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A study of the relationship between childhood incest and interpersonal relationships in adult life Pierce, Kathleen Anne 1989

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A Study of the Relationship Between Childhood Incest and Interpersonal Relationships in Adult Life By Kathleen Anne Pierce B.A., University of Winnipeg, 1971 B.S.W., University of British Columbia, 1988. A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SOCIAL WORK in THE FACULTY OF GRADUATE STUDIES SCHOOL OF SOCIAL WORK We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA July, 1989 © Kathleen Anne Pierce, 1989. In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department The University of British Columbia Vancouver, Canada Date DE-6 (2/88) ii Abstract The purpose of this study is to determine if it is possible to establish a relationship between childhood experiences of incestuous abuse and specific problems in functioning and in interpersonal relationships as an adult. Since incest occurs in families where other dysfunctional features are present, it is usually difficult to separate the different influences on the individual in their family of origin and how they are affected later in life. A single subject was studied using material from audiotaped counselling sessions over a five month period. The contents of the tapes were analysed to see if the client was dealing with difficulties in interpersonal relationships, and if so, how the incest experience might be related to these problems. The study was augmented by audiotaped interviews with five counsellors who work in the sexual abuse field to ascertain their views on the implications of incest abuse on development and its relationship to problems in adult functioning. The study was viewed from a developmental perspective and the stages of trust, identity formation and intimacy were identified as stages of development that were adversely affected by the incestuous abuse. The results of the interviews with the counsellors supported these findings. The findings from the study were also examined by reference to psychoanalytic, loss and feminist perspectives on the nature of the developmental problems the subject encountered. It was found that it was possible to identify specific areas where the incest experiences were seriously affecting the adult survivor, especially in the areas of sexual dysfunction and problems in forming intimate relationships. Other features of the family dynamic were also identified as significant especially the difficulty the subject had in resolving problems in her relationship to her father and stepfather as well as residual feelings of ambivalence in her relationship with her mother. Recommendations were made concerning the need for more research in the area of sexual abuse and the need for many more treatment resources to meet the needs of abuse survivors. i v T A B L E O F C O N T E N T S Abstract i i Table of Contents i v Acknowledgement vii CHAPTER I LITERATURE REVIEW 1 Introduction 1 Effects of Incest 2 Theoretical Explanations 15 Contradictory Findings 25 Methodological Difficulties 29 Summary 31 THEORETICAL FOCUS 32 The Psychosocial Theory of Development 32 Attachment Theory 35 Incest: Implications for Development 38 CHAPTER II RESEARCH DESIGN & METHODOLOGY 45 The Ideal Study 46 Methodological Considerations 47 The Research Study 50 Limitations of the Study 57 Summary 59 CHAPTER III RESULTS OF THE STUDY 60 Biographical/Social Assessment 60 Clinical Impressions 64 Presentation of the Findings 66 Presenting Problem 66 Findings 68 Relationships 68 Relationship Wi th Self 69 Relationship wi th Mother 71 Relationship Wi th Stepfather 72 Relationship W i t h Father 73 Relationship Wi th Males 74 Themes 76 Trust 76 Authentici ty 76 Basic Social Processes 77 Cognitive Confusion 77 Emotional Expression 78 Integration 78 Interviews With Professionals 79 Themes 80 Attachment and Development Implications 81 Specific Effects of the Incest Abuse 83 Summary 85 CHAPTER IV DISCUSSION & RECOMMENDATIONS 86 Development and Attachment Issues 87 Explanatory Theories 91 Psychoanalytic Perspective 91 Losses 97 Feminist Perspective 100 vi Specific Problems Related to the Incest and Physical Abuse 103 The Therapeutic Relationship 105 Significant Findings 107 Summary and Recommendations for Further Research 109 Poem: Stolen Innocence 112 REFERENCES 113 Appendix A 118 Appendix B 119 Appendix C 120 Appendix D 122 v i i Acknowledgement I wish to express my thanks to the School of Social Work at the University of British Columbia; most particularly Madeline Lovell and Hal Goodwin who offered valuable criticism and support in the preparation of this manuscript. I would also like to thank the unnamed client for allowing herself to be the subject of this study and who continues to discover herself in her life. I would also like to thank the professional counsellors who gave of their time and expertise in providing valuable supporting data for this study. Finally I would like to thank my partner, Paul, for his continued patience, support, belief and encouragement throughout this project. 1 CHAPTER I LITERATURE REVIEW  Introduction The effects of childhood sexual abuse on the future functioning of the adult are dependent on the relationship of a number of factors. These include the child's own intrapsychic processes, the family dynamics in which the abuse occurred, the nature of the abuse, the relationship to the perpetrator and so on. In this section of the report we will be looking at a cross-section of the literature in the sexual abuse area. The first part will look at studies which identify some of the effects of incest/sexual abuse on the later functioning of adult survivors. The second part will examine selected theoretical explanations of childhood sexual abuse and its aftermath. The third part will present some contradictory findings and methodological difficulties in various of the studies presented. The final section will summarize the material presented and address any outstanding methodological concerns. A word must be said about language. Incest in its broadest definition can mean a sexual relationship or contact between two related persons, excluding the marital relationship. Generally the term sexual abuse is used to describe the category of abuse to differentiate it from physical or emotional abuse. The term incest then is a sub-category of sexual abuse which refers specifically to sexual abuse occurring within the family. The type of incest referred to in this report is sexual contact or interaction between a father or person in the father role, for example, a stepfather, and a female child. The majority of the studies presented here are dealing with father-daughter incest. 2 Effects of Incest Jehu, Gazan and Klassen (1985) identified three groups of women who make up the population of sexually abused women in Canada and the United States. The first group is all those women who have experienced childhood sexual abuse, estimated at between one fifth and one half of all females. The next group are those of group one who experience psychological problems in adulthood. Just how large this sub-group is and the totality of types of problems they have is not known. The third group are those of group two who seek treatment. Because those who seek treatment represent a relatively small proportion of all those who have been abused there is a problem with the generalizability of the findings from clinical studies. Such women may be more disturbed by the incest experiences than others. Jehu et al. (1985) also note that the effects of sexual abuse are difficult to separate from other environmental factors. Nevertheless they identify a wide range of psychological problems that are experienced by previously abused women and divide these into three general categories: emotional, interpersonal and sexual. Jehu et al. (1985) studied a group of 22 sexually abused clients who had been sexually abused by a total of 45 offenders of whom one third were in the father role and two thirds were familial relations. From this group the emotional problems listed included low self-esteem (19 of the 22 clients), guilt associated with the abuse (18 of the 22 clients), depression (18 of the 22 clients), and miscellaneous complaints such as sleep disturbances/nightmares (16 clients), anxiety/phobic disorders (13), dissociation (12) and obsessions/compulsions (6). The 22 subjects exhibited a number of difficulties in interpersonal relations. Under general problem areas in social 3 relationships, 18 identified limited social skills and feelings of difference from others, 16 felt mistrustful of others and insecure in relationships and 11 were isolated or alienated from others. In relationships with men 17 expressed a fear of intimate relationships with men, 13 stated a fear of men, 11 tended to overvalue men and 9 avoided long-term relationships with men. Of particular significance is that all 9 women of the 22 who were in live in relationships expressed partner discord, 4 were oppressed by their partner and 3 were abused by their partner. Jehu et al. also noted a tendency for abused women to oversexualize their relationships, reflecting the belief that "no man could care for me without a sexual relationship" (p. 36). In regard to women, 8 of the 22 expressed anger and hostility toward other women. The third category of difficulties, sexual problems, was also well represented in this sample. 10 of the 22 clients noted a lack of interest in sex and 9 of the women experienced phobic reactions to sex. These may include reactions to being touched in certain ways, experiences of flashbacks and reactions to experiencing pleasure in the sexual encounter. 12 of the 22 women experienced impaired arousal either physiologically and/or psychologically. 7 clients noted impaired orgasm with a difficulty to reach climax during sexual encounters and 13 women experienced sexual dissatisfaction (Jehu et al., 1985). In her study, Meiselman (1978) addresses the question of the long-term effects of incestuous abuse. She realizes that it is difficult if not impossible to separate the effects of incest from the effects of being raised in a dysfunctional family. Therefore, because incest is not something that occurs in isolation Meiselman includes in the aftereffects of incest the family dynamics both before and after the abuse occurs. However, Meiselman further states that 4 even though an absolute cause-effect relationship between incest and later problems in adult life cannot be proven this does not mean that a relationship does not exist. She states that "it is possible to make relatively objective observations of various patient characteristics, such as appearance, presenting problems and degree of disturbance in the present and determine whether these characteristics are associated more frequently with incest case histories than with other typical case histories" (p. 198). Meiselman uses the analogy that cigarette smoking is to cancer as incest is to later problems. Meiselman's (1978) study consisted of an inpatient study of 26 cases of father-daughter and stepfather-stepdaughter incest. There was also a control group of 50 non-abused inpatients who had sought psychotherapy. Meiselman does not differentiate between natural fathers, stepfathers or adoptive fathers for the purposes of this study. Meiselman found that the patients reporting incest had more complaints than the control group and these fell into four categories: conflict with or fear of husband or sex partner, conflict with parents or in-laws, physical problems and sexual problems. In the first area, Meiselman (1978) found that there was greater marital instability and/or rejection of marriage as an option in the incest group. 39% had never been married and those who had been married had only been married 39% of the time as compared with 2 0 % and 55% respectively for the non-incest group. One hypothesis concerning the choice of marriage partner of incest survivors is that they are trying to find a father-figure. However, the daughters in this study were not seen as seeking father-figures. In fact the psychologically disturbed adult daughter is often seen as seeking to escape from men and sexuality rather than trying to recreate the incestuous relationship. Another possible explanation for difficulties in relationships for 5 adult survivors is that they are masochistic, that they seek out or passively tolerate abusive relationships. It is unclear if the pattern of repeated involvement in abusive relationships is a result of the incest experience or of the family dynamics which may have predisposed the daughter to assume a passive, dependent role. In the area of relations with family of origin members the incest survivors presented with more problems than did the non-abused control group. The areas of conflict centre around the daughters' relationship with their fathers and with their mothers. If the daughters felt strong negative feelings towards the father they tended to avoid him or if they forgave him they maintained contact. The daughters' relationship with the mother tended to be more conflictual since even if they strongly disliked her and blamed her for not helping them, they maintained contact. Perhaps this contact was maintained "out of guilt or a vague hope of finally obtaining the mothering she had missed as a child" (Meiselman, 1978, p. 221). In the area of physical problems one area that was looked at was that of obesity. However, while 31% of the incest group were described as obese 20% of the control group were also obese. There was a tendency for the incest group members to be more obese. This small difference may be due to chance or there may be a specific connection between obesity and incest. Obesity may also be a characteristic of psychologically disturbed women in general rather than specific to incest abuse victims (Meiselman, 1978). In looking at the area of psychopathology in the incest survivor Meiselman sites a study by Kubo (1959) which states that he found daughters of father-daughter incest to be much more disturbed than those who experienced brother-sister incest. However, Meiselman states that in her 6 opinion there is no association between father-daughter incest and any particular kind of disorder or pathology. She holds this opinion because the studies that resulted in diagnosis of character disorders or psychosis were done in settings which favoured these results and were based on very small samples or were conducted without a control group. She states that this is not to say that incest has no effect but rather that Incest is a serious source of stress that usually occurs in association with many other unfavourable background factors...