual actions were inappropriate and that he was solely responsible for the abuse. Typically, you should role-play the dyad interactions with the perpetrator in advance to make sure that he will actually take responsibility for the abuse and not minimize or deny the effects of his behavior. 

Madanes (1990) advocates having the perpetrator demonstrate sorrow and repentance for what he did in such a way that it is apparent to everyone in the room that he is sincere and truly penitent. Madanes also suggests having other family members demonstrate sorrow to the victim for not having protected her. She believes these steps help free the victim from feeling accused and needing to be punished. They may also help relieve her of victim status. Therapy should not only assist the perpetrator to develop strengths and avoid future abuse, but it should also empower each family member to resist inappropriate involvement of any kind. 

Treatment Suggestions

Issues to be considered in treating sexual offenders include the following:

• Confrontation

• Insight

• Family issues

• Sexual information

• The perpetrative environment

• Punishment

• Family separation 

A discussion of each of these issues follows

Confrontation

When working with sexual offenders, be caring and sensitive but confrontive. Sexual offenders must be confronted with what they have done. Try to create a moment of truth for the client that enables him to assume responsibility for changing his feelings, thoughts, or behavior that he has so far failed to recognize or has denied, ignored, or evaded. To effectively confront the client, do the following:

• Express your concern.

• Describe the client’s purported goal, belief, or commitment.

• Describe the behavior (or absence of behavior) that is inconsistent with the goal, belief, or commitment.

• Describe the probable negative consequences of the discrepant behavior.

The confrontation may follow this format:

“I’m concerned because you... (want, believe, are striving to—describe desired outcome), but your. . . (describe discrepant action, behavior, or lack of action) is likely to produce... (describe probable negative consequence).” Example: “I feel concerned about what you’re telling me. You’ve said that you love your daughter and don’t want to hurt her, but you keep going into her bedroom at night to molest her. That doesn’t make sense. Somehow you seem to think it’s all right for you to do that, even though you hated it when it happened to you as a child. I think you are kidding yourself and that your daughter is emotionally hurt just like every other child who is sexually abused.”

Actively confront rationalizations, denials, blaming, and methods used to control family members. Group therapy is often helpful in confronting incongruent behavior because group members recognize manipulative behavior and help to confront offenders. 

Offenders typically continue to minimize the extent of their abuse, often in very subtle ways. For example, the perpetrator may report that his drinking led to sexual abuse. Since he has given up drinking, however, he knows he will never be involved in incest again. You might confront such a statement by saying: “I think it’s good that you aren’t drinking anymore. But many people drink, and most do not sexually abuse their children.

What is unique about your situation that made you choose to molest your own daughter?” (The use of the word choose is important. Because many offenders see themselves as victims who do not have control over their lives, part of the task of therapy is to point out that they do have control.) The perpetrator wants to abdicate responsibility for his behavior, thereby reducing his feelings of guilt and pain. 

Elicit from the client a clear description of his abusive acts. Offenders tend to avoid disclosing painful details to therapists. Ask clear and concise questions. At times you will need to maintain that

you do not know everything about the abuse. If the client thinks that you know everything already, he may not divulge important facts about the abuse. This information typically comes in segments and continues to be discovered throughout the treatment process. 

Perpetrators also try to minimize and rationalize their sexual misconduct with statements such as, “I didn’t think it would hurt her,” or “The drugs made it so I wasn’t thinking straight.” A useful technique in countering these statements is to have the perpetrator factually describe the abuse as a third party, not allowing for commentary on feelings or reasons for his actions. Some perpetrators do not realize the gravity of their offenses until they have described them in this way.

Examine the perpetrator’s fantasies during sexual involvement with his spouse and with the victim. The sexual abuse is usually the offender’s maladaptive attempt to achieve emotional intimacy. Though the offender usually lacks this insight, an examination of his fantasies during sexual involvement often brings it to light. Fantasies often involve being loved and cared for. Without such insight, the offender may continue to believe that orgasm through sexual abuse will somehow bring personal fulfillment and familial bliss. As you help the perpetrator realize that this is not true, be often begins to understand that factors other than sexual gratification are important to his fulfillment. It is also important to help the perpetrator come to understand the difference between exploitive and appropriate sexual expression.

Insight

Help the perpetrator understand the meaning of his behavior. Explore the motivations underlying his actions and any primary needs that remain unmet. Help him learn appropriate strategies for meeting his needs. In many instances abuse is motivated only by the desire for pleasure, and the perpetrator perceives the victim as an object rather than a person. However, he may not perceive the victim as an object outside of the context of the sexual act. It may be important to help him determine whether he feels love for the victim outside of the abusive behavior. If he does, help him to see the victim as a person and understand how hurtful the abuse is.

Explore whether the perpetrator was previously abused. Many perpetrators were victims of sexual maltreatment as children. Identify any similarities between the abuse they suffered as children and their adult perpetrative behavior. Help them recall their feelings as victims, and use these recollections, as needed, during the treatment process. For example: “You have already told me how it made you feel to be abused. What similar feelings does your child have toward you?” 

Family Issues

Identify and treat family issues that influence the client’s current functioning. These may include authoritarianism, sexual myths, dysfunctional roles, losses, intergenerational enmeshment, and chaos. Perpetrators are often unsuccessful in therapy until family issues are resolved. 

Sexual Information

Teach the client about healthy sexual behavior. For example, clients need to know that sexuality is more than genital contact. It also includes hugging, touching, and so forth. Perpetrators believe and act on many sexual myths, such as the belief that the victim of the opposite sex has the sexual desires.

You can help to dispel sexual myths by doing the following:

• Educating the perpetrator about normal male and female anatomy and sexual functioning.

• Assigning the perpetrator to keep a daily log of irrational thoughts, feelings, and behaviors that reinforce sexual offenses. Help him to divulge the fantasies that fuel sexually abusive behavior. Disclosed fantasies can be examined. Then they are no longer personal, private images that the offender harbors in secret. When they are shared, they are less potent. You can use the log to help the client explore the inaccuracies of his pathological beliefs. 

The Perpetrative Environment

Identify aspects of the perpetrative environment that facilitate or impede the abuse. You can obtain this information by asking questions such as, “What takes place between you and the victim before, during, and after the abuse? Explain who is at home, where you are in the home, and what activities you are involved in that lead up to the abuse.” After thoroughly exploring these questions, move to similar questions about circumstances that make it unlikely for abuse to occur.

Through this process, you can help the perpetrator become cognitively aware of environmental factors affecting the abuse. You also receive information that will enable you to help restructure the family environment to prevent future abuse. For example, one woman sexually abused her son only when her husband was out of town and she was suffering from the luteal phase of premenstrual syndrome. This woman would reject her daughters and seek comfort from the third child, a son. Confiding in him eventually led to sexual fondling and arousal. Once this information surfaced, intervention included treating the mother for premenstrual syndrome, rescheduling her husband’s business trips so that he was home during the luteal phase, and helping the son find evening employment.

Punishment

Help the perpetrator see the therapeutic value of punishment through the legal system. Perpetrators tend to blame the consequences of abuse on the system, including law enforcement officials, social workers, and so forth. Your task is to help perpe­trators take frill responsibility for their actions, including the legal consequences. 

Incestuous families seldom resolve issues of blame, guilt, and responsibility unless the offender is punished. Punishment sends an unmistakable message to family members that the perpetrator is guilty of a crime against society. It also frees them from the distorted belief that the perpetrator is the only source of power and punishment. When punishment occurs, family members are more likely to start viewing the laws of society as beneficial to them personally. 

Family Separation

If the victim needs to be separated from the perpetrator to prevent further abuse, it is preferable for the perpetrator to leave home. Initial work with the perpetrator following the separation should include the following: 

• Have him write a letter to the victim admitting full responsibility for the abuse. Before the letter is sent, review it with the perpetrator, making sure that it wiil be helpful to the victim. Any collusive or manipulative statements should be discussed and deleted. Make sure the victim’s therapist also previews the letter to screen out any inappropriate statements. The letter should be given to the victim by her therapist.

• Find out how the family members react to the perpetrator’s leaving home. Help them overcome their tendency to blame or scapegoat the victim. One way to do this is to have the offender write a letter to each family member admitting full responsibility for the abuse and absolving the victim. You can also use the initial family therapy session to clarify that the offender is responsible.

•  Make sure that the perpetrator’s visits with family members are supervised to prevent further abuse, control, manipulation, and collusion. Visits must be supervised until therapy has progressed suffi­ciently to ensure that further abuse is unlikely. The wishes of the victim must be considered whenever visitation rights of the perpetrator are discussed. Make sure that the victim is not retraumatized because of the perpetrator’s visits to the family.

Use the perpetrator’s feelings of depression to motivate him through the therapy process. Perpetrators typically become depressed after being removed from the home. They may feel guilt, loss, pain, and anxiety. Skillful therapeutic use of the depression can help the perpetrator want to change.

• Help the perpetrator accept the changes that occur within the family structure once the abuse is stopped and members receive therapy. With therapy and the absence of the perpetrator, families typically change and become more functional, moving away from the perpetrator’s control. in some instances the nonoffending spouse chooses divorce. In many cases, the perpetrator must be helped to accept the loss of at least one member of the family because she wants nothing further to do with him.

•  Involve the perpetrator in group therapy with other offenders, if possible. As previously mentioned, group therapy is effective in identifying and confronting denial, distorted thinking, and rationalization about the perpetrative process. 

Involve the perpetrator in dyadic treatment with other family members (see part 11) and, when appropriate, in family therapy (see part 12). 

Help the offender to apply what he has learned in therapy to his work, his social life, and his religious life. Identify work-related experiences and influences that reinforce perpetrative thoughts and behavior. These might include exposure to pornography and the potentially provocative behavior of others.

Spiritual Direction

As perpetrators forsake wrongdoing and turn to the Lord with full purpose of heart, they can experience the mighty change of heart promised in scripture (see Mosiah 5:2). Thus changed, they will have “no more disposition to do evil, but to do good continually.” Experiencing this change is not easy, however. The perpetrator must fully commit to living gospel principles. Moroni has given this promise: 

“Yea, come unto Christ, and be perfected in him, and deny yourselves of all ungodliness; and if ye shall deny yourselves of all ungodliness, and love God with all your might, mind and strength, then is his grace sufficient for you, that by his grace ye may be perfect in Christ; and if by the grace of God ye are perfect in Christ, ye can in nowise deny the power of God.

