Treatment Issues

Dealing With Sexual Abuse Victims

James E. Hord, Jr. Ph.D.

The treatment of adult survivors of childhood sexual abuse is dependent on how the abuse has impacted on the individual. This perhaps sounds rather obvious, but it is important to understand at the beginning of this issue that the same experience may produce quite different effects with different individuals. Some adults appear to have little residual damage from rather extensive histories of abuse, while others have ruined lives stemming from relatively mild experiences. It is not the "behavior" that they were exposed to as much as the interpretation of those experiences at the time, and years later as an adult.

Therapy with victims of child sexual abuse must be focused on sensitive issues that sometimes clash with societal expectations.  Abuse is correctly defined only in terms of the social order in which it occurs.  What is abusive in some parts of our own social system, may not be considered abusive in others.  When we compare the standards of our society to the society of other countries, the definition of abuse becomes even more difficult.  Consider the grandmothers of the little Cuban boy rescued from the waters of Florida.  They were reported in the press as grabbing the boys genitals and making comments about how he would be a big hit with the girls when he grew up.  Abuse?  In this country, perhaps, but not in Cuba.  More importantly it is doubtful that the child viewed this behavior as anything negative or abusive.

To examine this difficult issue, consider that there appear to be at least three distinct ways to categorize sexual abuse experiences that we see in working in this area. Like with all such categorizations, the lines between them are not always sharp, and some abuse experiences may involve elements of more than one type, but in general they may be described as follows:

A. Traumatic Event:  A traumatic, forceful experience of abuse such as a rape or other attack which occurs once or few times, is reported almost immediately and cause considerable distress within the child's support group.

B. Seductive:  A pattern of abuse with increasing severity that involves the child and an abuser who is known to the child such as a family member, close friend or relative prior to the abuse beginning. In this pattern the abuse is discovered, or reported by the child, which stops the abuse.

C. Undisclosed:  An event or a series of events of sexual abuse, unreported and undiscovered. In some cases the event or events may or may not be recognized by the child as abuse for several years after the event, possibly adulthood.

D. False Reports:  Not typically considered as a source of abuse, to influence a child to produce a false report of sexual abuse is in itself abusive.  This is true even in cases where the child does not understand that the report is false at the time that it is made.

The important variable here is the perception of the child. It is not important in defining abuse in a legal sense, but it is important in predicting the child's adaptation to the event(s).

While not intended to be more than a brief description of the problems involved, the following is presented in the hope of shedding some light on the area of treatment considerations in the different situations outlined above.

A. Traumatic Event:

It is tempting to assume that all cases of sexual abuse in children are traumatic. This is not the case. If we administer questionnaires to functioning, healthy adults we find many who report some memory of an abusive event or events during their childhood years. Yet they appear to have been unaffected by the event and do not report emotional difficulties as a result. Let me hasten to add that I am not endorsing the idea that they were unaffected, but by their statements they appear to believe that to be the case.

However when there is trauma involved, it is quite likely that the emotional damage will be present for years into the future unless the child gets competent help from a mental health professional. The reactions of the family, the social system and others at the time of the initial report, confirm for the child that this is a significant event worthy of a great deal of attention. The child is suddenly treated differently by the family "because" of the event. The expectation is that life will now be different.

Occasionally severe and major diagnosable mental conditions result from such experiences, but more commonly serious disruptions in the function of the individual on a neurotic or "personality disorder" level results. Such disruptions lead to problems in interpersonal relationships, poor work histories, troubled marriages and a marked reduction in the quality and enjoyment of life. The individual matures with a sense of "impairment", of not being "as good" as others or of now being "flawed". This can significantly effect the self-concept and resulting expectations of self in all spheres of life experiences. Like the adult rape victim, this individual may feel that much of her (or his) life has been stolen from her (or him) and this sense of loss may overshadow all other areas of self-evaluation. Goal development and attainment are suppressed since self-expectation is impaired. The individual "settles" for what life easily offers rather than attempting to strive for goals not immediately in reach.  These feelings coupled with a need to fault those whom the patient feels are the source of mistreatment or are in some way a threat to the patient, may lead to diagnostic labels in the future such as Borderline Personality Disorder, Schizoid Personality Disorder or Avoidant Personality Disorder.