(and)...tends to predispose the daughter to become psychologically disturbed, but the precise nature of that disturbance...is...conditioned...by a host of other genetic and environmental factors that are only tangentally connected with incest (1978, p. 204). Meiselman further states that "it seems more likely...that the occurrence of incest does not create psychiatric conditions do novo but does predispose the individual to certain kinds of problems such as difficult relationships with men or sexual maladjustment" (1978, p. 204). The area of problematic sexual functioning received considerable attention. Meiselman (1978) found that there was a significantly higher incidence of sexual problems among survivors than among the non-abused patients. 87% of survivors versus 20% of the controls had sexual problems. She did find two cases with no sexual problems and found that in both cases the women, both as children and as adults had been competent and assertive and had insisted that the abuse end and did not tolerate abuse in current relationships. In looking at the frequency continuum of sexual activity Meiselman addresses the question of promiscuity and questions the definition of this word. If promiscuous means having more than one partner 7 premaritally or any extramarital activity, then many of the incest survivors would qualify. However, if a definition is used which takes into account current standards then only those clients exhibiting the most extreme behaviour would be considered promiscuous. Meiselman (1978) also examined the frequency of prostitution and found that only one woman in her sample had had such experiences in her background. In the area of orgasmic dysfunction 74% of the women in the psychotherapy sample had experienced orgasmic dysfunction in one or more heterosexual relationships. No specific mention was made of the prevalence of sexual dysfunction in the control group. It was hypothesized that unresolved conflicts from the incest situations were aroused in later sexual situations. Some of the women found that they could be orgasmic in specific situations and others avoided men completely while others associated with "safe" men, that is, men who were homosexual. Meiselman (1978) also addresses the area of lesbianism. 7 of the 26 women incest survivors had had some lesbian experience. By comparison homosexual behaviour was rare among the control group of psychotherapy patients. "Apparently father-daughter incest as a traumatic conflict inducing heterosexual experience in early life is associated with an increased incidence of lesbian feelings and behaviour in maturity, although the majority of postincest daughters remain heterosexual" (p. 259). Citing a study by Gundlach and Riess (1967), Meiselman refers to a nationwide (USA) survey of 217 middle class lesbians and 231 non-lesbians. They found that although some of the lesbians had experienced heterosexual trauma before age 15, 82% had no such experience. Although no absolute causal connection between incest and lesbianism can be made, it seems plausible that overt incest may 8 sometimes contribute to female homosexuality in some instances. "However while father-daughter incest frequently results in lesbian orientation in women who are psychologically disturbed, incestuous experience is not a background factor for the majority of self-identified lesbians" (p. 260). One difficulty with many of the studies in the sexual abuse area is that they are done with clinical populations. Diana Russell in her seminal study of 930 women in the San Francisco area conducted one of the few representative samples in this area (Russell, 1978). As such, the findings from her study are particularly useful. She found that 16% or 152 women had experienced incestuous abuse. In addressing the question of why incestuous abuse is an important issue Russell states "incestuous abuse is an important social problem because of the intense suffering and sometimes destructive long-term effects that result from it" (1986, p. 11). Russell further states that although long-term effects are not felt in all cases this is little consolation for the suffering that occurs in the short-term and for the long-term consequences that are felt by some. She states "we have only recently begun to uncover the extent to which child sexual abuse in general appears to be at least one of the causitive factors in many serious manifestations of self-destructive behaviour in female adolescents and adults" (p. 12). Russell (1986) compared her community sample of 152 incest victims from the San Francisco area with Judith Herman's sample of 53 women outpatients involved in short-term therapy groups for incest victims in the Boston area to examine the long-term effects of incestuous abuse. Russell found that 75% of the patient group reported incestuous involvement with a father or stepfather, as compared to 26% of the survey group. The patient group were also more likely to have been abused by more than one relative as 9 compared to the survey group, (23% versus 16%). The age at onset was younger for the patient group, (30% versus 11%). The level of force used was greater for the patient group than for the survey group, (23% versus 3%). Russell (1984) examined the same 152 incest victims of her 1978 survey to compare the prevalence and seriousness of abuse by fathers as compared to stepfathers. Russell found that the prevalence rate for abuse by stepfathers was one in six women whereas the prevalence rate for abuse by a biological father was one in forty. Russell also found that abuse by a stepfather was much more likely to be at the most serious level. Russell further compared those in her survey who had suffered the most extreme trauma to those who had suffered the least trauma. Russell had found that the victims identified in her survey were Significantly more likely than women who had never been incestuously abused to be divorced or separated at the time of the interview, to be younger at the time of first childbearing and to have defected from the religion with which they were raised (1986, p. 192). By comparing the most severely abused women to those women least severely abused in the survey, Russell found that those most traumatized were more inclined to marry, were five times more likely to be divorced or separated and were more likely to raise one or more children. On the social class status assessment Russell found three of five factors significantly related to the degree of trauma, namely, the victim's occupational status, her husband's educational status and her total household income. "Incest victims who reported extreme trauma held significantly lower status occupations in their adult lives than the victims who reported lesser degrees 10 of trauma" (Russell, 1986, p. 199). Further, they also had husbands with lower occupational status and had lower household incomes. In addition to the objective measures used in this study Russell also employed a subjective measure to assess negative life experiences. When asked to specify how their experiences of incestuous abuse had affected their lives, many victims spontaneously mentioned negative feelings about men, sex, or themselves. However, few of the women made a direct connection between their childhood sexual victimization and later negative life experiences such as adolescent pregnancy, marital separation or divorce, or repeated sexual victimization, although such experiences are much more common among women who have been incestuously abused than among those who have not. This seems to indicate a lack of insight on the part of these women into the relationship between their sexual abuse experiences and later negative life events. When Russell (1986) looked at the relationship between the objective and subjective measures of trauma reported by most victims she found a significant relationship. "This positive correlation is important because it shows that subjective measures can be useful, even years later, as indicators of long-term negative life experiences" (p. 202). Russell also identified five characteristics of incest that are statistically significant in relation to negative life experiences. These factors are: the severity of the abuse, relationship of the perpetrator, use of force, age disparity between the victim and her relative and the duration of the abuse. The duration of the abuse related significantly to revictimization and the severity of the abuse related significantly to poverty and downward mobility factors. Russell also noted that in light of the number of factors that influence a person's life, it is remarkable that any of the characteristics of incestuous 11 abuse related significantly to any of the factors on the negative life experience scale reflecting marital difficulties, economic hardship or revictimization experiences. In summary Russell (1986) found, (1) that incest affects the lives of 16% of women before the age of 18, (2) that secondary victims such as non-offending mothers and siblings are often greatly affected, (3) that the traumatic effect of incest affects the lives of friends and intimates at the time of the abuse and later in life, and (4) that the incest experience affects the way survivors raise their children. Herman, Russell and Trocki (1986) elaborated the comparison study already mentioned between Herman's (1981) study of 53 outpatients and Russell's (1986) 152 person non-clinical sample and made note of some shortcomings of the study. They state that of those in the non-clinical sample half of the respondents stated they were almost entirely recovered from the trauma. The authors feel that this may be too optimistic a view since, first, the most severely traumatized in the community were not included in the survey and second, that the statements are from retrospective self-reports in which the respondents only refer to those consequences which they identify as significant and therefore may overlook other features in their lives which may be related to the effects of incest. The authors summarize by saying that further study is needed to ascertain the environmental factors in childhood and adulthood that are significant for long-term recovery for incest survivors. Herman (1981) studied 40 incest victims referred by their private therapists and a comparison group of 20 psychotherapy clients whose fathers were seductive without committing overt incest. She begins by theoretically addressing the question of harm. Herman does acknowledge that not all 12 victims of incest suffer permanent or long lasting effects but says that Child victims as a group are more vulnerable to a number of pathological developments in later life and that a considerable number of them suffer lasting harm...particularly where the sexual relationship involved the use of force, was of long duration, or where the offender was a relative or family member (p. 29). Herman states that several researchers and the pornographic press maintain that no harm comes to the child from incestuous contact and that in fact it may be helpful to the child. Referring to conclusions Larry Constantine (1980) arrived at following a review of 30 studies on the effects of early childhood sexual experiences in about 2500 subjects, in which he postulates that healthy sexual contact can occur between adults and children based on informed consent, Herman challenges the concept of informed consent between children and adults. She states that given the differences in power between children and adults "there is no way that a child .can be in control or exercise free choice" (1981, p. 27). Herman defines incest as "any sexual relationship between a child and an adult in a position of authority" (1981. p. 70). She notes the importance of the relationship between the adult parental power and the child's dependence. Herman defines sexual relationship as "any physical contact that had to be kept secret" (1981, p. 70). She states that from the child's point of view the sexual motivation of the contact and the fact that it had to be kept secret are far more significant than the exact nature of the act itself. "From the moment that the father initiates the child into activities which serve the father's sexual needs, and which must be kept hidden from others, the bond between parent and child is corrupted" (1981, p. 70). 