 “And again, if ye by the grace of God are perfect in Christ, and deny not his power, then are ye sanctified in Christ by the grace of God, through the shedding of the blood of Christ, which is in the covenant of the Father unto the remission of your sins, that ye become holy, without spot” (Moroni 10:32—33). 

You can help perpetrators examine their spiritual feelings. Working with the bishop or other resource persons, you can help offenders make their behavior congruent with their spiritual values. The desire to live a Christlike life can be a powerful incentive to make needed behavioral changes. As perpetrators, victims, and others who are burdened with serious problems turn to the Lord with full purpose of heart, they can receive the powers of heaven to assist them through the process of change.

TREATMENT IN DYADS

When you have completed part 11, you should be able to do the following:

Types of Dyads

Because sexual abuse takes place in dyads, dyadic treatment is usually effective in helping to resolve it. Dyads include any two family members — perpetrator-spouse, perpetrator-victim, nonoffending spouse-victim, sibling-victim, or sibling-sibling. The purpose of dyadic treatment is to replace learned, dysfunctional, abusive relationships between family members with functional relationships involving new rules, boundaries, and communication processes. As you work with dyads, review and apply the therapy suggestions in parts 8, 9,10, and 12.

Victim Dyads

Listed below are suggestions for treating the victim in combination with the perpetrator, nonoffending spouse, individual siblings, and other victims in the family.

Help the victim explain her perspective on the abuse. Other family members must clearly understand her pain, fear, confusion, chaos, and enmeshment. As mentioned previously, most perpetrators rationalize that the child wants and likes the abusive behavior. Nonoffending spouses often believe that the child invited the abuse.

Dyadic treatment is particularly effective in dispelling such mistaken beliefs.

•  Help the victim identify her anger and resolve it with the appropriate family members. Help the victim understand that she is responsible for her feelings of anger. She must resolve them and not blame them on others.

•  Help the victim understand that she was the victim of, rather than the cause of, problems that exist between the parents. The parents can share this information with the victim.

• Incestuous, enmeshed families often do not allow differences. Through dyadic treatment, encourage the victim and other family members to recognize and accept differences, freely express themselves, and resolve problems without the typical restraints imposed by incestuous parents.

• Help the victim understand that the perpetrator is responsible for the abuse. Counteract the tendency of family members to blame the victim or rescue the perpetrator. Where family members have colluded to perpetrate the abuse, help them understand the roles they played in the collusion.

• Help the victim begin to resolve her relationship with the perpetrator. For example, the victim may decide she no longer wants to live with the perpetrator. Help the victim and other family members make rational choices. Help family members accept each other’s choices.

•  Observe how the victim and the nonoffending parent interact with each other. Teach appropriate parenting skills. Use role playing and coaching to help the parent and child learn better ways to treat each other. 

Spouse Dyads

In dyadic treatment sessions between husband and wife, you can deal with issues that emerged in individual therapy. Such issues might include the following:

• The wife’s abdication of her sexual role in marriage.

• The husband’s inability to express love.

• Sexual dysfunction.

• The nonoffending spouse’s tendency to blame herself for the abuse.

• Sexual myths that reinforce abusive behavior. The couple’s attitude toward the victim.

• The perpetrator’s tendency to control the spouse and all family members through collusion.

• Anger about the abuse.

• Religious issues, such as disciplinary councils, loss of membership, or social isolation.

• Environmental factors that reinforce the abuse.

• The decision to separate or divorce. Provide traditional marital therapy using approaches such as those suggested in the module An Approach to Treating Marital Problems (1981). In cooperation with ecclesiastical leaders, assess the couple’s spiritual values and commitment to their marital relationship. If an eternal marriage is important to them, help them analyze what they must do to achieve it. President Joseph Fielding Smith said:

“If all mankind would live in strict obedience to the gospel, and in that love which is begotten by the Spirit of the Lord, all marriages would be eternal, divorce would be unknown. .. . A man would not get tired of his wife, if he had the love of God in his heart. A woman would not get tired of her husband, if she had in her heart the love of God, that first of all commandments. They could not do itt” (Doctrines of Salvation, comp. Bruce R. McConkie, 3 vols. (Salt Lake City: Bookcraft, 1954—56], 2:80—81).

Help the couple examine the feelings and behaviors that keep them from being fully committed to their marriage relationship and from feeling the love of God in their feelings for one another.

Sibling Dyads

During therapy, you may discover that other children in the family are also being abused— physically, sexually, psychologically, verbally, or through neglect. Even when not abused, siblings often feel isolated and ignored. They may be angry at the victim, perpetrator, and nonoffending spouse. They may also blame you for creating the family chaos. Suggestions for working with siblings in dyads include the following:

• Assess each sibling based on the information in the preceding paragraph.

• Explore how the sibling perceived the abuse. Clarify myths and distortions, replacing them with accurate information.

•  Work out new relationships between the sibling and other family members so that he or she feels part of the new family structure and does not collude in reestablishing dysfunctional family patterns. For example, siblings are often rewarded for leaving the victim and perpetrator alone. You should help the sibling make sure this does not happen again. Such treatment may need to occur in triadic relationships including the sibling, the victim, and the perpetrator or nonoffending spouse. The offender may need to tell the sibling how he encouraged the siblings to blame the victim, and how he isolated the victim from siblings by treating her with favoritism. Such actions create resentment toward the victim and discourage family members from wanting to solve problems.

• Obtain insights from sibling-perpetrator dyads to help you establish nonabusive relationships between the perpetrator and all family members. A sibling’s nonabusive relationship with the perpetrator helps you understand the nonabusive ego states of the offender. Help the perpetrator see how to use these nonabusive experiences in his relations with the victim, the spouse, and other family members.

• Be aware of the tendency for siblings to act out their anger, frustration, and jealousy. Help them to resolve such feelings in the appropriate dyadic relationship. 

Perpetrators

Because perpetrators are involved in the dyadic relationships explained above, no specific dyad therapy suggestions are given for the perpetrator. They have already been outlined.

FAMILY THERAPY

When you have completed part 12, you should be able to do the following:

Treatment Rationale

Family therapy is usually the last stage of intervention with incestuous families. The purpose of family therapy is to ensure that family members can function harmoniously without further abusive beliefs or behaviors. Never undertake family therapy while there is danger of further abuse. Before such therapy begins, individual therapeutic relationships should be established with key family members. Then you should assess the family’s contribution to the abuse.

In conducting a family assessment, consider two major issues. When the abuser is outside the family, determine to what degree the family failed to protect the victim. When the abuser is a family member, determine to what degree the family failed to set appropriate limits. Then examine the following areas

Poor Supervision

Poor supervision of children by their parents may have allowed circumstances in which sexual abuse could occur. Determine whether children are allowed to be in unsuitable environments or if they are exposed to inappropriate behavior in the home.

In many cases, parents of abused children perceive that the children are able to care for themselves. They are unable to see that young children are vulnerable when exposed to situations that might encourage abuse.

Poor Choice of Baby-sitters

The perpetrators of child abuse include baby-sitters or other caretakers. Parents must take responsibility for entrusting a child to others. How do the parents choose baby-sitters? Do they establish who can visit the baby-sitter in the home?

Inappropriate Sleeping Arrangements

Sometimes the sleeping arrangements of family members contribute to sexual abuse. Inappropriate arrangements are associated with blurred role boundaries within the family. Does an older sibling sleep with a younger one of the opposite sex? Do children of the opposite sex regularly sleep together, placing them at a higher risk of becoming sexually active with each other?

Other Family Practices

Assess family practices that encourage inappropriate genital exposure, lack of privacy in bathrooms, and open physical intimacy to determine how they have contributed to sexual abuse.

Treatment Suggestions

Family treatment should accomplish the following:

• Resolve issues of control. Teach family members to adopt a nonauthoritarian, decision-making approach that reflects the appropriate roles of the father, mother, and siblings.

• Clarify those factors that made abuse possible and determine what must be done to prevent any further abuse.

• Analyze the family members’ fantasies about the abuse. Sometimes the victim is the only family member who has been sexually abused. Other family members may develop distorted fantasies about the abuse and how it has affected the victim. These fantasies may affect the way they relate to the victim. For example, an eight-year-old child who was molested by a male may be perceived by family members as having experienced all the activities that would entice him into the world of homosexuality. In reality, however, the child may perceive the incident only as “a mean man who hurt me.” Unless family members receive help, they may not allow the victim to resume a normal role within the home. They may unknowingly contribute to continued abuse.

•  Help family members identify and resolve their feelings about any family member who is unwilling or unable to respond to therapy. For example, the perpetrator may choose to reject help and leave the family; the nonoffending spouse may refuse to forgive the perpetrator or may choose to stay in an abusive relationship; a sibling may not be willing to resolve his feelings about the perpetrator or forgive the victim for the disruption caused by the abuse~ or the victim may choose to leave home or to stay in a victim role.

• Deal with the intergenerational aspects of incest.

Therapy disrupts incestuous behavior. Extended family members may attempt to influence the family you are treating to maintain incestuous patterns of behavior. You must help the family take sole responsibility for their own actions, recognize pathological influences from their extended family, and remove themselves from such influences. This is particularly important when extended family members do not want to accept intervention or change.

• Help the family clarify their values regarding discipline, sexuality, morality, education, marriage, and religion. Determine whether these values will help the family function effectively. Determine which values need to be challenged or restructured to prevent further abuse. Establish an environment in which each family member can express opinions about family values.

• Family members often bring their “ghosts” into family therapy. These are people from their past or from outside the immediate family who continue to influence family behavior in a pathological way. For example, one incestuous father resisted changing his methods of discipline because they derived from his culture and family traditions. Family ghosts must be recognized and eliminated.

•  Help the family to communicate openly with one another. Do not let them become secretive or collusive. Use relevant issues from previous treatment sessions as discussion topics for the whole family. If dyadic sessions continue, the issues discussed in them should be discussed and clarified during family therapy sessions. 

Conclusion

Family therapy is most successful when the focus moves from the abuse to relationships, individuality, differences, healthy closeness, and adaptability.

TREATING ADULT VICTIMS OF CHILD SEXUAL ABUSE

When you have completed part 13, you should be able to do the following:

Overview of the Problem

Because of societal taboos, feelings of shame, nonoffending parents who do not accept the claims of abuse, threats of perpetrators, and other factors, many sexually abused children have grown to adulthood without disclosing the abuse. However, as society becomes more open about sexuality, the victims of abuse, particularly women, feel less threatened about discussing sexual assault.