Such individuals often feel devalued and expect others to see them that way also. They expect to experience rejection and subsequently seek out others who they identify as being "socially flawed" in some way, as a hedge against being rejected by those of higher personal competence, whom they avoid.  Their behaviors are then shaped largely by the group they identify with which leads to a very different set of life experiences than otherwise would be the case.

Ego-enhancement therapeutic efforts can be extremely helpful for people in this category, while humanistic, sympathetic efforts may be more harmful than helpful. The reason for this, stated quite simply, is that the supportive input from the therapist is provided in response to the description of the experience of abuse and the resulting effects. Support (TLC) is a reinforcer, particularly from someone esteemed by the patient. Reinforcers strengthen behavior. In this case, the reinforcers may strengthen the sense of helplessness and incompetence, reinforcing a "victim" role  I would submit that victims of such abuse do not need help in strengthening such damage. That, at least, seems clear.

Certainly the events and the patient's symptoms that result do not need to be dismissed or ignored in therapy. But if they become the single focus of the therapy experience, the outcome will likely be poor. Instead, therapy is best aimed at building confidence, ego and self-esteem. The event(s) of abuse need to be contained in some way rather than allowed to continue as a major determinant of future development for the patient.

B: Seductive:

The most frequent cases of childhood abuse are probably defined in this category. Here, the child is gradually introduced into some sexual play or activity. Usually this situation stems from an existing and close relationship with the perpetrator and may or may not have been consciously planned or intended by the perpetrator. The relationship begins as a normal, attentive and even loving interaction.  Gradually, inappropriate touching begins, usually with the perpertrator fondling the child but also may involve the child being encouraged to touch the perpetrator.  The child may be told to keep such behavior a secret, that it is "special" to the child and perpetrator, or even that others would turn against the child if they knew.  Additional behaviors are typically added over time as the perpetrator is successful in having the behaviors occur without censure.  Often, because the child begins to realize that such behaviors are not common to their friends and finally as wrong, the child reports this behavior to an authority figure or a friend.  A report is made and the perpetrator is separated from the child which then ends the abuse.

What is not frequently considered, is the child's perception of the behaviors. We tend to assume that the child will view the behaviors in question in the same manner as do the adults who then deal with the child. We expect children in this position to see themselves as victims because we see them that way. Although somewhat distasteful to recognize, often that is not the case.  This is a somewhat unreasonable assumption on our part when we consider that the history of the child in this involvment began as a positive experience, and often as one that remained largely positive as the pattern of abuse developed.  At what point should we expect the child to shift to an identification with "victim"?

The very definition of seduction is one of shaping the behavior of one, to the wishes of the other.  In child abuse cases the child is "seduced" into accepting the sexual behaviors of the perpetrator as part of a relationship that the child trusts, feels as a close and loving relationship and the usual social cues available to an adult are missing.   As the relationship ages the child may feel the reduction shift to being primarily defined by the needs of the perpetrator, with a reduction of the those cues and behaviors that were characteristic of the initial development of the involvement.  The child's discomfort with the involvement increases but the child is very confused and conflicted.

The factors to consider in this scenario are these. First, the perpetrator was someone close to the child before he or she was a perpetrator in this case. That means there was an existing relationship, positively defined, prior to abuse. Typically the child views the perpetrator as someone of trust and acceptance. Often the perpetrator has genuine feelings of love and caring for the child, and will strongly tell us that.