13 From her own study Herman found that the incest survivors suffered from various problems in adult life. They tended to feel different from other people and had feelings of shame, often referring to themselves in derogatory terms. They also suffered from loneliness and had difficulties in forming trusting relationships. The legacy of their childhood was a feeling of having been profoundly betrayed by both parents...(and)...they came to expect abuse and disappointment in all intimate relationships; to be abandoned, as they felt their mothers had abandoned them, or be exploited as their fathers had exploited them (1981, p. 90). 35% of the women described themselves as promiscuous at some time in their lives and had difficulty in forming permanent relationships that were non-abusive (Herman, 1981). An interesting feature of the repeated mistreatment was that most of the women did not express anger towards men but rather "tended to overvalue and idealize men...and...tended to direct their anger towards women...seeming to regard women, including themselves, with contempt" (Herman, 1981, p. 103). Herman theorizes that this may reflect an attempt by the incest survivors to seek a sense of self-esteem by identifying with the powerful male and likewise, their reaction to female relationships may reflect a longing for a caring relationship with a woman. Although the majority of women in Herman's study were heterosexual a small number sought homosexual relationships. The women who were involved in lesbian relationships seemed to regard them as "an adaptive and positive way of coming to terms with the incest trauma" (Herman, 1981, p. 105). Regardless of the nature of their relationships most incest victims expressed problems with sexual enjoyment. These problems included 14 flashbacks to the incest experiences and feelings of being dominated and controlled. As well as their problems, Herman (1981) also commented on the incredible strength of the incest survivors. Many incest survivors despite personal unhappiness are very successful in work and in their obligations to their children. Work and children are often what serve to keep an abuse survivor anchored to life. However, the identity or sense of purpose acquired through work and children are not enough, as incest survivors do not derive much satisfaction from their competence and strength. It is this external strength that prevents the inner pain from being seen. The consequences of incest, like the original events, remain hidden and secret. In their study of personality disturbances of incest victims Wheeler and Walton (1987) use a fairly narrow definition of incest. They define incest to be "sexual relations between two persons so closely related that they cannot legally marry" (p. 598). It is unclear from this definition if this would include step- or adoptive fathers. The sample consisted of 60 subjects, 28 incest victims and 32 non-incest victims who were clients at various counselling agencies. They found that the personality profiles of the two groups differed significantly. The composite personality profile of the incest population indicated a basic personality style as asocial, avoidant, submissive and passive-aggressive. There was a high prevalence of borderline personality disorder and symptoms of anxiety, depression, substance abuse and psychotic thinking. Bryer, Nelson, Miller and Krol (1987) and Bagley and McDonald (1984) both found that the repercussions of childhood sexual abuse in adulthood were compounded when physical abuse was present as well. Bryer et al. in 15 their study of 66 psychiatric patients found that "the correlation of the severity of adult psychiatric symptoms with childhood physical and sexual abuse is the most important finding" (1987, p. 1429). In their study of 57 maternally separated girls (of whom 20 were sexually abused) and a control group of 30 girls who had experienced a non-disruptive childhood, Bagley and McDonald (1984) found that there was a higher correlation between sexual abuse and symptoms of depression, sexual maladjustment and poor self-esteem than there was in connection with physical abuse, neglect or maternal separation. They conclude that The evidence—suggests that (a) the adverse effects of untreated sexual abuse during childhood, within the family context are indeed frequent, gross and long lasting; (b) those effects are intertwined with but distinguishable from the effects of other early trauma...and that sexual abuse has specific influences on later mental adjustment (1984, p. 24). Tsai and Wagner (1978) in studying groups for women who had been sexually abused, found many of the same symptoms of abuse that previous studies have found in clinical samples of individual women. The format of group therapy conducted with these women focused on issues of guilt, negative self-image and depression, problems in interpersonal relationships, mistrust of men, inadequate social skills, repetition compulsion and sexual dysfunction. It was found that the short-term therapy group helped alleviate some of these symptoms. Theoretical Explanations In this section several theoretical perspectives will be considered that attempt to explain the apparent relationship between childhood sexual abuse 16 and difficulties in adulthood. Browne and Finkelhor (1985) propose a model to conceptualize the impact of sexual abuse. They refer to four factors causing trauma as traumagenic dynamics. These are traumatic sexualization, betrayal, powerlessness and stigmatization. While these dynamics may occur in other kinds of trauma, in sexual abuse all four of the traumagenic dynamics are present rendering the impact more severe. As a result of these traumagenic dynamics, the child's cognitive and emotional orientation to the world is affected and the child's self-concept, world view and affective capabilities are distorted. Browne and Finkelhor (1985) have identified the four traumagenic dynamics as four broad categories that may be used for organizing and categorizing our understanding of the effects of sexual abuse. Traumatic sexualization is a process which occurs when the development of a child's sexual feelings and attitudes is distorted by sexual abuse. Various factors influence the traumatic sexualization of sexual abuse. These include the degree to which the child understands the events, whether a sexual response is encouraged from the child, the use or absence of force (the absence of which may make the child feel more responsible) and the degree to which the child is encouraged to participate. Betrayal is the realization by the child that someone who they are dependent upon for their survival has harmed them. Children experience betrayal from the abuser and from other members of the family, for example, from the mother who is unable to protect, defend or believe them. Powerlessness or disempowerment is the process of complete disregard of the child's wishes or sense of personal efficacy. Sexual abuse is also a transgression of the physical boundaries of the body. Either by coercion or fear of disclosure or fear of not being believed, the child experiences herself as being trapped in a situation she is unable to escape 17 from. Stigmatization refers to the negative affective consequences of the abuse. The child comes to see herself as a bad person and experiences feelings of guilt and shame, which are incorporated into her self-image (Browne & Finkelhor, 1985). Gold's 1986 study of 103 adult women and 88 controls focused on the subjects' attributional styles for bad events. The hypothesis was that "a person's causal attributions and expectancies mediate response to uncontrollable situations" (p. 471). An attributional style that was internal, stable, and global was expected to correlate with poor functioning. The author found that the victimized women differed significantly from non-victims on measures of "(a) childhood, family and social experiences, (b) attributional style and (c) level of depression, self-esteem and sexual problems" (1986, p. 471). Sexually victimized women's adult functioning was related to their attributional style for bad events, perception of the actual experiences and quality of their social supports. Women who were sexually victimized as children displayed an attributional style for bad events that was internal (self-blame), stable (does not change over time), and global (applies to all situations). Gold's findings were related to the theory of Learned Helplessness (Abramson, Seligman & Teasdale, 1978) which is the belief that events outside oneself are uncontrollable or unaffected by one's actions. In the case of sexual abuse, the abuse is seen as an uncontrollable situation for which the victim often blames herself, and in relation to which she had little or no support in dealing with it, for example from her mother. This study found that the women's perception of the abuse experience and their perception of their mother's response to it, significantly related to their adult 18 functioning, and the nature of their social supports related to their sexual functioning. Conte and Schuerman (1987) also refer to attributional beliefs in their study of young children. They studied a group of 369 abused children and 318 non-abused controls and found that the child's support system can play a key role in ameliorating the impact of the abuse. This study also points out the importance of understanding the victim's perception of the abuse, of his/her role in the abuse, of his/her family supports and the victim's perception of the abuser. Assuming responsibility may bring the child a measure of protection. The authors say that "blaming oneself in an uncontrollable situation may be the only means of maintaining a sense of control and may therefore be associated with less serious impact" (p. 211). Steele also assesses the context of child sexual abuse as a significant factor in the impact of the abuse. In his article Notes On Early Child Abuse Throughout the Life Cycle, Steele (1986) is referring to all forms of abuse. While he recognizes that the different forms of abuse may have different consequences, he demonstrates most concern about how the abuse affects the psychic development of the individual in the cognitive, emotional and social areas because of the disruption in object relations between the child and the caregivers. He notes further that the psychological and emotional setting in which the abuse occurs and the relationship to the offender are key factors in determining the nature of the effect and the extent of the damages. Damage occurs when the abuse comes from someone to whom the child looks to for love and protection and when there seems to be no relief from the abuse. It is not just the physical act but the betrayal of a significant relationship that increases the effects of the trauma. Steele also found some trends towards 19 generational repetition of patterns of abuse wherein the mother of the victim was herself abused as a child. Like other researchers Steele expresses that caution needs to be exercised when trying to draw causal connections between abuse in childhood and problems in the adult, but notes, however, that there are common themes that emerge as we study the life histories of adults who seek treatment. In the area of psychological problems Steele (1986) notes that problems of low self-esteem and identity difficulties are common. He also notes that adult survivors tend to suffer from an inability to find pleasure in a number of areas in life, including the sexual area and that there seems to be a connection between sexual abuse, particularly incest, and juvenile prostitution. Gelinas (1983) looks at persisting negative effects of incest from a psychodynamic perspective. She provides a definition of incest that is similar to that used by Meiselman (1978) in that the relationship between the abuser and the victim is a key element. She states that there are two criteria that define incest, sexual contact and a pre-existing relationship between the adult and the child. Gelinas refers to incest as sexual activity between close relatives by blood, marriage or adoption. Gelinas also concurs with the findings of other researchers in that "sexual abuse by surrogate fathers appears to be indistinguishable in acts or effects on the victim, from that of biological fathers" (1983, p. 313). Gelinas also defines sexual activity as "some form of overt sexual behaviour such as fondling of sexual areas, oral-genital contact and vaginal or anal intercourse" (1983, p. 313). Gelinas further makes note of those situations where, although no overt sexual contact occurred, the situation 20 could be seen as incestuous due to the relational and power dynamics involved. She gives the example of a father who showed pornographic material to his daughter and masterbated in her presence over a period of three years. The daughter in this situation tried to avoid him and was fearful that the situation would progress to physical contact. Gelinas (1983) classifies the persisting negative effects of incest in three categories similar to those used by Jehu, Gazan and Klassen (1985) and Jehu and Gazan (1983). The first category is chronic traumatic neurosis, similar to Jehu et al.'s (1985) emotional category; the second is relational imbalances, and the third is intergenerational risk. Gelinas notes that the incidences of traumatic neurosis are often stimulated by developmental milestones such as sexual development. Of key importance is the author's observation