Retrospective reports estimate that 10 to 38 percent of women have been victims of sexual abuse (Salter, 1988). About 17 percent of women report being victims of incest.

The similarities in client symptoms have led many professionals to conclude that adult victims of child sexual abuse form a discrete mental health population. Some of the terms used to describe these women are AMACs (Adults Molested as Children); adult survivors (or victims) of child sexual abuse (Courtois, 1988; Sgroi and Bunk, 1988); adult children of dysfunctional families (Whitfield, 1987); and adult retrospective victims (Agosta and Loring, 1988). All of these terms refer to adults who suffer symptoms resulting from traumatic abuse in childhood. 

Several mental disorders in adults have been shown to be associated with child sexual abuse. Professionals who work with sexual abuse victims often view these patients as suffering from posttraumatic stress disorder (PTSD) (Donaldson, 1983; Patten, et al., 1989). The American Psychiatric Association (1987) includes the following symptoms in its description of PTSD:

• Reexperiencing of the traumatic event in recollections, dreams, flashbacks, and so forth.

•  Avoidance of stimuli associated with the event or numbing of general responsiveness, for example, the person may avoid activities that arouse recollections of the trauma.

•  Increased arousal, shown by such things as difficulty falling asleep, hypervigilance, and an exaggerated startle response.

Reports of these symptoms are very common among survivors of child sexual abuse.

As many as 80 percent of patients diagnosed as having multiple personality disorder were sexually abused as children (Maltz and Holman, 198 7), and 35 percent of borderline patients were victims of incest (Patten, et. al, 1989). Preliminary evidence also suggests that child sexual abuse is associated with prostitution and drug or alcohol abuse (Browne and Finkelhor, 1986). Approximately 60 percent of prostitutes report being sexually abused in childhood. 

It is important to note, however, that no studies have been conducted showing that sexual abuse in childhood causes specific symptoms in adulthood. Though the association exists, all studies to date are retrospective. They reveal only that a certain number of adults suffering various kinds of disorders report having been sexually abused as children (Sgroi and Bunk, 1988). We cannot accurately predict whether a sexually abused child will grow to adulthood with specific mental health problems. 

In therapy, many adult survivors present some or all of the clinical features exhibited by child victims (see part 8). 

Theoretical Assumptions for Treatment

In working 0with adult victims, the therapist’s attitudes and assumptions about child sexual abuse are vitally important to the outcome of treatment. Goodman and Nowak-Scibelli (1985) suggest the following theoretical assumptions as guides to effective therapy with adult survivors: 

Responsibilities of the Adult

Whenever abuse occurs between an adult and child, the adult is always responsible. A child cannot give consent, because consent implies informed knowledge of the meaning, responsibilities, and consequences of the behavior, as well as the ability to say no. Treatment is aimed at helping the adult victim clearly understand that she was not responsible for her abuse. The guilt and shame often felt by adult victims can be dramatically reduced when they are helped to understand and accept this assumption.

Spiritual Assistance

Victims must receive spiritual assistance to free them from guilt based upon the belief that they committed sin through their abuse. Personal visits with ecclesiastical leaders and the following official Church statements can be helpful: 

“Victims of rape or sexual abuse frequently experience serious trauma and unnecessary feelings of guilt. Church officers should handle such cases with sensitivity and concern, reassuring such victims that they, as victims of the evil acts of others, are not guilty of sin, helping them to overcome feelings of guilt and to regain their self-esteem and their confidence in personal relationships.... 

“Young victims of sexual abuse are. . . guilty of no sin where they are too young to be accountable for evaluating the significance of the sexual behavior. Even where acts are committed with the apparent consent of a young person, that consent may be ignored or qualified for purposes of moral responsibility where the aggressor occupied a position of authority or power over the young victim” (First Presidency letter to General Authorities, Regional Representatives, and other priesthood leaders, 7 Feb. 1985; reprinted in Child Abuse: Helps for Ecclesiastical Leaders, p. 3). 

Love-Hate Feelings

Regardless of the duration and extent of the abuse, adult victims continue to have positive and negative feelings (a love-hate relationship) toward both parents. You must understand this and allow a strong sense of loyalty to exist and to be explored during sessions. Otherwise, clients may leave therapy prematurely to protect their families.

Discharge of Feelings by the Victim

Treatment must allow the victim to discharge her anger, outrage, guilt, and humiliation over having been abused. According to Miller (Courtois, 1988, p. 168), “the healing process begins when the once absent, repressed reactions to trauma~ation... can be articulated. . . ; then the symptoms, whose function it had been to express the unconscious trauma in a disguised, alienated language incomprehensible both to the patient and to those around him, disappear.”

The victim must be able to express her negative feelings without feeling that she is betraying family members. You can encourage her by inviting her to express her feelings, by not expressing shock over reports of incestuous acts, and by neither agreeing nor disagreeing with issues that result from her anger. Help her understand that the discharge of anger is often an essential but temporary part of resolving negative emotions.

Avoiding Scapegoating

Treatment must help the victim hold the offender accountable without scapegoating. Help the victim examine the circumstances under which she was abused as a child. The perpetrator chose to abuse her and must never be excused for his actions. However, it will be helpful for the victim to understand that there were probably major life events that contributed to his abusive behavior. Exploring such events accomplishes two objectives:

The adult victim realizes that she was not flawed or evil, nor did she deserve the abuse.

The incest or abuse was the result of problems that the abuser did not handle in an acceptable manner. With this understanding, the adult victim is able to view herself and the perpetrator more realistically. She must do this before she can forgive herself and the perpetrator. The process of forgiveness can be lengthy. Therapy can help the victim become aware of and begin to resolve feelings of anger toward the perpetrator.

Treatment Approaches

Therapy for sexual abuse survivors may include individual, group, couple, and family therapy. The literature suggests that most clinicians and adult victims prefer group therapy. Short-term individual therapy is commonly an adjunct. Therapy usually begins with one or more individual sessions followed by group work. Additional individual sessions are added, if needed. Regarding the benefits of individual therapy for adult survivors, Van der Kolk (Courtois, 1988) observed:

“Most trauma victims benefit initially from individual therapy. It allows disclosure of the trauma, the safe expression of related feelings, and the reestablishment of a trusting relationship with at least one other person. Patients can explore and validate perceptions and emotions and experience consistent and undivided attention from one other individual.... [The) victim can begin dealing with both the sense of shame and the vulnerability.... Individual therapy allows for a detailed examination of the patient’s mental processes and memories that cannot be replicated in a group therapy setting” (p. 245).

Sgroi and Bunk (1988) agree that some individual work should be done before the client enters group therapy. They observe, “Most survivors need the experience of discovering that they can tell a clinician about the abuse in an individual session before they can speak about it in a group therapy session (pp. 155—56). They recommend a treatment program that includes six to twelve individual sessions, including a clinical evaluation and the development and achievement of specific goals. Group therapy follows. As an incentive, clients who complete the cycle of group therapy are offered couple or family therapy if they desire. The authors do not recommend long-term individual therapy because the survivors become dependent on it and tend to display the dysfunctional distancing behaviors they have employed since childhood.

Some adult victims can benefit from couple therapy. Women who psychologically associate sexual activity and pleasure with abuse and develop an inhibited sexual response need help to break that association. In couple therapy a victim can examine her spouse’s thoughts, intentions, and actions during sexual intimacy and contrast them with those of the perpetrator. This provides her with new information that can help her separate sexuality in marriage from the sexual abuse in her childhood. Group therapy, in which adult victims work together, is the most important aspect of treatment. The remainder of this section will focus on group therapy and will give you the basic tools to facilitate adult victim therapy groups.

Rationale for Group Therapy

Van der KoIk (1984, p. 4) suggests several reasons why group therapy is the treatment of choice for adult victims of sexual abuse.

Many victims feel isolated and alone. Group therapy allows them to share their problems with others who have had similar experiences and to establish close, nonabusive relationships. The experiences that group members have in common encourage them to trust one another and build relationships.

• Abuse results in chronic feelings of helplessness and powerlessness (see also Goodman and Nowak-Scibelli, 1985, p. 532). Adults abused as children still feel that their lives are out of control and consequently assume a passive stance, leaving themselves vulnerable to repeated abuse. Group treatment in a supportive environment helps the adult to confront and change her passive life-style.

•  Participating in groups helps adults correct distorted thoughts and feelings based upon early childhood experiences with sexuality. When young children are abused, they develop many unhealthy beliefs. They tend to view the world egocentrically and so blame themselves for causing the abuse. They accept responsibility for family problems, they feel undue guilt, they believe that they axe unworthy and unlovable, and so forth. These beliefs are discussed in earlier sections of this module. Such feelings are difficult to overcome and are often carried into adulthood. They may lead to many debilitating problems. As victims tell their stories in group therapy, the unhealthy thoughts, feelings, and beliefs usually surface. Other group members, including the therapist, are able to give feedback and support, helping to correct distorted thinking. Groups-can also help members in the following ways:

• Provide a place for group members to express anger without fear of retaliation or losing control.

• Serve as a laboratory where group members can experiment with basic social skills and receive feedback (Agosta and Loring, 1988).

• Stimulate memories that have been repressed or denied. As group members listen to the stories and struggles of other survivors, they are frequently reminded of aspects of the abuse that they may have denied. They can then explore and resolve these previously unresolved issues (Courtois, Ibid., 1988).

• Enhance survivors’ sell-esteem as group members accept and support them.

Cautions about Group Therapy

The benefits of group therapy for adult victims of sexual abuse are well-documented. However, LDS Social Services practitioners should observe certain cautions to ensure that a group’s therapeutic value is not diluted by prolonged discussions of the abuse itself. Excessive rehearsal of a victim’s past can hinder other more beneficial processes necessary for psychological and spiritual healing.

Consider the following cautions taken from a general conference address by Elder Richard G. Scott of the Quorum of the Twelve Apostles:

“I caution you not to participate in two improper therapeutic practices that may cause you more harm than good. They are (1) excessive probing into every minute detail of your past experiences, particularly when this involves penetrating dialogue in group discussion; and (2) blaming the abuser for every difficulty in your life.

“While some discovery is -vital to the healing process, the almost morbid probing into details of past acts, long buried and mercifully forgotten, can be shattering. There is no need to pick at healing wounds to open them and cause them to fester. The Lord and his teachings can help you without destroying self-respect.