Too often, following disclosure, the child is encouraged to report how "bad" the behavior was to experience, how much the child "suffered" during the experiences, etc. While the child may quickly learn that these are the appropriate ways to classify the experience, such descriptors are often at odds with the child's recollection of the events themselves. The child may not recognize any elements of having been harmed (until much later) but remembers the attention and attributes of this "special" involvement.  When we inadvertantly put a child in this position we may also increase the child's sense of "guilt", not over the events themselves, but over what the child "does" to the perpetrator by reporting the abuse! Now this is an unpleasant concept, but we cannot afford to dismiss the fact that it does occur.  

Over the years I have seen many examples of how this double bind can be harmful for children. One of the first examples of this kind of damage that I encountered involved a young lady of about 12 years of age whom I met when she was a patient admitted to Milledgeville State Hospital in Georgia. This child was admitted with psychotic symptoms.  Her history indicated a fairly unremarkable history of social and school adjustment, but she had reported to the school that she had been involved in sexual activities with her parents for most of her life.  She reportedly functioned without difficulty through the arrest, trial and sentencing of her father but had an emotional breakdown when she received a letter from her father in jail, assuring her that it was his fault, she was not responsible and that he loved her.  At that point, overwhelmed with guilt for the "betrayal" she felt she had shown her father, she was hospitalized.

I am in no way suggesting that the legal outcome in such cases should be anything different. Of course the father (and mother in my view) in the example above was responsible. Of course he should have gone to jail. Of course we want children to report such events. But we must always be sensitive to the "perceptions" of the child and recognize that they will be different from our own.

In most cases the damage from this perceived guilt will be less dramatically expressed. However various forms of self-punitive behaviors may ensue as the child seeks "punishment" for her (his) perceived wrongs, combined with the disruption of primary relationships and structure. We see deterioration in grades, school behavior, social behavior, sleep patterns, etc. after the behavior is reported in many cases where such problems were not found before the report.   More often we see such patterns developing before the report only to increase dramatically following the report.  In both situations, it is the report that marks an increase in indications of stress.

The child may learn to display "suffering" to the remaining parent or caregivers, to reinforce the image of being truly victimized.  Of course they were victimized, but their own perception may not have been that of a victim prior to discovery. In this situation the sense of guilt will likely increase as the child acts out emotions that were not felt.  At this point the child is very confused and attaches strongly to the show of support that is given due to their displayed suffering.  Therefore the support, a reinforcer, is attached to the displayed emotions of suffering.  Actions reinforced, increase in frequency of occurrence.  

We must learn to take our victims as we find them and not force our image of them into something that may be more comfortable for us, but not helpful for them.  Therapy aimed at understanding "people" can make a lot of sense in this category of cases. Concepts of "good" verses "bad" people are generally not good to pursue although acceptable and unacceptable behaviors can be helpful to explore. "Good children do bad things" is true, but so is "good adults do bad things", as much as we like to believe otherwise. A child may more easily accept that their relative did a bad thing, than that their relative was a bad person, particularly when this is not their perception in the first place. Therapy focus on some events that happen to some people, rather than on "uncle joe" who was involved with the victim,  can help the child feel less unique, singled out and "different". You need your patients to accept and believe your therapeutic input. To do that, you  must start where their beliefs already exist. Your beliefs are not the issue.

C: Undisclosed:

The victim of child sexual abuse who reaches adulthood without reporting that abuse, has in some manner, formed ways of coping with the memory of that abuse. This is not to say that they have successfully dealt with those memories, but they have handled them in some manner.

Beyond that recognition, there is a wide range of emotional damage that may be experienced. The effects of self-impairment that ensues from such descriptions of self, are far reaching. While not presenting themselves as a "victim", the individual may go through life feeling like others would reject them if "they knew" about the abuse.  They feel fraudulent, as not being as good, or intelligent, or likable as others believe they are.  They believe there are things about them that would cause others to dislike them, although if asked to describe these "things", they are wide ranging and not limited to the abuse history.