that "the long latency between termination of the abuse and emergence of the traumatic neurosis helps to explain some of the incest literature that contends that victims are not harmed by their experiences or that incest does not carry negative consequences" (p.318). In the area of relational imbalances Gelinas (1983) notes that the incest affects the victim's psychological development and sense of self. She may have an overdeveloped sense of responsibility from being placed in a caretaking role in her family and may be underdeveloped in areas of self-esteem, social skills and personal abilities. This limits her ability to form and maintain relationships with family of origin members, partners, children and friends. These effects may last through a victim's lifetime. The intergenerational implications have to do with repetition of the incestuous situation in the victim's adult relationships. The relational imbalances in her family of origin, if untreated, are at risk of being repeated in the victim's 21 marital relationship as she is likely to marry a male with strong caretaking needs and perhaps put her own child at risk of abuse by demanding caretaking responsibilities of her. In summary Gelinas (1983) notes that the traumatic neurosis and its related elements, such as, confusion, repressed memories and affect, are attributable to the incest itself especially if the perpetrator is a paternal figure. The degree of parentification, that is, the extent to which the child was placed in a parenting role and the relational imbalances in a family contribute to developmental difficulties. These take the form of incomplete separation and autonomy from the parents, a lack of a sense of initiative and the right to have her needs as a child met, as well as guilt and a sense of being responsible for the abuse. The survivor's poor self-esteem seems to be affected both by the incest and the dysfunctional family situation. Tamar Cohen (1983) comments on the inability to establish a cause-effect relationship between incest and psychopathology in the incestuous family. However, a psychoanalytical point of view would suggest that "the occurrence of incest means a severe disruption of the sequence of personality development. Thus, the younger the daughter when incest occurs, the more severe the psychological disturbances she is likely to manifest as an adult" (1983, p. 158). Cohen comments on the implications for the adult's heterosexual relationships. She identifies incest as a specifically sexual form of abuse to differentiate it from the effects of other family pathology and notes that the feelings connected with the abuse are likely to be aroused during sexual encounters. She also notes that the child's defense mechanism of suppression of arousal comes to be the adult's mode of keeping the memories suppressed. However, this defense mechanism limits sexual enjoyment and pleasure. Cohen also notes that relationships with family of origin members 22 will likely be impaired and that the mother-daughter relationship is likely to be ambivalent, encompassing feelings of anger at, and longing for the mother. Cohen sums up her findings by saying that incest is a violation of the child's normal development and threatens her sense of personal security and violates her personal boundaries. The generational pattern of abuse has been mentioned as one of the categories involved in the effects of abuse (Gelinas, 1983). The following studies examine these generational patterns and address some of the questions concerning what factors are important in determining whether abusive patterns will be repeated in the next generation. Joy (1988) studied the cycle of abuse from a generational perspective. She looked at women who had been physically and emotionally abused as children to discover the differences between those women who went on to abuse their own children and those women who did not continue the cycle of abuse. Her key finding was that the abused women who did not abuse their own children were in touch with their own pain, the feelings and emotions of their own abuse experience, while the abused women who did abuse their own children, while cognitively aware that they had been abused themselves, expressed no affect connected with it. The latter group not having re-experienced the anger and other feelings connected with their own abuse seem unable to respond sympathetically to their children and are vulnerable to repeating the abusive patterns. Although this study did not consider sexual abuse itself, there are implications here that may relate to sexual abuse survivors as, if they abuse their children it is often of a physical and/or emotional nature; or their children may be vulnerable to being set-up to be sexually abused themselves (Gelinas, 1983). 23 Raphling, Carpenter and Davis (1967) present a generational study of incest. This is a case study of a single family in which three generations of incestuous activity and a variety of incestuous relationships were reported. The grandfather had an incestuous relationship with his eldest daughter and his son did the same, that is, with his sister. The grandmother initiated incest with the son which disgusted him. The grandfather initiated incestuous contact with the two youngest daughters and the son also started incestuous relations with them, that is, with his younger sisters. As an adult the son had sadistic sexual relations with his wife and eventually started incestuous relationships with his own daughters. The father initiated his son into incest with his sisters and encouraged him to approach his mother sexually. His mother rejected his advances. The grandfather and an uncle also attempted to have sexual relations with the son's oldest daughter but were rejected. This is a case of intrafamilial generational incestuous abuse. Although the family was aware of the incest taboo, they chose to disregard it. The daughters in both generations who were abused had a number of symptoms such as passivity (in the eldest), abdominal pains, anorexia and gastric problems, depression and apathy. One of the daughters had an attack of transient blindness. What is unusual about this family is that the incestuous abuse was common knowledge to all the family members yet this did not prevent it from continuing. In contrast to the above study, MacFarlane and Korbin (1983) report on a study of multiple victimization within three branches of one family which remained a secret for two decades. 11 female members were sexually abused on numerous occasions over two decades without any of them being aware 24 that the abuse was occurring to other family members as well. The offenders were two males, a father /uncle and a brother/cousin. The father abused his three daughters and a niece and the brother abused his two twin sisters and five female cousins. The secrecy surrounding the incest in this family was maintained by the feelings of guilt of each of the victims, their fear related to the consequences of disclosure, attachment to and dependency on the abusers and unconscious denial, that is, the belief that this couldn't be happening to anyone else. The disclosure finally occurred in order to protect a young niece from being abused as well. The survivors in this family appeared outwardly successful in societal terms. They were educated, married with families and some had successful careers. However, most of the survivors had difficulties with sexuality and their marital relationships were generally poor. They also suffered from guilt feelings because they held some positive feelings towards the abusers. Of significance to note is that the mothers in all three branches of this family were weak, ill or absent and generally unavailable to protect or support their children. The studies by Joy (1988), Raphling, Carpenter & Davis (1967) and MacFarlane & Korbin (1983) all delineate the intergenerational aspect of abuse. Although these studies do not categorically provide absolute evidence that abuse is repeated in the next generation, they do indicate that this does occur in certain circumstances and the possibility of generational abuse itself argues for early detection and treatment to prevent the cycle of abuse being repeated. 25 Contradictory Findings In this section several articles will be presented which question whether childhood sexual abuse does have adverse consequences in adulthood. Fromuth (1986) conducted a study of 383 female college psychology undergrads. Her purpose was to study the association of childhood sexual abuse with later psychological and sexual adjustment in a non-clinical sample. Her hypotheses were (1) that childhood sexual abuse would be predictive of depression, low self-esteem and general symptoms of psychopathology, (2) that childhood sexual abuse would be associated with sexual problems and extremes of frequency in sexual behaviour, that is, abstinence to promiscuity, and (3) that any association that did emerge would be over and above that predicted by the family background alone. The sample was obtained by verbal announcements concerning the study being made in psychology classes, and the respondents were then self-referred. Because there were no figures kept as to how many heard the announcements, it is not possible to determine the percentage who responded. Of the 482 respondents, 22% or 106 reported at least one sexually abusive relationship while a child. The average age of the respondents was 19.41 years and they were 98% white and middle class. 383 women completed all sections of the questionnaire. As an incentive, the respondents were granted extra course credits for their participation. The questionnaire contained a number of scales including parental support scale, locus of control scale, Beck depression inventory, Hopkin's symptom checklist, Rosenberg's self-esteem scale, sexual self-esteem scale, as well as items requesting demographic information and data regarding family 26 h i s t o r y a n d r e l a t i o n s h i p s , c h i l d h o o d s e x u a l e x p e r i e n c e , a n d p s y c h o l o g i c a l a d j u s t m e n t . R e f e r r i n g to the o r i g i n a l h y p o t h e s i s , F r o m u t h (1986) f o u n d a h i s t o r y o f c h i l d h o o d s e x u a l a b u s e w a s n o t s i g n i f i c a n t l y p r e d i c t i v e o f d e p r e s s i o n , l o w s e l f - e s t e e m , o r g e n e r a l s y m p t o m s o f p s y c h o p a t h o l o g y , n o r w a s i t a s s o c i a t e d w i t h s e x u a l p r o b l e m s o r the f r e q u e n c y o f s e x u a l b e h a v i o u r . H o w e v e r , F r o m u t h d i d f i n d tha t a h i s t o r y o f c h i l d h o o d s e x u a l a b u s e w a s p r e d i c t i v e o f p h o b i c a n x i e t y f r o m the H o p k i n ' s s y m p t o m c h e c k l i s t sca le a n d w a s a s s o c i a t e d w i t h n o n - c o i t a l s e x u a l b e h a v i o u r o v e r a n d a b o v e t h e e f fec ts o f f a m i l y b a c k g r o u n d . It m a y a l s o b e r e l a t e d to w h e t h e r o r n o t s e x u a l i n t e r c o u r s e h a d e v e r b e e n e x p e r i e n c e d . T h o s e w i t h a h i s t o r y o f s e x u a l a b u s e w e r e m o r e l i k e l y to r e fe r to t h e m s e l v e s as p r o m i s c u o u s , w e r e m o r e l i k e l y to h a v e h a d h o m o s e x u a l e x p e r i e n c e a f ter age 12 a n d w e r e m o r e v u l n e r a b l e to b e i n g i n v o l v e d i n s o m e f o r m o f n o n - c o n s e n s u a l s e x , t ha t i s , r a p e , o r a n y e x p e r i e n c e w h i c h i n v o l v e d the u s e o r t h rea t o f f o r c e . T h e r e a r e s o m e p r o b l e m s w i t h F r o m u t h ' s s t u d y w h i c h m a y af fec t the r e l i a b i l i t y o f h e r f i n d i n g s . T h e f i r s t i s the q u e s t i o n o f g e n e r a l i z a b i l i t y . H e r s t u d y w a s a s e l f - r e f e r r e d , h o m o g e n e o u s g r o u p o f y o u n g c o l l e g e w o m e n . T h e r e f o r e t he r e s u l t s m a y n o t be r e p r e s e n t a t i v e o f o t h e r w o m e n o f d i f f e r e n t a g e s , races a n d e d u c a t i o n . S e c o n d , the sub jec ts w e r e s e l f - r e f e r r e d w h i c h m a y h a v e p r e c l u d e d t h o s e w i t h s i g n i f i c a n t p r o b l e m s f r o m r e s p o n d i n g . T h e m o s t f r e q u e n t s e x u a l o f f e n c e r e p o r t e d w a s s e x u a l f o n d l i n g (50%), w i t h i n t e r c o u r s e a n d o r a l g e n i t a l con tac t b e i n g ra re . 