“There is another danger. Detailed leading questions that probe your past may unwittingly trigger thoughts that are more imagination or fantasy than reality. They could lead to condemnation of another for acts that were not committed. I know of cases, likely few in number, where such therapy has caused great injustice to the innocent from unwittingly stimulated accusations that were later proven false. Memory, particularly adult memory of childhood experiences, is fallible. Remember, false accusation is also a sin.

“Stated more simply, if someone intentionally poured a bucket of filth on your carpet, would you invite the neighbors to determine each ingredient that contributed to the ugly stain? Of course not. With the help of an expert, you would privately restore its cleanliness.

“Likewise the repair of damage inflicted by abuse should be done privately, confidentially, with a trusted priesthood leader and, where needed, the qualified professional be recommends. There must be sufficient discussion of the general nature of abuse to allow you to be given appropriate counsel and to prevent the aggressor from committing more violence. Then, with the help of the Lord, you can bury the past. “I humbly testify that what I have told you is true. It is based upon eternal principles I have seen the Lord use to give a fullness of life to those scarred by wicked abuse” (in Conference Report, Apr. 1992, p. 46; or Ensign, May 1992, p. 33).

Structuring the Group

Although groups may continue for long periods, most are limited to between ten and twenty sessions of ninety minutes each. Without time limits, members tend to become dependent on the group. They are not motivated to take control of their lives and survive on their own without the continual support of others. 

When forming an adult survivors’ treatment group, screen prospective clients to ensure they are suitable for the group. Time-limited groups usually restrict their membership to women who are without severe psychological impairments. However, Herman and Schatzow (1984) found that their groups could incorporate one member with an apparent thought disorder and one or two members with borderline personality organization (p. 607). Because incest survivors commonly feel isolated and different from others, it is important to minimize differences that could isolate group members. Such differences include age, race, social class, or occupational status (Courtois, 1988). Members should be willing to talk about themselves, to work through the effects of abuse, and to be active participants in the group.

Optimum group size is difficult to determine from the literature because of limited research data. The time-limited groups used in Hermann and Schatzow’s study (1984) consisted of five to seven members. Bergart (1986) found that a group of three was too small and inhibited members’ willingness to discuss personal issues. She eventually increased group membership to seven. Courtois and Leehan (1982), however, recommend a maximum of six members to allow ample time for each member to talk. Try to ensure that groups are large enough so that members feel comfortable disclosing their problems and small enough to allow each member time to work through her issues. 

No specific group treatment format is universally recommended in the literature. However, most groups contain a number of common elements. Usually, the first one or two sessions are devoted to getting acquainted and establishing basic ground rules. Such ground rules usually include the following (Courtois, 1988):

• Keeping confidences. Members establish the rules for sharing information outside the group.

• Attendance. In most cases members are required to attend every meeting. Exceptions can be resolved by the group.

• Time limits. In short-term group therapy, it is important to adhere to time limits, particularly closing time. This prevents some members from engaging others in listening to their personal problems after the time for sharing has expired.

• Safety. Although considerable emotion should be expected in adult survivor groups, it should be expressed in constructive, nontheatening ways. Verbal and physical behavior that may be harmful to others must not be allowed.

The remaining sessions are usually spent in setting individual therapy goals and allowing each participant to share the story of her abuse. Each member is given time during the sessions to discuss her goals with the other group members. The goals members select to accomplish during therapy usually fall into four categories: recovery of memories, improved relationships, improved sell-esteem, and sharing the secret with a family member or close friend (Herman and Schatzow, 1984). Because these groups meet for a limited time, individual goals become an important focus of therapy.

In some groups, a specific amount of time is allotted each group member to disclose the facts and feelings of her abuse experiences. In others, group members ask at the beginning of each session for a certain amount of time to share their stories. Members negotiate the use of time so that their needs can be met. Asking and negotiating for time is particularly helpful for those who feel that their needs are not as important as those of others or who have difficulty asserting themselves.

For most adult survivors, sharing their stories is an important part of healing. The feelings of guilt and shame and the sense of being flawed seem to dissipate rapidly as stories are shared with trusted peers. However, do not to mistake this “flight into health” for a full recovery. 

Frequently, client symptoms worsen after the initial disclosure. Clients feel they have disclosed too much or trusted too quickly, and they may revert to their former defensive patterns. Tell group members about this possibility. Allow clients to move at their own pace. A client who needs to continue denial or dissociation should be gently encouraged to slowly understand and deal with past abuse. Keeping a journal, looking at childhood photographs, and talking to childhood friends and approachable family members can often help these individuals recover early memories.

During the second half of group treatment, therapy sessions begin to focus on accomplishing individual goals. Members could role-play disclosing the secret to a family member. They could receive reports from those who have had success in disclosing their stories or in recovering memories. They may help a group member improve troubled relationships. Discovery techniques such as empty-chair and sculpting are often useful in helping members express anger or sadness and deal with difficult family issues. In some groups, members are given assignments to do between sessions. These may include reading relevant literature on adult survivors (see the Bibliography), keeping a journal, or writing letters. Periodically remind group members of the importance of working on and accomplishing their goals.

It is helpful at the beginning of each session to allow each member to discuss significant events that have occurred since the last session. Rehearsing positive events reinforces the strengths and coping abilities of group members. 

A frequent topic in group treatment is confronting the abuser. Many victims feel they must confront the offender in order to lay the issue to rest. They may have vivid fantasies of verbally confronting and even harming the abuser. They may hope to receive an apology or a plea for forgiveness. However, the actual consequences of approaching the offender are often much less satisfying and can even be dangerous. Sex offenders typically do not admit culpability or take responsibility for their actions. Often, when confronted, the abuser denies the allegation, accuses the victim of fabricating the story, and turns other family members against her. He may threaten or even assault her. Acknowledg­ment of the abuse and expressions of sorrow are the exception rather than the rule. If a group member expresses a desire to confront her offender, you should help her understand what might happen and ensure that she is aware of the potentially serious consequences. 

The last group session should address the termination of the group and the effect this might have on group members. Herman and Schatzow (1984) prepared clients for termination by giving instructions at the end of the ninth session to help them prepare for the tenth and final session. The instructions were as follows:

•  Describe what you have accomplished in the group and what work remains to be done.

•  Write down specific feedback for other group members and for the group leaders.

• List three people you can call for help and support. The authors believed that these things helped clients to focus on their achievements in therapy and to recognize that sources of support would still be available.

If you are interested in conducting therapy groups for adult survivors, you should read Courtois’s (1988) excellent chapter on group treatment. Also review Donaldson’s (1986) audiotape and other materials on individual and group therapy. Appendix 3 contains the group treatment approach used by the Pocatello Idaho Agency, which may also be helpful.

Stages and Processes of Therapy

In addition to viewing therapy in terms of time limits, content, and goals, one can view it as stages in a process (Goodman, Nowak-Scibelli, 1985). The stages include the following:

Beginning Stage

The beginning stage is characterized by the group members’ anxiety over disclosing their abuse. Victims may have kept their abuse secret for years, fearing that any disclosure would be met with punishment or disbelief. Such fears often diminish, however, as victims hear the experiences of others.

Group leaders may ask one or two former group members to help with the group. In the beginning stage, these volunteers can lead out in sharing their experiences, making it easier for other group members to feel comfortable with self-disclosure. The experiences members have in common help them to rapidly develop trust in one another.

Middle Stage

The middle stage of group treatment is characterized by a working relationship between members. Members trust one another and are more willing to share their experiences. As the details of abuse are disclosed, strong feelings begin to emerge. Members frequently feel depressed as they grieve for their losses. They feel anger, resentment, and fear as they struggle to control destructive thoughts and emotions. Though it is vital for such feelings to be expressed, help the members to remain in control of their feelings and behavior.

During treatment, female victims may transfer onto a male therapist the feelings they have about men in general and the perpetrator in particular. These feelings include hostility, anger, fear, and helpless­ness (imagining that the therapist has more powers than he actually does). Group members frequently mask their ‘vulnerability, terror, and pain behind a tough facade.

Avoid the problem of transferred feelings by helping clients to recognize their feelings for what they are and to understand their source. Clients will eventually respond in a more appropriate manner. You can penetrate a tough facade only by consis­tently caring, accepting, and being nonjudgmental.

Though the involvement of a male therapist in groups may present challenges, it is helpful for female victims to view a man in a nonexploitive role.

Final Stage

The final stage of group therapy is often the most difficult for clients. It involves bringing closure to what some members describe as the first time they have felt a sense of belonging. Long-held feelings of abandonment and loss may resurface. Members may feel anger toward leaders who are responsible for ending the group. Such feelings need to be recognized and discussed.

During the final stage, emphasize the members’ accomplishments during the group experience. Help each member to look at her strengths and see her potential for taking control of her own life. Also help members to set goals for continued progress through life-style changes and additional therapy.

Group Treatment Goals

Treatment groups have an educational focus and provide opportunities for group members to share stories of abuse and the resulting trauma. Though the duration of treatment and content of sessions may vary, the primary goals of treatment are to do the following:

• Facilitate identification and relationship among group members who have shared similar experiences.

• Present didactic information on the trauma and maladaptive behavior patterns that result from abuse.

•  Encourage group members to share the experiences and effects of abuse with each other.

• Review ecclesiastical policy that absolves victims from responsibility for the abuse.

• Help group members resolve feelings of sell-blame, shame, and guilt, and promote forgiveness of self and others.

• Help members develop new ways of handling situations that previously elicited negative feelings and dysfunctional behaviors.

Therapy Outcome

The benefits that come to those who participate in therapy include the following:

• Catharsis. This is the result of sharing with others who have had similar experiences.

• Acceptance. Victims who have felt unacceptable and worthy of rejection begin to feel that they are of worth.

• Belonging. Victims recognize that they are not alone and that others have suffered similar problems.

• Hope. They come to believe that their lives can change as they see the lives of group members changing.

• Support and courage. They are able to undertake the difficult task of changing themselves.

• Self-esteem. Positive feelings increase as they cope successfully through disclosing themselves, solving problems, and building relationships.

• Spirituality. This is a result of self-acceptance, resolution, of guilt, and restructuring of relationships with others.

• Preventive skills. Victims learn to interrupt the perpetuation of problems that may have endured for several generations.

• Perspective. Victims have a chance to look beyond themselves and help others.