A particularly sad feature of this scenario is that the actual occurrence of abuse may have been very mild or even non-existent, but the resulting damage from the "belief" or perception of the adult can run the gauntlet of damage. I have seen women who truly viewed their life as ruined by an event that when described, consisted of a very mild event that would be difficult to view as abusive.  I have seen other women who described ongoing intercourse with a relative for years, and as an adult asked why that didn't "bother me" as she grew up. Again, I am not making light of any of these events, but it is important to recognize that it is not the behavior, but rather the perception of that behavior, that is damaging.

The expectation that childhood sexual abuse will cause emotional damage is so common in our society that we have seen some unfortunate examples in which a woman with neurotic symptoms consults a therapist,and is told that the presence of such symptoms indicates the likelihood that she was sexually abused.

Through therapy, this woman may "remember" such abuse, only to discover later that the memory was created by the therapy process. We refer to such events as "False Memory Syndrome" and that in turn makes all such recovered memories suspect. When such cases are found, it seems obvious that we are dealing with the expectations of the therapist, not the patient or the patient's experiences.

Therapeutic efforts in this case need to be aimed at helping the patient explore their own beliefs and ideas, and less on leading the client to where we think those beliefs should be. Interpretations presented to the client should be held to a minimum lest we seriously impede the therapeutic process. These last patients need confirmation that they are of value to the world, not explanations as to why they are not.

D.  False Reporters:

This last catagory is something of a black hole, in terms of understanding just what adjustment problems may stem from the experience.  Experts estimate that somewhere from 2%  to 6% of child abuse allegations are false reports.  This doesn't mean that those children lie, but that the events that they report are not correct.  I once say a young girl who had been investigated by HRS at the age of two, when she reported that she saw her daddy "playing with himself."  Now this is hardly the phrase one would expect to naturally spring to mind when a child encounters male masturbation, but never-the-less it is a popular adult phrase.

The case was dismissed for lack of supporting evidence, but the child's mother pressured for something to be done to protect her child.  The case was presented to HRS two or three times, before the mother sought the support of the Governor of the state.  At that point I saw the girl, now about 4 or 5 years old.

The child repeated her phrase to me in the form of a valid complaint against her father.  Clearly she saw this as something that the father should not do.  Clearly she saw it as "bad" behavior.  However when I asked her to describe where this occured, in which room, what the father was wearing, how he went about "playing" with himself, etc. all the child could say was, "I don't know".  Clearly this child was brought to believe in the phrase, but without any substance to attach the phrase to.

On another occasion, a 10 year old girl made the same complaint.  This time, she demonstrated the action, by taking her closed fist and moving it to and from her own lap to show me how he played with himself.   She was very convincing in this demonstration, and she had been seen by a number of people, convinving them all of the father's behavior.  I asked her was her father standing or sitting when he did this (sitting), did he have his shoes on (yes) or his shirt on (yes) ...his pants on (well yes).  Did he have all of his clothes on (yes) or were any of his clothes undone or open (no) etc.  In this case, the child had seen someone "demonstrate" adult male masturbation, but the demostrator did not have a penis in their hand at the time.  This child was instructed in how to make a false report.

Rare events?  We all hope so.  The question is, how does it impact on the child growing into the adult years, to carry the knowledge of false reports (even if this knowledge was late in development ) and the impact of those reports on the principals such as court and jail?  I think that this is a terrible burdon to place on a child, and that it will significantly impact on their sense of worth, value and ego.

Summary:

Each of the categories above deserves much more description than I can give them in this brief overview. The important point however is that we should recognize that the range of the problem cannot be adequately reduced to simple terms like "abuse", nor can we simply describe the impact of the experience of abuse by the limits of the actual behavior that occurred. People are too complex for that. Each case must be dealt with as a unique problem, with unique cues for us to attend to, and we must try to avoid thinking of our clients as controlled by the dynamics of the clients we have seen before.  The same caution applies to the dynamics of the abuser and is important for those working with the abuse in therapy, to consider.