6 0 % of the o f f ences w e r e s i n g l e o c c u r r e n c e s . T h i r d , the y o u n g age of the r e s p o n d e n t s m a y h a v e p r e c l u d e d i n f o r m a t i o n c o n c e r n i n g s e x u a l p r o b l e m s that m i g h t b e p r e s e n t i n o l d e r 27 women. Fourth, nowhere in the study was the term sexual abuse used, so this may have affected the type of responses given. Martinson (1979) presents a discussion of child sexuality. He states that the North American view of sexuality has been to see it first as a basis for gender identity and role socialization, then as a means of procreation and lastly as a source of pleasure. As changes have occurred for adult sexuality in moving away from sex solely as procreation and acceptance of sex for pleasure, he raises the question of changing our conception of child sexuality to include individual child sex play, autoerotic sex play with other children, and adult-child sex play as valid sexual activities. The traditional view of child sexuality has been as a means of identity and role formation and the erotic side of child sexuality has been denied. The author postulates that sexual activity within the family, that is incest, is not negatively regarded in all families or communities in North America. He refers to writings of the children's rights literature and Parent Liberation literature which speaks of family sexuality and claims that sex as gender identity and sex as affectional erotic activity are dependent on cultural goals and norms regulating child sexual conduct (Martinson, 1979). He claims further that sexual activity does not damage people but that abuse of sexuality does. The author defines abuse as sexual activity involving coercion, violence or rape. He blames the effects of sexual abuse not on the events themselves but on the incest taboo that creates guilt and conflict in the child. In summary, Martinson (1979) claims that very young children are capable of and appear to enjoy sensual, including sexual, activity, and that early sensual stimulation contributes to physical and psychological 28 development. He further states that most persons do not appear to be seriously harmed by their experiences and that extensive sexual experience in childhood contributes towards an easier transition to adulthood. Constantine (1979) reviewed 30 studies which looked at the impact of childhood incest and sexual encounters with adults which included over 2500 subjects. He analysed these studies for outcomes of the abuse experiences that were either negative, neutral or positive. "A negative outcome (10 studies) is a finding or conclusion that childhood incest or other sexual encounters were disturbing or traumatic, or impaired the children who participated (at the time or later as adults) in social, emotional or intellectual functioning" (p. 155). Despite the classification all but one study reported some negative findings. Those classified as neutral (14) were studies where some or all subjects were not harmed or damaged or were not significantly different from the general population. Positive studies (6) were those where some subjects benefited from the experience. Although Constantine notes the contradictory findings of various studies, he also notes that the absence of harmful effects does not mean these experiences were harmless, neither does the presence of effects mean that the experiences were harmful. He states that the contradictory findings make one thing clear, that some children are not detrimentally affected by early sexual experience with adults or with family members. He does not mention the obvious converse, that therefore some children are adversely affected. In summary, Constantine states that the factors found to influence reactions and outcomes in childhood sexual experience are not special or limited to experiences prior to puberty or post puberty. He states that childhood sexual experiences do not differ qualitatively in their effect from those in adulthood. 29 In addressing the question of effects of sexual abuse or no effects, Conte (1985) refers to Constantine's (1979) study directly. He states that there seems to be an assumption that if sexual abuse is found not to produce significant long-term effects, that there is nothing wrong with it. As a result, the absence of harmful effects may be used as justification for adults who want to have sex with children. Conversely, child advocates use the possibility of harmful effects to argue against adult sexual involvement with children. Conte (1985) states that above and beyond the question of effects of child sexual abuse, are the larger questions based on social, personal, religious, ethical and political principles which concern the way an enlightened society wishes its' children to be treated, what kinds of experiences they should be exposed to and how adults may or may not use them. He states further that the question of effects of sexual abuse should not be the primary consideration in establishing socially accepted principles of adult-child interactions. Similarly Greenberg (1979) also comments on the question of harmful effects of childhood sexual . abuse. He states that "the absence of unequivocal evidence of damaged children in no manner supports any hint or fantasy that childhood sexual experiences, especially incest, facilitate development, strengthen mental capacities or increase adaptational functions" (p. 28). Methodological Difficulties In general there are considerable methodological difficulties with the studies conducted on sexual abuse. Often the samples are drawn from clinical populations which may represent those who suffer the most severe effects but do not provide the whole range of effects (Meiselman, 1978). Therefore, the question of generalizability is raised. It is unclear how relevant the findings 30 are to the general population. Another common feature of many studies is the small size of the sample (Jehu, Gazan & Klassen, 1985). This again raises the question of generalizability. How is it possible to extrapolate general indicators from so small a sample? Many studies lack a control group with which to compare outcomes (Bryer, Nelson, Miller & Krol, 1987). Furthermore, it is extremely difficult to control for family background influences. As a result, it is difficult to separate the possible effects of the incest from those of the dysfunctional family background. A final feature of many studies is that the measurements used or research methods used are difficult to replicate and therefore do not facilitate the repetition of similar studies in different settings. This makes the comparison of studies difficult. An example of this latter problem is the study by Russell (1986). She conducted a quantitative survey of 930 women. The object was to discover the true magnitude of incestuous abuse, extra-familial child abuse, rape, and other forms of sexual assault. Russell employed two methods, the first was face to face interviews which involved 39 questions which elicited the subjects' subjective responses. These responses were then analysed using an objective measure of a 9-point, negative life experience scale. While some significant relationships were found between sexual abuse and later negative life experiences, the scale itself was an artificial construct that was arbitrarily imposed on the data. Since it gave equal weight to a variety of negative life experiences that ranged from early pregnancy to abusive relationships, that may have very different meanings and importance to each woman surveyed, the results take on a somewhat biased flavour. Conte (1985) addresses such issues and suggests that further research is needed to develop valid and 31 reliable assessment or measurement devices that apply directly to sexual victimization. Summary Notwithstanding the methodological issues mentioned, the studies included in this literature review provide an overview of some of the problems areas that should be explored with women who have experienced incest or sexual abuse as a child. The four main areas of difficulty are: relationships, including issues of trust, marital conflict and problems with family of origin members; sexual problems, including sexual dysfunction and possible, albeit tentative, connections to lesbian experiences; psychological problems which include low self-esteem, guilt, depression and an increased vulnerability to repeated victimization; and physical problems, including obesity and somatic ailments such as rashes, sleep disturbances and so on. Of particular importance are some of the factors which have been identified as affecting the impact of the sexual abuse. These are the severity of the abuse, the duration of the abuse, the relationship of the child to the abuser, the use of force and the age disparity between the child and the abuser. Also, a key finding was that the presence of physical abuse with sexual abuse compounded the trauma experienced by the child. All these factors seem to indicate that incest and sexual abuse have a significant impact on the lives of girls and women. The long term effects of incestuous abuse which have been presented in the review of the literature need to be considered in relation to the development of the child. These effects may be related to and affect the developmental stages and bonding process and as such have implications for 32 therapy. This report will now present the theoretical basis of the current study. THEORETICAL FOCUS In this section of the literature review two theories will be addressed which focus on areas of human development which may be significantly affected by incest and by other problematic dynamics in the incestuous family. These two theories are the Psychosocial Development Theory by Erikson (1963) and the Theory of Attachment by Bowlby (1969). The Psychosocial Theory of Development Erik Erikson, an ego psychologist, proposed a theoretical conception of development from birth through the adult years. Unlike Freud's concept of psychosexual stages which focused on impulses connected with the Id, Erikson's emphasis was on ego functions and how the development of the ego was interrelated with the social environment in which the development occurred. Erikson's theory of psychosocial development was the first to emphasize development throughout the life cycle. Erikson describes the shape of this development with eight developmental stages. These are: Age Positive Negative Mature Age 65-+ 8. Integrity vs Despair Adulthood 25-64 7. Generativity vs Stagnation Young Adulthood 20-24 6. Intimacy vs Isolation Adolescence 12-20 5. Identity vs Diffusion School Age 6-11 4. Industry vs Inferiority Play Age 4-5 3. Initiative vs Guilt Early Childhood 1-3 2. Autonomy vs Shame Infancy Birth-1 1. Trust vs Mistrust (Phares, 1984, p. 116). 33 This report will be concerned with the first six stages. At each stage there is a critical juncture which forces the individual to resolve a particular crisis of development. This is not usually resolved completely positively or negatively but it is the degree of balance of the positive to the negative that is important (Phares, 1984). Because the outcome of each developmental crisis is not completely resolved at each stage, the issues remain to be addressed as development continues. Trust versus mistrust, for example, is the key psychosocial developmental task in the first year of life. If a basic sense of trust can be established in the infant through the interrelationship with a significant caregiver, usually mother, then the infant has a good foundation upon which to progress to the stage of autonomy versus shame and doubt. The stages are cumulative and each stage affects the ones following. The successful resolution of the preceding stage prepares the child to meet the next developmental challenge. However, if the child fails to satisfactorily negotiate the crisis of trust versus mistrust, for example, then the successful negotiation of future stages is jeopardized. Even if the issue of trust is resolved satisfactorily at stage one, the sense of trust established can be affected at later stages by events in the environment, such as the death of a parent, or by abuse and neglect. During the first year of life, the critical social task is to establish a basic sense of trust. This involves the establishment of primary attachment in the parent-child dyad (Anderson & Carter, 1984). The infant must develop a feeling of trust in others and in the self through the initiation of an object relationship with the primary caretaker. The stability of this relationship allows the child to establish an inner certainty as well as an external 34 predictability (Anderson & Carter, 1984). Poor attachment to a primary caregiver has been associated with the inability to form interpersonal relationships as an adult (Cleveland, 1986). The second stage deals with the issue of autonomy versus shame and doubt. The child is dealing with the conflict between the need to assert herself as an autonomous being and the feelings of doubt that she is able to do so. The move towards autonomy involves giving up some of the dependency on the primary caregiver. This occurs as the self develops and comes to be differentiated from the primary relationship. For successful negotiation of this stage the child must be treated with dignity and respect. If the child fails to develop a sense of autonomy she will experience feelings of shame, doubt and unworthiness (Cleveland, 1986). The third stage involves the issue of initiative versus guilt. The child is engaged in a quest to establish who she is, in other words, a sense of self. Successful negotiation of this stage will provide the child with a sense of purpose and direction and will enable her to initiate social behaviour and transactions (Anderson & Carter, 1984). To accomplish this task the child must move away from the family of origin and widen her social contacts, especially with other children. Parental attitudes that are discouraging can create feelings of inadequacy or guilt within the child. Erikson's fourth stage is that of industry versus inferiority. Here the child is attempting to master the learning tasks posed by the larger social institutions, such as the school and the church as well as the informal social structures of peers. What is key here is the feeling the child has about her own competence, that she is able to do things. Without this feeling the child will feel inferior and doubt her abilities. 