• Direction. Victims acquire the resolve to move on in life in a positive and healthy way.

RITUALISTIC CHILD SEXUAL ABUSE

When you have completed part 14, you should be able to do the following:

Introduction

Ritualistic child abuse has in recent years been iI\widely reported in the popular press and is beginning to appear in professional journals. It includes physical and sexual abuse used as part of religious or quasi-religious rituals. Most reports come from adults who claim that they were ritually abused as children and from criminal investigators who find evidence of ritualistic abuse in the course of their work. The professional community is divided about what is really happening. This subject should be approached cautiously as more information is gathered.

The purpose of this section is to summarize the current literature related to ritualistic sexual abuse, to provide guidelines for recognizing the problem in children and adults, and to offer recommendations for helping victims.

What Is Ritualistic Abuse?

Reports of ritualistic abuse usually, but not always, include satanic worship ceremonies. Victims describe perpetrators as men and women who wear hooded black or red robes and use satanic symbols and paraphernalia. Symbols include the goat’s head, the inverted cross or pentagram, black candles, and sacrificial altars. The perpetrators recite prayers to Satan and invoke evil spirits. The abuse that takes place in these ceremonies is described as more sadistic and cruel than typical sexual abuse. Police investigators and victims report the following (Kahaner, 1989; L.A. County Commission for Women, 1989):

•  Child-child and child-adult sexual relations.

•  Ingesting or smearing the body with blood or human excrement.

• Human and animal sacrifices.

•  Threats of torture or death for the victim or the victim’s family or pets.

•  Birthing rituals in which the victim is placed inside the carcass of a dead animal, then symbolically born into membership in the group.

•  Forced sexual contact with animals.

• Rectal or vaginal insertion of symbolic objects such as a crucifix, knife, or gun.

• Repeated sexual assaults by men, women, or other children.

Some victims also report having been drugged, hypnotized, bound, buried, nearly drowned, or having undergone “magic surgery.” In magic surgery, the victim is convinced that an evil spirit or an explosive device has been placed inside her that will harm or kill her if she discloses the abuse (L.A. County Commission for Women, 1989).

Whereas typical child sexual abuse involves one perpetrator and one victim, ritualistic abuse usually involves multiple perpetrators and victims. Little is known about alleged perpetrators of ritual abuse. Some are reported to have been raised in families involved in satanic worship and to have continued the practice as adults (L.A. County Commission for Women, 1989). Others are antisocial or sadistic personalities who are attracted by the sex and violence found in satanic cults (Wheeler, et al., 1988).

Victims of ritualistic abuse are often children raised in Satan-worshiping families or those in child-care institutions, summer camps, or other group settings where they are separated from parents. One victim’s account tells of runaway teens who are recruited by satanic cults, children who are raised for use in satanic rituals, and babies born to breeder females and used as human sacrifices (Stratford, 1988).

Purposes of Ritualistic Abuse

Rituals used in the sexual abuse of children appear to serve a variety of purposes (L.A. County Commission for Women, 1989; Snow and Sorensen, 1989). They may be part of an elaborate belief system into which the child is being inducted, a means of intimidating child-victims into silence (Cozolino, 1989), or a means of detracting from the credibility of victims to protect the perpetrators from prosecution.

Stratford (1988) claims that perpetrators of ritualistic abuse hope to undermine a child’s belief in God, destroy allegiance to family and country, and ensure that a child is kept in satanism throughout her life.

Effects of Ritualistic Abuse on the Victim

Like most sexual abuse victims, children who report ritualistic abuse feel considerable guilt. The perpetrator attempts to reinforce the guilt by blaming the victim and threatening her with incarceration, physical harm, or death. He hopes to dissuade her from disclosing the abuse. Fearful of the threatened consequences of disclosure, the child usually keeps the secret to herself. Parents and therapists should not expect a child to disclose ritual abuse voluntarily. However, certain unusual beliefs, fears, and behaviors may suggest that abuse has occurred.

In her work with abused children, psychologist Catherine Gould (1989) identified 105 signs or symptoms that suggest the occurrence of ritualistic abuse. The symptoms are divided into twelve categories. Several of the categories and their associated signs and symptoms are listed below.

Problems Associated with Sexual Behavior and Beliefs

•  Child talks excessively about sex and shows age-inappropriate sexual knowledge.

• Child is fearful of being touched or of having genital area washed. Resists removing clothes for baths, bed, and so forth.

• Child touches others sexually or asks for sex.

•  Child claims she has witnessed sex acts between adults, adults and children, or adults or children and animals.

Problems Associated with Toileting and the Bathroom

• Child avoids bathrooms, seems fearful of bathrooms, or becomes agitated when she has to enter a bathroom.

• Child acts out in toileting behavior, eliminating in inappropriate places, handling urine or feces, dirtying an area or sibling with bodily wastes, tasting or ingesting bodily wastes.

Problems Associated with the Supernatural, Rituals, Occult Symbols, or Religion

• Child believes evil spirits inhabit her closet, enter the house, peer at her through windows, accompany her, torment or abuse her to make sure she keeps secrets, inhabit her body, or direct her thoughts and behavior.

•  Child sings odd, ritualistic songs or chants, sometimes in a language incomprehensible to the parent, or sings songs with a sexual, bizarre, or “you better not tell” theme.

Problems Associated with Dying

•  Child is afraid of dying, claims she is dying, or fears she will die on a particular birthday.

•  Child states that she is practicing to be dead or is dead.

• Child talks frequently of death and asks many questions about illness, accidents, and other ways in which people die. Questions may be overly anxious, compulsive, or even bizarre.

Problems Associated with Certain Colors

•  Child fears or strongly dislikes red or black (sometimes orange, brown, purple), refuses to wear clothes or eat foods of these colors, or becomes agitated in the presence of these colors.

• Child states that black is a favorite color, for peculiar sounding reasons.

Emotional Problems (Including Speech, Sleep, Learning Problems

• Child has rapid mood swings, is easily angered or upset, has temper tantrums, and acts out.

• Child resists authority.

• Child is agitated, hyperactive, and wild.

• Child feels she is bad, ugly, stupid, or deserving of punishment.

• Child hurts herself frequently or is accident prone.

• Child has frequent or intense nightmares, fears going to bed, cannot sleep, or has disturbed sleep.

Problems Associated with Play and Peer Relations

• Child destroys toys.

• Child acts out death, mutilation, cannibalism, and burial themes by pretending to kill play figures, taking out eyes, pulling off head or limbs, pretending to eat the figures or drink their blood, or burying the figures.

• Child’s drawings or other creative productions show bizarre, occult, sexual, excretory, death, or mutilation themes.

Other Fears, References, Disclosures, and Strange Beliefs

• Child fears the police will come and put her in jail or claims that a bad policeman hurt or threatened her.

• Child fears the house will be broken into, robbed, or burned down, or claims that someone threatened these things would happen Child may wish to move somewhere else.

•  Child discusses unusual places, such as cemeteries, mortuaries, church basements, and so forth, or claims that she or others have been taken to such places. Child displays seemingly irrational fears of certain places.

•  Child alludes to pictures or films of nude people, sometimes with references to sexual acts, unusual costuming, unusual involvement, and so forth. Child fears having pictures taken or strikes provocative poses. Child states she was a victim of pornography.

• Child talks about animals, babies, or other humans being confined, hurt, killed, mutilated, eaten, and so forth.

Symptoms in Adult Victims

The reactions of adults who were child victims of ritualistic abuse appear to be similar to those discussed earlier for adult victims of child sexual abuse. Therapists report high frequencies of post-traumatic stress disorder (see part 13) and multiple personality disorder (MPD) (Cozolino, 1989; Snow and Sorensen, 1989; L.A. County Commission for Women, 1989). Given the tendency for most child victims to dissociate during sexual assaults and the fact that the dissociative process facilitates the development of MPD, it is not surprising that 75 to 90 percent of MPD patients were abused as children (Kluft, 1987; Malta and Holman, 1987). Although the DSM III-R places MPD and PTSD in different diagnostic categories, therapists are finding a relationship between the two disorders. Kluft (1987) states that “many clinicians working with both multiple personality disorder and posttraumatic stress disorder have remarked on the similarity of the two conditions” (p. 364). Kroll (1988) noted the overlap between dissociative states and MPD, their probable common origins in childhood abuse, and “the close relationship of both to post-traumatic stress disorder” (p. 150).

Though research on ritualistic abuse and its effects is still in its infancy, clinicians frequently diagnose MPD in victims of ritualistic abuse. After reviewing the literature relating to the causes of MPD, Cozolino (1989) noted: “The severity, chronicity, and alternating nature of abuse and love involved in ritual abuse appear to fit the requirements for the development of MPD.” Additional research on ritualistic abuse is needed to substantiate these clinical impressions. 

Therapy Considerations

Ritually abused children will probably be less inclined to reveal the abuse than victims of other forms of abuse. They have been subjected to more violent forms of abuse and more severe threats against disclosure. Clinical experience shows that these children will not disclose the abuse until they have found security and trust in an ongoing therapeutic relationship (Snow and Sorensen, 1989). 

Diagnosis and treatment, particularly for young children, usually require play therapy. Play therapy includes the use of dolls (human and animal), clay, stories, coloring books and crayons, sand (in which children can bury and hide objects), and other aids through which the child can symbolically disclose ritual abuse. Once the child begins to discuss the abuse, she may talk about it continually for several sessions. It is important to allow the child all the time she needs to talk about the abuse (Gould, 1989). Because the memories are often traumatic and upsetting, the child may seem to get worse—for example, developing obsessions, becoming hyperactive, or acting out aggressively—before she gets better (Snow and Sorensen, 1989). But disclosing the abusive experiences and working through the fears with a skilled therapist are important parts of the healing process. 

In addition to acknowledging and disclosing the abuse, both adult and child victims of ritual abuse must also work through symptoms of denial, dissociation, shame, and guilt. Treatment of these symptoms is discussed in other sections of this module. Resources for the treatment of multiple personality disorder are listed in the bibliography.

Bibliography

Cozolino, L. (1989). The ritual abuse of children: implications for clinical practice and research. The journal of sex research, 26(1), 13 1-38.

Gould, C. (1989). Signs and symptoms of ritualistic abuse in children. Paper presented 16—17 February at the University of Utah, Salt Lake City, UT. 

Kluft, R. P. (1987). An update on multiple personality disorder. Hospital and community psychiatry, 38(4), 363—72.