35 The fifth stage deals with the issue of identity versus diffusion. Erikson later came to refer to this as identity versus identity confusion (Anderson & Carter, 1986). This is the task of the adolescent who must ask and find answers to the question, "who am I?". The search for personal identity involves feelings of worth and competence but is more than the integration of the childhood identifications. It is the integration of the previous experiences, with the changing physical self, with natural attributes, and with the available social roles (Erikson, 1963). Ego identity means an internal identity that is consistent and an external identity that is acknowledged by others. Identity confusion results from a lack of this internal consistency and the inability to identify adequately with others. The crisis of identity must be resolved before the later tasks of adulthood can be accomplished, especially those involving intimate relationships with another. The final stage we will consider is that of intimacy versus isolation. This adult period calls for the individual to maintain their own ego identity and share this sense of identity with others. The theme of this stage is that of caring, the ability to nurture and feel concern for others. Erikson paid particular attention to the first stage of trust versus mistrust and to the fifth stage of identity versus identity confusion. This is consistent with much of the child developmental research which focuses on the critical periods of infancy and adolescence. Attachment Theory Closely related to Erikson's first stage of trust versus mistrust is Bowlby's (1969) theory of the attachment process between the infant and the primary caregiver who is usually but not necessarily the mother. The relationship with the mother is seen as a "complex interweaving of reciprocal 36 expectations and behaviours that forms a starting point for later relationships" (Parkes & Stevenson-Hinde, 1982, p. ix). Parkes & Stevenson-Hinde elaborate by stating that the first attachment the child makes to another person gives rise to expectations and assumptions about the world which will affect the child throughout her life. Obviously, as with Erikson, this first attachment of the infant to another is seen as a crucial phase in the developmental process and there is again a sense of the cumulative nature of development with effects on the ability of the child to form satisfactory relationships in the future. Attachment behaviour is seen as any behaviour that helps the child establish or maintain closeness to some other differentiated and preferred person who is usually seen as stronger and wiser (Ainsworth, 1982). Typical attachment behaviours in infants are clinging, crying, calling, greeting, and smiling. Attachment behaviour begins at about four months and continues through the second and third years of life when it is particularly strong and then slowly diminishes. Although it is less evident in its frequency and intensity, attachment behaviour persists during adolescence and adulthood and is especially obvious when a person is ill, afraid or disturbed. Bowlby (1969) felt that by the age of one, a child had more than one attachment figure but that these are arranged hierarchically with one person being primary. In a study of 80 children subjected to the strange-situation test with mother, then at a separate time with father, only one child exhibited secure attachment to both mother and father (Ainsworth, 1982). It seems that it is difficult to form a secure attachment to more than one person. Mary Ainsworth, considered an authority on infant/mother attachment, developed the strange-situation test to evaluate the nature of the 37 child-mother attachment (Ainsworth, 1982). Essentially the test involved the child, age one year, and the mother being present in a comfortable laboratory room. First the infant and mother were brought in, then a stranger enters and talks to the mother, then mother leaves, then mother returns and the stranger leaves, then mother leaves the infant alone and the stranger returns, then the mother returns once more. The reactions of the infant are monitored during these steps which occur at three minute intervals. It was found that three groups of infants could be identified. Group B were identified as being securely attached. These children explored actively when mom was present, were upset in the separation episodes and explored little, and responded strongly to the mother on her return, seeking close bodily contact or keen interest in interaction with her. Groups A and C were identified as anxiously attached. Group A exhibited avoidant behaviour. They showed little or no distress during the separation episodes and avoided contact or interaction with mother in the reunion episodes. Group C children exhibited resistance or ambivalence. They were anxious in the pre-separation episodes, very upset during separation, and upon reunion with mother, wanted close bodily contact but also resisted contact and interaction with mother (Ainsworth, 1982). Two main factors of the attachment process were identified; a security-anxiety dimension and behaviour relevant to close bodily contact. Groups A and C could be distinguished from group B along both the security-anxiety and bodily contact dimensions. With respect to the mothers' behaviour, two further dimensions were found, namely insensitivity and rejection. The mothers of the group A avoidant babies displayed an aversion to close bodily contact, were angry, had wooden facial expressions and were compulsive. 38 The mothers of the group C ambivalent babies were more diverse. They were not rejecting and seemed to enjoy close bodily contact but they were highly insensitive to the needs of their children. The mothers of group B, securely attached babies, were comfortable with bodily contact and were sensitive to their child's needs without being overly protective. They seemed bonded to their child and their child attached to them. It is hypothesized that the securely attached babies form a 'working model' of mother in their mind which is revised over time. The tendency of patterns of attachment to be stable over time implies both stability in the nature of the mother's behaviour in interaction with the infant and stability in the infant's own inner organization of her attachment to mother. Incest: Implications for Development Erikson and Bowlby have identified the primary attachment of dependency and trust in the infant-parent dyad to be of crucial importance for the future well being of the child. Researchers examining the long-term effects of incest on adult survivors have found such concepts to be very useful in conceptualizing how incest interfaces with an individual's development. Bergart (1986) uses the Erikson model to help incest clients in group therapy. Bergart identifies the issues of trust, autonomy and initiative as unresolved developmental tasks which are reactivated as the adult survivor attempts to establish close relationships. Adult survivors of incest have learned that, "to trust is to risk betrayal; to be autonomous is to invite the loss of love; to take initiative is to stimulate guilt" (p. 267). Bergart states that most survivors who seek help are in their twenties and thirties and are unable to establish satisfying intimate relationships. The adult 39 developmental task of intimacy versus isolation has become overwhelming and raises problems of flashbacks and feelings of loss of control. Gordy (1983) addresses the developmental stage of trust versus mistrust in doing group work with incest survivors. In discussions with the group members, Gordy conveys to them that it was their parent's responsibility to instill and nurture trust in them and help them move towards autonomy and a sense of their own initiative. As the members experience relief of their sense of guilt around the abuse they realize that a basic sense of trust is essential to developing emotional closeness to another person. Courtois & Sprei (1988) see the therapy process as a time of reparenting when the client can reexperience and rework unresolved developmental tasks. They see Erikson's first stage of trust versus mistrust as being the basic task that affects the client's ability to form healthy and mutual relationships. They also see the tasks of Erikson's second stage, autonomy versus shame and doubt and the third stage, initiative versus guilt as being related issues because of the guilt, shame and sense of badness that the clients' carry as part of their self-image. Cleveland (1986) studied the personal histories of three female survivors of incest abuse. The women were homogeneous in that they were all Caucasian females between the ages of 26 and 28 years of age. They were also currently or had been married and the incestuous experiences involving the natural fathers occurred prior to the subjects' adolescence. Aside from these common variables the subjects differed on socio-economic backgrounds and education levels. In her study of these three women incest survivors and the impact the incest and other factors had on their development, Cleveland analysed their relationships with their mothers, fathers, peers and intimate 40 relationships with males in terms of Erikson's developmental stage theory. She found that the relationship with the mother affected the first two developmental stages in that issues of trust and autonomy were unresolved. Cleveland's study revealed that all three women felt betrayed by their mothers in some way. Two of the subjects' mothers knew of the sexual abuse and did not intervene. The mothers of these same two subjects were also absent from the home frequently which further undermined the establishment of a level of trust. The mother who was at home lacked adequate parenting skills. One of the mothers also lied to her children and husband concerning her extra-marital affairs. She also verbally and physically abused her daughter. These circumstances added to the daughter's sense of helplessness and confusion. In reference to Erikson's second stage, autonomy versus shame and doubt; this was affected by the interaction between the mothers and daughters. All three of the subjects were involved in role reversal with their mothers. The mothers were dependent on the daughters who assumed many of the household responsibilities including care of younger siblings and eventually the sexual role. The role reversals involved the daughters in responsibilities that were beyond their capabilities and interrupted the normal developmental process. Rather than being able to meet their own developing needs for autonomy, the subjects had to meet their mothers' dependency needs. This would suggest an intergenerational repetition of a pattern of dependence as the mothers seemed to have unresolved issues of autonomy themselves. In their relationships with their fathers, Cleveland found that the basic sense of trust had been further eroded and they were left with feelings of 41 mistrust, shame and guilt and had difficulty in subsequent relationships with males. Cleveland (1986) states that the major psychological impact of the incestuous abuse by their fathers was the violation of the child's trust in the parent/child relationship. One of the subjects' fathers was also frequently absent from home and was physically abusive towards his daughter. This further undermined her development of trust. Two of the subjects' fathers engaged in extramarital affairs which also undermined the daughters' sense of trust in their fathers. The chronic marital discord in the families of all three subjects contributed to their mistrust of heterosexual interactions (Cleveland, 1986). The second developmental stage of autonomy versus shame and doubt was also affected by the incestuous relationship. The subject who had been able to stop the sexual abuse by her father had most successfully completed this stage. It is not clear from the study what enabled this subject to end the abuse. This may be related to the fact that this subject's incestuous experiences were of a less severe nature in that they did not progress past inappropriate kissing and fondling. Therefore, this subject did not appear to suffer the extreme feelings of shame and doubt which were experienced by the other two subjects. The act of being able to end the abuse herself seems to have been an empowering experience which gave her a sense of control in her life and the ability to assert herself. This subject also had considerable contact with people and activities outside the home which may have aided her development of a sense of autonomy and initiative. The other two subjects both felt powerless to stop the incestuous abuse. They seem to have assumed responsibility for it and have experienced strong feelings of shame and doubt which interfered with their ability to resolve their issues of 42 autonomy. They also experienced guilt concerning the incestuous abuse which further hampered their developing a sense of their own initiative, the developmental task of stage three (Cleveland, 1986). The nature of the subjects' peer relationships is reflected in the varying degrees of difficulty they experienced in completing Erikson's next three developmental stages; stage three, initiative versus guilt, stage four, industry versus inferiority and stage five, identity versus identity confusion. The category of peer relationships included the amount of involvement each subject had in school and church activities, relationships with siblings, the sex of most of their friends, periods of promiscuity, drug and alcohol abuse and whether or not they had experienced lesbian relationships. Cleveland (1986) reports that all these women failed to develop a positive self-concept in childhood and described themselves as feeling weird or different from others while growing up. "The negative feelings of not being like other people interfered with their ability to get close to others" (p. 101). Hence they tended to develop feelings of guilt rather than initiative. Two of the subjects had limited interaction with other children. This isolation impaired their being able to develop age appropriate patterns of behaviour. In the fourth stage, industry versus inferiority, two of the subjects had success in school. They were able to develop some positive feelings about themselves as they measured their abilities against those of their peers. They also received positive reinforcement from teachers in high school. The other subject dropped out of high school in grade nine due to being pregnant by her father. With limited access to peers or adults as models, she was unable to complete many of the tasks and social skills necessary for successful functioning in society. 43 In the stage of identity versus diffusion, all the subjects were suffering from sex-identification confusion to varying degrees (Cleveland, 1986). The incestuous abuse from their respective fathers and the absence of appropriate sex-role models for males or females resulted in this confusion. One of the subjects is still struggling to develop a sense of personal identity as an adult. Cleveland (1986) analysed the subjects' resolution of Erikson's sixth stage, intimacy versus isolation by examining the nature of the subjects' intimate relationships. Cleveland states that for all the subjects their basic mistrust of males made it difficult for these women to become involved in intimate relationships. All three subjects had been involved in abusive relationships with males in the past. The one subject who had been able to stop the incestuous abuse by her father, was better able to terminate the abusive relationship with a male. The other two subjects tended to repeatedly choose abusive, addicted males as companions. Cleveland suggests that their poor parental role models and the abuse by their fathers predisposed them to expect abuse from males and to feel powerless to stop it. The same two subjects had promiscuous sexual histories. Cleveland (1986) conjectures that the promiscuity served two purposes, as a means of punishing themselves for the guilt they felt because of the incestuous abuse and as a means of seeking the love and affection they lacked in their lives. Two of the subjects were eventually able to establish strong, mutually supportive marriages. In conclusion, Cleveland (1986) identifies the violation of the child's trust as the basis for the major psychological difficulties these women experienced in later life. Cleveland states that the betrayal by the father and the lack of support from the mother made it difficult for these women to 44 establish trust in relationships as adults. Cleveland states further that incestuous abuse with one's father appears to increase the risk of the child having a number of difficulties in later life. Erikson's theory of psychosocial stages of development and Bowlby's theory of attachment are useful ways of both conceptualizing and serving as a framework for the examination of the impact of the traumatic life events in childhood. References will be made to both these theories in the presentation of the findings of the current study. The methodology of the current study will first be presented. 45 CHAPTER II RESEARCH DESIGN AND METHDOLOGY The literature reviewed forms the backdrop for the present study. Various studies were presented which looked critically at the question of the long-term effects of incest. A word must be said about the concept of "effects" of incest on adult functioning. From the literature we are aware that incest does not occur in a vacuum, (Meiselman, 1978) and that there are numerous other features present in the background of the incestuous family, other forms of abuse, marital discord and so on. It is therefore difficult to clearly show direct causal relationships between childhood incest and specific difficulties in adulthood. However, when it's known that incest is a feature in a person's background and they are exhibiting difficulties in certain areas as an adult, sexual dysfunction, for example, we may be able to infer a relationship between these events. The purpose of the present study is to look at the presenting problems and current functioning of an adult incest survivor to determine (a) what present difficulties the client is experiencing, (b) what factors in the client's background might be impinging on her current level of functioning and (c) what, if any, relationship exists between the history of incest and specific areas of dysfunction as an adult. The theory of the psychosocial stages of development and theory of attachment will be used as a framework to discuss the client's present functioning and to identify the developmental issues that remain 46 unresolved. The nature of the client's key family relationships and their impact on the developmental process will be assessed. The incest will be discussed and assessed for impact on the client's development and current functioning in conjunction with additional significant family dynamics. The Ideal Study Since this study has a developmental focus there were several options for the format that would have made for an ideal study. The first option was to focus on the presenting problems, current functioning and life histories of women at different stages of the life cycle but who had each experienced incest at a similar developmental stage in childhood. A second option was to study adult survivors at the same stage of the adult life cycle but who had each experienced incest at different developmental stages as a child, for example, prior to age three, age three to six, and so on. It would have been possible to compare the problems in current functioning to see if there were indications that incestuous abuse at any particular developmental stage had more negative consequences for later functioning. Still another option was the study of clients at the same stage of the life cycle, such as early adulthood, who had experienced incest at a similar developmental stage to determine if there were common presenting problems or common difficulties in current functioning. However, it was not possible for this study to be conducted in one of these ideal forms due to the demands and realities presented by the clinical setting from which clients were obtained. 4 7 Methodological Considerations The clinical setting was that of an agency in British Columbia which specializes in individual adult and child counselling, family treatment, and group counselling for survivors of incest and sexual abuse. Clients on the waiting list are randomly assigned a counsellor. The waiting list for individual therapy had been closed for several months at the time of this study, as those already on the list had been waiting six to eight months for treatment. When the client first contacts the agency (usually by phone) a brief intake form is completed with personal information but rarely with many details concerning the circumstances of the sexual abuse. Thus, it was not usually possible to determine in advance the precise nature of the abuse the client had experienced. The clients assigned to this investigator were selected by the supervising social worker in consultation with the director of the agency. These consisted of two cases of sexual abuse by siblings and one case of sexual abuse by a stepfather. Since the focus of this study is incestuous abuse from a father or male in the father role, only one client assigned to this investigator was appropriate for this study. No other suitable cases were referred to the agency during the period of this study, September 1988 to April 1989. A single case study is considered to be empirically weak, and vulnerable in the case of subject withdrawal. Patton (1980) addresses the question of size and depth in research designs. He states that the decision on size has to do with the nature of the focus of the study. The larger the sample the more data that will be collected. However, this data may have less depth than that of a smaller sample. The advantage of a single case design or a small sample size is that it can provide data of considerable depth. Nonetheless, the findings 48 from the data will not be generalizable to other cases or other populations. To address these issues several possibilities were considered. First the agency was approached to see if it would be possible to conduct interviews with and/or conduct a survey of other clients who were in therapy there. However, because of the sensitive nature of the issues around incest, the agency had ethical concerns with interviews being conducted or with questionnaires being circulated in case they had detrimental effects on the client's therapeutic progress. Some of the potential effects of interviews with sexual abuse survivors are the triggering of suppressed memories of the abuse which may be very painful and distressing and the arousal of feelings related to the abuse experience which have been denied. This can lead to panic attacks, feelings of despair and suicidal ideation. Because abuse survivors are often not aware of the feelings they carry about the abuse, they are often not ready or able to protect themselves from the emotional repercussions of discussing these events. There was also some question as to how rich the data would be if collected solely from questionnaires. The option of conducting interviews with members of self-help groups for adult incest survivors in the community was also considered. However, after discussion with several professionals it was decided that the risk of stirring-up issues that may have major psychological impact was too great. The investigator was also concerned because it was not possible to offer them supportive counselling at the same time. Finally, a third option was considered and chosen. It was decided to augment the single case design by interviewing professional counsellors in the sexual abuse field to gather information on their views concerning the implications of incest for the adult survivor with particular reference to the theories of development and attachment. 49 Given the methodological considerations just discussed, it seems necessary to emphasize the problems encountered in doing research in the sensitive area of sexual abuse. The type of information this study needs requires the individual survivor to consider their present level of functioning, look back at their family history, including the history of abuse, and perhaps make some connections between the past abuse and their present circumstances. This process can cause long suppressed memories of the incest to come flooding back. These memories can shake the foundations upon which the individual has constructed her personality, her sense of being, by bringing into question the myths in her family that have perpetuated the secrecy for so long. Myths such as "our family is fine" or the myth of loving parents, for example. These memories can undermine their sense of trust in reality and they may be overwhelmed with the losses involved. They may be unable to go to work and they may have few trustworthy personal supports to help see them through this crisis stage. The lack of readily available, affordable counselling in this area is also a problem in that a client may often have to wait for months for an appointment. If they become very upset there is a long wait for help given that there are few agencies working in this area and the waiting lists are often closed or very full. The stirring-up of difficult memories and experiences from the past may also de-stabilize a marriage or relationship. The client may also, on becoming aware of the indicators of abuse, start to wonder if her own children have themselves been victimized. Conflicting feelings may also be raised for clients in relation to their mothers and they may experience a sense of betrayal for her not protecting them and not believing them. The impact of this material can be severe enough to lead to suicidal ideation, attempted suicide or self-mutilation to deal with the pain. 50 Substance abuse of alcohol, drugs, and/or food, may also start, resume, or increase at this time as a means of coping with the reactivated memories. From this brief description of the possible impact of research in this area, it is important to ensure that adequate safeguards are in place to lend support to the client. The Research Study The description of this study is that of an uncontrolled, experimental field study of a single case with the perspective being primarily ex post facto, after the fact. Kerlinger (1973) addresses the difference between experimental and ex post facto research. He states that the main difference is in control. In experimental research the investigator has control over the independent variables so that their effect on dependent variables can be evaluated for a cause-effect relationship. In ex post facto research, both the independent and the dependent variables have already occurred in the past. Therefore, it is not possible to control the independent variables which makes it difficult to assert a causal relationship between two events, with any degree of confidence. Caution must be exercised in ex post