Kroll, J. (1988). The challenge of the borderline patient: Competency in diagnosis and treatment. New York: W. W. Norton & Company. 

Los Angeles County Commission for Women. (1989). Ritual abuse. Report of the Ritual Abuse Task Force. 15 Sept. 

Malta, W., & Holinan B. (1987). Incest and sexuality. Lexington, MA: D.C. Heath and Company. 

Snow, B., & Sorensen, T. (1989). Ritualistic child abuse in a neighborhood setting. Paper presented at the Eighth National Conference on Child Abuse and Neglect, Salt Lake City, UT. 

Stratford, L. (1988). Satan’s underground. Eugene, OR:   Harvest House Publishers.

Wheeler, B., Wood, S., & Hatch R. (1988). Assessment and intervention with adolescents involved in satanism. Social work, 11, pp. 547-50.

Conclusion

It is hoped that the information provided in this module will help you help those who have been involved in or affected by sexual abuse. Because of the complexities of abuse and treatment, this module cannot include all pertinent information.

You should read available books and documents on this topic and participate in relevant seminars as you have opportunity. There is a continuing need for study and skill development as new approaches come to light.

APPENDIX 1 - INITIAL VICTIM INTERVIEW

State and local agencies typically have child abuse teams that specialize in investigative work with victims. According to established policy, LDS Social Services practitioners do not conduct investigative interviews for the legal system. If you work with child sexual abuse victims, however, you should know how such interviews are conducted so that you can effectively help a client explore her abuse. One procedure used by local and state workers is described below.

Conducting Investigative Interviews

The following guidelines are used by those who conduct investigative interviews:

Interviews should be held in the therapist’s office whenever possible. Reasons include the following:

1.  A child is usually much more willing to talk about the abuse in the therapist’s office. Where incest is involved, it would be difficult for the child to violate family rules by discussing the abuse in the environment where it occurred.

2.   The office contains materials and equipment such as anatomically correct dolls, doll houses, crayons, paper, toys, and video camera, where appropriate. These can help the therapist effectively observe and evaluate the child. Any abuse that a child has experienced may be manifested in the way she plays. A child can give only information that comes from personal experience. Unless the office contains materials that allow the child to share that experience by showing as well as telling, the amount of infor­mation that can be obtained may be limited, particularly with younger children, who lack sexual knowledge and verbal skills.

Be attentive to the needs of the child. Don’t become overly involved in writing notes. Those who do investigative interviews for the courts often use videotapes or audiotapes to accurately record what happens. Take your time doing the evaluation. Do not rush the victim. Don’t be dissatisfied if you can’t get everything in one session. Information is not likely to be obtained, especially with young children, when a hurried approach is used.

The child should be interviewed alone, never in the presence of the perpetrator or the nonoffending parent. The child may take cues from them, withhold information, attempt to rescue the perpetrator, reverse roles with the mother, or protect both of them.

•  Convey interest in the child as a person. She is more than the victim of abuse. Ask about the child’s interests — school, friends, hobbies, talents, quality of relationships with family members, and so forth. Find out who the child is. You are role-modeling the value of therapy for the child. Value her as an important human being with a unique personality. Your interview may be the first experience the child has with someone who really cares about what she has to say.

•  Sit in front of the desk facing the client or on the floor with her.

Before discussing the abuse, talk with the child about her family, their relationships, life-style, and so forth. Moving directly into a discussion of the abuse may elicit only the information that the child has been coached by parents to give. In addition, the child may feel that information about the abuse is the only thing you feel is important.

• Never allow the child to feel that she is in trouble or at fault because of the abuse. Likewise, avoid displaying any horror, shock, or disapproval of the child, her parents, or anything she may say about the situation.

• Don’t suggest answers to questions you have about the abuse. Investigative workers have learned that legal cases may be thrown out of court if it can be shown that they led the victim in any way.

• One good approach to obtaining information about the abuse is to ask the child to talk about herself as if she were a house. Ask her to tell you about her good rooms, her happy rooms, and her sad rooms. As she describes each room, you can ask her why it is a good, happy, or sad room. Through this approach, the child often describes the rooms in which abuse occurred and what took place that led to her unhappiness.

• Another effective way to determine if and how abuse occurred is through the use of anatomically correct dolls. Although dolls are used most often with preteenagers, they can also be used with teenagers who may need help in explaining how they were abused. Dolls may be used in one or more of the following ways:

1.   Have the child select a doll that represents herself and dolls to represent other members of the family. Ask her to act out with the use of the dolls such behaviors as bathing, eating dinner, disciplining, and expressing anger, as well as physical and sexual abuse, showing exactly what happened and who was involved. Such information can be helpful in assessing family dynamics and pathology.

2.   Give the child a girl doll and ask her to name the various articles of clothing as you remove them and to name body parts. You can then use her words throughout the interview to help you understand what occurred. If a child reacts negatively when you show a genital part, you can ask, “Has anyone ever touched you there?” If the answer is yes, you can say, “Show me what happened.” Remember, children lack verbal skills and can show you something much more easily than they can explain it.

3.   Have the child set up the environment as it was at the time of the abuse by using words, drawing, or playhouse and toys. Have her act out, with the use of dolls, events that occurred before, during, and immediately after the abuse.

This enables you to see the abuse within its broader context rather than as an isolated event. If the information is inconsistent with what you know about where the abuse occurred, you may need to question the validity of the child’s disclosure. You will need to determine whether the child is old enough to be expected to accurately describe the environment.

• Ask specific questions when inquiring about how the child was abused. Most victims are not sexually experienced or articulate. They may convey information suggesting, for example, that penetration took place, but the claim is not supported by evidence from the physical exam. Where investigative interviews are conducted for the courts, a case may be dismissed unless accurate information is obtained. Superficial investigation is unsuitable. Frequently, what victims describe as vaginal penetration is actually external, intralabial intercourse. Had the therapist asked specific questions, more accurate data could have been obtained.

• Before the interview, discuss with the child or with her parent or caretaker the sexual terminology used by the family and child. This will enable you to use the child’s words in learning exactly what abuse took place. Do not criticize a child’s choice of words or language. Ask the child to clarify any words and terms you do not understand.

•  Do not push the child into telling you what occurred. Most children have been threatened with punishment for telling what happened. One effective way of allowing the victim to communicate without fear of punishment is to say: “I don’t want you to tell me. I want you to use the dolls and show me what happened.”

•  Do not assume that the abusive experience was painful for the child. Children often associate the abuse with warmth, nurturance, and love.

• Whenever possible, tell the child what you are going to do with the information obtained from the assessment interview. Abused children seldom feel they are an important part of adult decision making. Including them will help them feel important. In addition, the child may have to talk about the abuse with several people. She should clearly understand why she must speak with each person. Also, when it is appropriate, explain in detail about foster care, removal of the parent or child from the home, and so forth.

•Answer the child’s questions about what may happen to the perpetrator. The child should know that the perpetrator needs help. Assure her that telling is the right thing to do and will facilitate the process of helping the perpetrator. Describe the treatment process in which the perpetrator may be involved.

• Determine what additional evaluation or treatment is needed. Such steps might include psychological and intelligence testing, medical intervention, and treatment for physical abuse. For example, if oral sex occurred, the child needs to be referred to a physician who will test and treat bacterial or viral infection. If intercourse has taken place, you need to be concerned about the possibility of pregnancy and venereal disease.

•Make sure that you have access to a supervisor or colleague who can help you deal with feelings of frustration and confusion in connection with the cases you treat. After the initial interview, a therapist often needs help in dealing with personal feelings.

State and community workers who conduct investigative interviews have a responsibility to inform parents of their legal rights with regard to the investigation. They must tell the parents why the interview is taking place in a direct, honest, professional, and understanding manner. As in working with the victim, workers should refrain from judging or from displaying horror or shock over the alleged abuse. LDS Social Services practitioners should have these same attitudes in working with families.

APPENDIX 2 - THE CIRCUMPLEX MODEL

Some professionals have found the Circumplex Model to be helpful in assessing families with incest problems and making treatment decisions. The following description of each of the axes and quadrants will help you better understand how to use this model. As you study the model, please review figure 1 on page 14. 

The Cohesion Axis

Family cohesion is the degree to which members are. separated from or connected to their family. It is defined as the “emotional bonding that family members have toward one another” (Olson, et al., 1983, p. 70). On one extreme of the cohesion axis is enmeshment — a relationship in which one person loses his individuality, voluntarily or involuntarily, in the personality of the other. Only the dominant individual senses any fulfillment. Enmeshed relationships result when one spouse is overly dependent on the other; when one person feels trapped, belittled, controlled, physically forced, or psychologically and environmentally manipulated by another; or when one spouse’s jealousy isolates the other spouse from friendships and support systems. Incest is more likely to occur in enmeshed families.

In enmeshed families, personality development is inhibited. An individual may become so involved in gratifying another’s needs that he suffers a loss of self and is unable to differentiate his thoughts, needs, and perceptions from those of another.

At the other extreme of the cohesion axis is disengagement. Disengaged personalities, typical of sexual offenders, want to be close to others, but they are not willing to give of themselves. They see commitment and intimacy as privileges they have already earned, not as qualities that require daily effort, understanding, or work. Their relationships with others are based on working together, owning things jointly, or pursuing external and material things. They are protective of feelings and resist sell-disclosure. They do not want to become involved in mutually solving family problems, developing nurturing relationships, or doing things that demand emotional energy and risk. They tend to neglect personal feelings and emotional needs of their spouse and children while still expecting their family members to love and care for them. They disengage as a means of protection.

The Adaptability Axis

The other axis in the model is adaptability. Family adaptability is the extent to which the family system is flexible and able to change. It is defined as the “ability of a marital or family system to change its power structure, role relationships, and relationship rules in response to situational and developmental stress” (Olson, Ibid.). A person who is adaptable can function as an independent entity in a variety of relationships and circumstances.

One extreme of this axis is chaos. A sexual perpetrator is a prime example of the chaotic personality. He has little self-discipline or self-direction. He has little control over his environment, emotions, or reactions to others. He may expect others to fulfill the needs that he lacks the discipline to meet. He is unwilling to resolve problems responsibly. Family members may give up even expecting him to adapt. Instead, they try to please him. Family members live with behaviors they do not understand but which the chaotic individual demands.

Such an individual can create emotional chaos in his family by making his spouse and children believe that they are responsible for making him happy, even at the expense of their own happiness. The passing of responsibility for sell to others allows him to control his chaotic, confusing relationships and environment. His actions teach chaotic functioning, low sell-esteem, failure-focused living, and extremely unrealistic expectations. The entire family may get caught in a life-style in which their own needs are not being met and their efforts to meet the needs of the chaotic controller are always unsuccessful. Family members may resort to leaving problems unresolved or blaming others. They may experience despair and depression.

Perpetrators with chaotic personalities have not learned to solve problems or to adapt. Chaotic functioning protects them from family members and others who may try to get too close or force them into relationships. Minimal to massive amounts of energy are invested to maintain this type of behavior.

Evidence of chaotic functioning may be seen in unfinished business —a partially completed basement, an unkempt home, three old cars parked behind the garage that are going to be fixed someday, thirty pounds of extra weight, unresolved health problems, or chronic marital conflicts. Whenever they feel threatened, chaotic perpetrators sabotage the problem-solving process through blaming others and denying personal responsibility for problems. Problem avoidance is a major characteristic of all perpetrators of sexual abuse.

Spouses of perpetrators also frequently function chaotically and avoid problems. Consequently, children have no parental models for healthy functioning and problem resolution. Incest victims in such homes lack assertiveness skills and have no understanding of how to resist sexual advances. They have often been continually belittled and taught that problems in relationships are a sign of stupidity. Chaos becomes the expected familial process. The child and spouse learn that if life is free of apparent problems, chaos must be created to cover up real difficulties and to please the perpetrator.

During intervention, these families strive to create chaos among helping agencies and personnel. They will often blame you, the therapist, for their problems and will want you to accept responsibility as the problem creator and bad guy. To effectively intervene, you must help the family unlearn their chaotic behavior and replaced it with problem-solving skills. Family members must learn how to solve problems without blaming.

The other extreme on the adaptability axis is rigidity. A rigid personality demands that others live by rules that he establishes, rules that are often unrealistic, impossible to follow, and without any alternative. Family members lose the desire even to try because the rules are impossible to obey. A rigid, sexually abusive perpetrator may make statements such as, “The only way to do something is the right way, and the right way is my way.” There is no allowance for others’ feelings and differences. Linear, rigid beliefs are reinforced: “You’ll never get anywhere doing work like that.” “I’ll support you in school only if you’ll be an engineer or take a job of my choosing.” “Music and drama studies only produce fruits and nuts.”

Such rigidity creates continuous family conflict. Family members may decide that living by the rules is impossible. They fail to learn adaptive skills and may give up and feel that suicide is the only way out of life’s problems. The rigid person knows nothing of alternative solutions to problems or healthy reliance on others. The rigidity and lack of alternatives create feelings of isolation, personal weakness, and lack of trust in self and others.

The Enmeshed-Rigid Quadrant

A parent or spouse who operates in the lower right quadrant—rigid and enmeshed—is prone to physically abuse his mate or children. He wants others to focus their lives on his needs and sacrifice their individuality for him. He also rigidly demands to be in control. He often argues, loses his temper, and uses physical force to demand compliance. He is unable to adapt to varying situations, and he demands that others believe as he does. Conflicts often reach an explosive state. Physical abuse is often the only release he knows to release internal or external pressure.

A protection fantasy is often associated with this abusive quadrant. The abusive spouse or parent may think, “I must protect my family and spouse from the outside world, for they do not understand what is out there waiting to hurt them.” Or, “I’m afraid they might find a better life with another person, so I must keep them isolated and socially unprepared.”

The Enmeshed-Chaotic Quadrant

Individuals in the upper right quadrant teach and demand chaos and enmeshment. They allow little individuality and are confused about how to adapt to their circumstances. They may sexually abuse others because they do not have well-established boundaries in their relationships and because they have undisciplined life-styles. Due to their enmeshed way of obtaining closeness, they are inept at allowing others freedom in relationships. Needs for closeness become confused with sexual needs. Sexual behavior becomes a way of gaining acceptance and is carried out in a secretive, dysfunctional environment.

The Chaotic-Disengaged Quadrant

People in the upper left quadrant—chaotic adaptability and disengaged cohesion—do not know how to establish close relationships or create alternatives for adaptable living. When problems arise in their lives, they neglect or abandon relationships. This is especially true when they become parents. They lack the skills to cope with the extra requirements of parenting since parenting requires bonding. The requirement that parenting places upon them for close relationships is confusing and disrupts their lives. They often respond with increased chaotic coping and disengaged behavior.

Child neglect may be the most prominent symptom of families in this quadrant. Parents may fail to meet the child’s most basic needs because they cannot adapt to her or establish a schedule for her healthy care. They know little of the closeness and sacrifices needed for bonding. Such parents need social, cognitive, behavioral, and emotional retraining with an abundance of healthy modeling to correct this imbalance. The child may need immediate medical help because of weight loss, isolation, and other traumatic effects of this neglectful environment.

The Disengaged-Rigid Quadrant

Those in the lower left quadrant—disengaged cohesion and rigid adaptability—do not know how to have lasting, meaningful, mutual relationships. They see individuation as a burden, as an unallowable luxury, or as nonexistent. They  have learned that the rules for living are rigid and hard, and they tend to psychologically abuse others. They commonly engage in inappropriate sexual activity and abuse drugs and alcohol. They use substance ingestion, including overeating, to dull their senses and to cover up the anxieties and confusions that are caused by their lack of healthy relationships. 

People in this quadrant easily develop victim roles and behaviors. They may think, “The only way I know to get close to someone is to have sex with her.” “The rules are so hard for me. And it’s hard to get close to someone, so if I like the way she looks and we have good sexual relationships together, the friendship will come later.” They give themselves up to some addiction as a substitute for the arduous task of maintaining loving relationships. (See Victor L. Brown, Jr., Human Intimacy, for further study.) 

People in this quadrant easily become perpetrators. Since the rules are so rigid and they don’t know how to develop relationships, they rationalize that they can use others sexually at will. They may reason, “If I see someone I want, I’ll use drugs or alcohol to set her up, and then I’ll just take what I want, if and when I want it. All women want sex. They just need to be convinced a little, sometimes by force.” 

These individuals are angry, aggressive, violent, and determined. Closeness always eludes them. They seek love in places and situations where it can never be found. They practice sex in a controlling, power­oriented, nonmutual atmosphere. Abuse is present in almost all of their behaviors and thoughts. They may constantly belittle others and attempt to destroy their sell-esteem. Those around them often feel that the world is unloving and rigid and that they may be abandoned. They may also isolate themselves from others. The behavior typified in this quadrant is conducive to the development of mental abuse, substance abuse, and spouse abuse, as well as sexual abuse

Extreme Behavior in All Quadrants

All the personalities portrayed by this model must have the cooperation of others if they are to maintain their extreme behaviors. The cooperation may be voluntary or involuntary. The victim must— by reason of age, physical stature, learned behavior, or lack of alternatives —join with the perpetrator in his demands. The unique personality of each child and adult triggers a different response. For example, when a perpetrator is in the physically abusive quadrant (enmeshed and rigid), a child, because of her personality or behavior, may trigger the rigid adaptability in the perpetrator’s personality and become the victim of physical abuse. Another child placed in the same circumstances may not provoke the perpetrator into abusing her. A third child placed in the same circumstances may trigger the perpetrator’s chaotic inadaptability instead of his rigid inadaptability and be sexually abused.

When a perpetrator learns extreme behavior in one quadrant of the model, he is likely to exhibit extreme behavior in another quadrant. He learns to shift his behavior as needed to different polarized positions on the model, depending on the personalities of the people who come into his life. He may neglect some people while physically, sexually, or psychologically abusing others. All types of abuse may, therefore, occur within one family and be taught to every member of the family. This does not mean that all family members will abuse others. Some may develop moderate life-styles in which they do not perpetuate the abuses they saw and experienced as children.

Treatment Implications

The Circumplex Model gives you a frame of reference that can help guide the treatment process. By becoming familiar with each of the four quadrants, you can better identify client and family symptoms. A general guideline is that treatment must move the client or family toward a moderate position on the model. For example, a rigid client or family should be moved toward greater flexibility and willingness to change. A chaotic client or family needs to learn structure and problem-solving skills.

An enmeshed client or family requires greater autonomy and independence. A disengaged client or family needs to learn relationship skills and become more connected.

Accomplishing these changes may require you to use many of the skills you have acquired throughout your therapeutic practice. Several approaches may be needed, including behavioral, psychodynamic, cognitive, insight, and supportive therapies in both individual and group sessions.

POCATELLO ADULT VICTIM GROUP TREATMENT PROGRAM

In response to the large number of clients presenting with symptoms related to child sexual abuse, several LDS Social Services agencies have developed adult victim treatment groups as part of agency clinical services programs. One such program developed by the Pocatello Idaho Agency is described below. This is not intended as a recommended group treatment approach to be used by every agency. Rather, it is a sample of elements that have been used successfully in one group therapy program. Remember that the assistant commissioner must approve content and materials before a therapy group is conducted in any LDS Social Services agency.

Session One
Orientation of group members; introduction of therapist and volunteers, rules, fees, number of sessions, historical involvement ‘with abuse, and so forth; brief introduction of group members; sharing of abuse stories by volunteers; review of course objectives.

Session Two
Didactic presentation on effects of abuse on children (identity confusion, guilt, dysfunctional ways of dealing with anger, guilt, and responsibility); presentation on ways of resolving long-standing misconceptions of sell and others; group interaction (sharing and discussion of personal abuse experiences and their effect).

Session Three
Presentation on life space, including how it has been affected by sexual abuse; presentation on kinds of touching (difference between what is appropriate and what is flOt); group interaction.

Session Four
Discussion of questions such as, “Why me?” “Why didn’t Heavenly Father stop it?” “Why wasn’t I believed, rescued, or protected?” Discussion of talks and writings about the eternal significance of life’s problems, the responsibility to prevent the perpetuation of problems into future generations, sell-esteem; group interaction.

Session Five
Presentation about and discussion of common relationships victims have with perpetrator, spouse, nonoffending parents, siblings, sell, and others; presentation about determinants of sell-esteem; group interaction.

Session Six
Prescriptions for self-esteem; group interaction.

Session Seven
Focus upon strengths of group members; relaxation exercises; group interaction.

Session Eight
Presentation on the grieving process as it relates to the victim; group interaction.

Session Nine
Presentation on stress management; group interaction.

Session Ten
Focus on healthy attitudes and behaviors for human intimacy.

Session Eleven
Presentation on guilt feelings (causes and cures) and forgiveness; group interaction.

Session Twelve
Focus on therapeutic gains, expressions of thanks; group relationships; future goals.

If you are interested in a complete course outline, handouts, or readings, contact the Pocatello Idaho Agency. Other agencies have conducted open-ended groups in which the content of each session is determined by the needs of group members.

APPENDIX 3 - BIBLIOGRAPHY

Agosta, C., & Lonng, M. (1988). Understanding and treating the adult retrospective victim of child sexual abuse. In S. Sgroi, Vulnerable population. Lexington, MA: Lexington Books.

American Association for the Protection of Children (1985). Reports of child maltreatment increase again. Protecting the children, 2(1), 3.

American Psychiatric Association (1987). Diagnostic and statist.ical manual of mental disorders (3rd ed. revised). Washington, D.C. - An approach to treating marital problems (198 1]. Salt Lake City: The Church of Jesus Christ of Latter-day Saints.

Baisden, M. J. (1971). The world of rosaphrenia: The sexual psychology of the female. Sacramento, CA: Allied Research Society.

Bergart, A. (1986). Isolation to intimacy: Incest survivors in group therapy. The journal of contemporary social work, 266—75.

Bernard, J., & Densen-Gerber, J. (1975). Incest as a causative factor in antisocial behavior. New York: Odyssey Institute.

Borysenko, J. (1990). Guilt is the teacher, love is the lesson. New York Warner Books, Inc.

Bradshaw, 1. (1988). Healing the shame that binds you. Deerfield Beach, FL: Health Communications, Inc.

Bradshaw, 1. (1990). Homecoming: Reclaiming and championing your inner child. New York: Bantam Books.

Briere, I., & Runtz, M. (1986). Suicidal thoughts and behaviors in former sexual abuse victims. Canadian journal of behavioral science, 18, 413—23.

Brown, A., & Tyson, C. (1978). Fourteen characteristics of incestuous families. Workshop presentation, graduate school of social work, University of Utah.

Brown, L., & Holder, W. (1980). The nature and extent of sexual abuse in contemporary American society. In W. Holder (Ed4, Sexual abuse of children: Implications for treatment. Englewood, CO: American Humane Association.

Brown, V. (1981). Human intimacy: Illusion and reality. Salt Lake City: Publishers Press.

Browne, A., & Finkelhor, D. (1986). Impact of child sexual abuse: A review of the research. Psychological bulletin, 99(1), 66—77

Carnes, P. (1985). Counseling sexual abusers. Minneapolis: CompCare Publications.

Child abuse—Help for ecclesiastical leaders. (1985). Salt Lake City: The Church of Jesus Chnst of Latter-day Saints (32248).

Conte, J. R., & Berliner, L. (1981). Sexual abuse of children: Implications for practice. Social casework, 62, 601—6.

Courtois, C. (1988). Healing the incest wound. New York: W. W. Norton and Company.

Courtois, C., & Leehan, J. (1982). Group treatment for grown-up abused children. The personnel and guidance journal, May, 564—66.

Cozolino, L. (1989). The ritual abuse of children: Implications for clinical practice and research. The journal of sex research, 26(1), 131—38.

Division of Family Services report on child abuse and neglect. (1990). Project Coordinator, Barbara Thompson.

Donaldson, M. (1983). Incest years after: Putting the pain to rest. Fargo, ND: The Village Family Service Center.

Donaldson, M. (1986). Incest years after: A lecture on theory and treatment. Audiotape. Fargo, ND: The Village Family Service Center.

Feinauer, L. (1988). Relationship of long-term effects of child sexual abuse to identity of the offender: Family, friend or stranger. Women and therapy, 7(4).

Finkelbor, D. (1984). Child sexual abuse: New theory and research. New York The Free Press.

Finkelhor, D., & Browne, A. (1985). The traumatic impact of child sexual abuse: A conceptualization. American journal of orthopsychiatri, 55, 530-41.

Giarretto, H. (1976). “The treatment of father-daughter incest: A psychosocial Approach.” Children today, 5(4), 2—5, 34—35.

Giarretto, H. (19 82a). A comprehensive child sexual abuse treatment program. Child abuse and neglect.6(3), 263—78.

Giarretto, H. (1982b). Integrated treatment of child sexual abuse: A treatment and training manual. Palo Alto, CA: Science and Behavior Books.

Goodman, B., & Nowak-Scibelli, D. (1985). Group treatment for women incestuously abused as children. International journal of group psycho therapy, 35(4), 53 1—44.

Gould C. (1989). Signs and symptoms of ritualistic abuse in children. Paper presented 16—17 February 1989, at the University of Utah, Salt Lake .

Grolf, M. G. (1987). Characteristics of incest offenders’ wives. Journal of sex research, 23 (1), 91—96.

Groth, A. N. (1982). The incest offender. In Sgtoi, S. (Ed.), Handbook of clinical intervention in child sexual abuse. Lexington, MA: D. C. Heath, pp. 215-39.

Herman, J., & Schatzow, E. (1984). Time-limited group therapy for Women with a history of incest. International journal of group psychotherapy, 34(4),05—16.

Kahaner, L. (1989). Cults that kill. New York: Warner Books, Inc.

Kantrowit, B., Wingert, P., King, P., Robbins, K., & Narnuth, T. (1988). And thousands more. Newsweek, 12 Dec.

Kempe, C. H. (1977). Sexual abuse: Another hidden pediatric problem. C. Anderson Aldrich Lecture.

Killorin, E., & Olson, D. H. (1984). The chaotic flippers in treatment. Reprinted from Edward Kaufman (Ed.), Power to change: Alcoholism. Gardner Press, Inc.

Kluft, R. P. (1987). An update on multiple personality disorder. Hospital and community psychiatry, 38(4), 363-72.

Kroll, J. (1988). The challenge of the borderline patient: Competency in diagnosis and treatment. New York: W. W. Norton and Company.

Leaman, K. M. (1980). Sexual abuse: The reactions of child and family. Sexual abuse of children. National Center on Child Abuse and Neglect, Washington, D.C.: Government Printing Office (DHHS Publication No. 78—30(6 1) 21—24; Falconer, N. E., and Swift, K. (1983). Preparing for practice: The fundamentals of child protection. Toronto, Canada: Children’s Aid Society of Toronto, pp. 65—66.

Los Angeles County Commission for Women. (1989). Ritual abuse. Report of the Ritual Abuse Task Force, 15 Sept.

McDonald, L. A. (1981). The psychodynamics of incestuous families: Implications for treatment. Symposium presented at the Western Psychological Association, Los Angeles, CA. May.

MacFarlane, K (1978). Sexually abused children. In J. R. Chapman & M. Getes (Eds.), The victimization of women. Beverly Hills, CA: Sage Publications, pp. 81—109.

Madanes, C. (1990). Sex, love, and violence. New York W. W. Norton and Company.

Malta, W., & Holman B. (1987). Incest and sexuality. Lexington, MA: D. C. Heath and Company.

Money, 1. (1986). Lovemaps. New York Irvington Publishers.

Olson, D. H., Russell, C. S., & Sprenkle, D. H. (1983). Circumplex model of marital and family systems: VI.   Theoretical update. Family process, 22:69-83.

Ontario Ministry of Community and Social Services standards and guidelines₅ Children’s services (1979). As cited in Falconer, N. E., and Swift, K. (1983). Preparing for practice: The fundamentals of child protection. Toronto, Canada: Children’s Aid Society of Toronto, p. 61.

Patten, S., Gatz, Y., Jones, B., & Thomas, D. (1989). Posttraumatic stress disorder and die treatment of sexual abuse. Social work. May.

Pecora, P. (1985). Social research newsletter. The Graduate School of Social Work, University of Utah.

Porter, F., Blick, L., & Sgroi, S. (1984). Treatment of the sexually abused child. In S. Sgroi, Handbook of clinical intervention in child sexual abuse. Lexington, MA: D. C. Heath, pp. 109—145.

Powell, G. (1979). Presentation given at the National Conference of Child Abuse, Los Angeles, CA.

Rosenfeld, A. (1977). Sexual misuse and the family. Victimology, 11 (2) pp. 226—35. Cited in Summit, R. C. (1977). The child sexual abuse accommodation syndrome. Child abuse and neglect, (7) 177—93.

Russell, D. E. (1983). The incidence and prevalence of intrafarnilial and extrafamilial sexual abuse of female children. Child Abuse and Neglect, (7) 133—46.

Russell, D. E. (1986). The secret trauma: Incest in the lives of girls and women. New York Basic Books.

Salter, A. C. (1988). Treating child sex offenders and victims: A practical guide. Sage Publications.

Sgroi, S. M. (Ed.) (1984). Handbook of clinical intervention in child sexual abuse. Lexington, MA: D. C. Heath.

Sgroi, S., & Bunk, B. (1988). A clinical approach to adult survivors of child sexual abuse. In S. Sgroi (Ed.) (1988). Vulnerable population. Lexington, MA: Lexington Books.

Sgroi, S., & Dana, N. T. (1984). Individual and group treatment of mothers of incest victims. In S. Sgroi (Ed.) (1984). Handbook of clinical intervention in child sexual abuse. Lexington, MA: D. C. Heath, pp. 191—214.

Snow, B., & Sorensen, T. (1989). Ritualistic child abuse in a neighborhood setting. Paper presented at the Eighth National Conference on Child Abuse and Neglect, Salt Lake City, UT.

Stratford, L. (1988). Saran’s underground. Eugene, OR: Harvest House Publishers.

Utah Department of Social Services, Division of Family Services. (1985). State child abuse statistics (Contact person: Sherry Reese, State Child Protective Services Specialist, Division of Family Services.)

Van der Kolk, B. (1984). Post-traumatic stress disorders. Printed in The Harvard Medical School mental health letter, 1(5), 1—4.

Weiner, I. (1962). Father-daughter incest: A clinical report. Psychiatric Quarterly, (36).

Wheeler, B., Wood, S., & Hatch, R. (1988). Assessment and intervention with adolescents involved in  atanism. Social Work, 11, 547—50.

Whitfield, C. (1987). Healing the child within. DeerIield Beach, FL: Health Communications, Inc.

Posted: July 2004 RH