facto research concerning making statements of cause-effect relationships between events. The most that can be stated is that a significant relationship appears to exist between these events. Reid & Smith (1981) refer to experimental designs as those which deliberately seek to alter phenomena and then study the effects of the interventions. This study differs from the strict experimental model in that the investigator is not attempting to test the outcome of a treatment model or other variable, but rather to gather material from the subject to generate hypotheses concerning the research problem. However, the investigator 51 gathered the data from tape recordings of therapy sessions with the client. By nature, the therapeutic process produces change in the client in terms of her sense of herself and her functioning in the world. By being a part of this process, the investigator influenced the outcome just by the type of questions that were asked. (See Appendix A). However, it was the client who set the agenda of each session and who raised the issues that were dealt with. The investigator therefore is not studying or evaluating the effectiveness of the therapeutic intervention, but rather identifying the issues the client is raising so that these may be analysed for relationships to the childhood incest experiences and/or other preceding events, particularly events that occurred in childhood. This study is theoretical in scope. It's purpose is to gather information to further describe and explain the theory that incest in childhood does have implications for adult functioning. Information was gathered from a number of different sources including a review of the literature, an analysis of the client's tapes, interviews with professionals and the investigator's own knowledge and professional experience. It is hoped that although this is a single case study the information obtained will be detailed. Although not generalizable to other cases the study results may provide material that will further inform existing theories in the sexual abuse area. The data collected from the sessions with the client was primarily retrospective, dealing with events that occurred in the client's childhood as well as events in the client's present life. The material the client is raising is what is impacting on her today and her perspective on how these issues relate to events in her past. The counselling sessions were conducted weekly over a five month period. The data thus not only reflects the issues the client was raising but also incorporates change over time. This dimension adds to the explanatory nature of the study. It is hoped that the material from the counselling sessions will provide evidence to test the theory that there is a relationship between incest experiences in childhood and later problems in adult functioning. Also, the process of therapy over five months will be evaluated as a whole to see if a basic social process of change in the client is revealed which may be helpful in providing additional information concerning the therapeutic process itself. A Basic Social Process (BSP) as delineated by Glasser (1978) refers to a social structure in process, for example, growth or deterioration. A BSP has two or more clear stages and involves a process of change and movement over time. The stages should differentiate and account for variations in the problematic pattern of behaviour. The stages serve an integrating purpose which tie together various sets of conditions, and allows for the theoretical tracing of change over time. Stages have a time dimension with a beginning and an end but the length of each stage can vary considerably. The length of the stage will depend on what brings about the transition from one stage to another. It may be a critical juncture that moves one forward into the next stage or it may be a less clearly marked set of general indicators. In this study the stages of the client's progress through therapy are marked by a set of general indicators. The details of this process will be described in the findings section. The methodological orientation of this study is that of a qualitative research approach. This approach attempts to delineate the character of social and psychological phenomena (Grinnell, 1985). Since this study is not attempting to show a cause-effect relationship between incest and problems in 53 adulthood, but rather to deepen the knowledge about problems in adult functioning for people with incest as a feature in their background, the quantitative approach which is used to count and correlate social and psychological phenomena (Grinnell, 1985) would not be appropriate. Ruchdeschel and Farris (1981) examined the standard quantitative single case design and raised a number of questions concerning validity and usefulness. They proposed a qualitative alternative in single cases, that takes into account the client's perspective as well as that of others in informing the purposes of the research. The qualitative approach provides an opportunity to study complex social phenomena in an intensity and depth that quantitative research could not. In this study the investigator is interested in the therapeutic process and the type of material the client is raising in therapy. With a theoretical background informed by the literature, the investigator was able to observe both predictable areas of difficulty for the client as well as some that revealed themselves through the process of therapy. The richness and authenticity of the data is extremely valuable as the client was not trying to explicitly or cognitively present the information. There was nothing premeditated or controlled about the client's words and the investigator consciously avoided trying to guide the client to discuss any particular issues unless they had first been raised by the client herself. The investigator's work with this client was supervised on a weekly basis. This was done by the investigator and the supervising social worker listening to the audio tapes of individual sessions and discussing the therapeutic work. The request by the investigator to the client for the use of the audio tapes for this study was also recorded. The 54 supervising social worker listened to this recording as a crosscheck to ensure that no pressure was brought to bear on the client to comply with the request. The audio tapes of the client covered a five month period. The content of these tapes was analysed using the constant comparative method as noted in Glasser and Strauss (1967). This involves four stages. Each incident in the transcribed material is coded into as many categories as possible. While this coding is going on a constant comparison is made to material already coded in the same category. From this constant comparison of incidents, the theoretical properties of a category begin to emerge. As the theoretical properties of a category emerge, theoretical memos are written to record the investigator's thoughts about the categories and possible connections between different categories. Constant comparison continues but now between incidents that are being coded from the transcribed material and the properties of the categories that have emerged from the earlier coded incidents. As the coding continues similarities may appear between the various categories that begin to indicate a theory. The analyst then begins to write the theory based on the coded categories, memos and theory which have emerged. The confidential nature of the taped material and the confidentiality assured the subject prevented the content analysis and coding of the material from being rated by others besides the investigator. An example of the coding from the present study may be helpful. Two indicators from the transcribed material were, "I need to start being honest" and "I need to start dealing with things." These were coded as the need to make new beginnings in two ways, to be honest, and to face up to problems. At the next level of abstraction a memo was written addressing the client's desire to be authentic. This same category and memo continued to emerge 55 through other indicators until it became clear that one of the key categories for the client was the search for the authentic self, the need to be authentic, to be real. There were twenty tapes in total but five could not be used due to poor quality. These were tapes of sessions 5,6,7,8,and 15. These tapes comprise 25% of the data and are therefore a significant loss to the study. The time period that tapes 5,6,7 and 8 cover is the Christmas period which is traditionally a time of family. As such it is a time of year that can stimulate thoughts and feelings related to the family of origin. However, precisely because it was the Christmas period, the investigator has a good memory of the nature of these sessions, which involved discussion of the client's plans for the season and also the client's reaction to a phone call from her father inviting her to spend Christmas in Toronto. Although this material will be very subjective, and dependent on the investigator's recall, it will be included in the findings because it reveals a significant feature of the client's relationship with her father and how the client deals with her feelings. The tapes of the first four sessions were not affected. All the remaining tapes were transcribed and coded using the constant comparative method described above. Since the tapes were actual recordings of the counselling process, they were not interviews as such. Any questions that were asked or comments made were in response to the issues the client was raising. The questions were therefore not open-ended nor neutral but were for the purpose of helping the client clarify thoughts, feelings, beliefs and make connections between events in the present and the past. Given this, the contents of the therapeutic questions were not coded nor included in the coded material. These questions may have biased the data since they could tend to cause the 56 client to focus on specific areas that the therapist felt were important and which the client may otherwise have ignored. Confidentiality concerning the client's identity and concerning the taped materials was assured the client both in the consent form and verbally. Since this is a single case study with no control group, it was decided to augment the study with interviews with counsellors working in the sexual abuse field, to seek their views on the relationship of childhood incest and later problems in interpersonal functioning in their clients. The counsellors interviewed came from varied therapeutic settings and provided a variety of theoretical and professional experiences. The material collected from the interviews with the counsellors is a presentation of their current theoretical orientations to the sexual abuse field together with their clinical experiences. To be selected for inclusion the counsellors had to have had experience counselling adult clients with a history of incest as opposed to other forms of sexual abuse. The sample size of five counsellors was an arbitrary figure selected by the investigator as being the minimum number that would be sufficient to provide a cross-section of opinion and experience. Those selected are from a snowball sample in which two of the counsellors known to the investigator suggested the other three counsellors. The investigator interviewed these five counsellors who have all had experience with adult incest survivors. Three of the five counsellors have also had experience with child victims of incest. The five counsellors represent quite different settings: two practice in clinical settings, one in a parenting program, one in a mental health clinic, and one is in private practice. The five counsellors also had quite different educational and experiential backgrounds. One of the counsellors has a Ph.D. in Psychology, two are Masters of Social Work, one 57 has a B.A. with extensive training in the sexual abuse and child development area and one is a Master of Arts in Counselling Psychology. The average number of years of experience in the therapeutic field is 15. As well as the area of sexual abuse counselling the counsellors also have experience in family and marital counselling, parenting and child development, and play and art therapy. The interviews were conducted with each counsellor individually and took approximately one hour. Sessions were tape recorded. The interview took the form of ten open-ended questions which had been developed by referring to the literature review and from the material emerging from the clinical tapes of the client. Verbal probes were also used to clarify points or ask additional questions. The ten questions are included, as used, in Appendix B. The tapes from the interviews with the counsellors were transcribed. The content was then analysed and coded using the constant comparative method as noted in Glasser and Strauss (1967). Limitations of the Study A study of this type, a single case design, has considerable limitations. The lack of generalizability of the findings and the limitations of the ex post facto design have already been discussed. A problem related to the ex post facto design is the difficulty with the retrospective nature of the data. Gold (1986) states that retrospective studies have two problems. First, it is not possible to control for the effects of events which intervene between the victimization experiences and the present. Second, the data is subjective in nature and dependent on subject recall which may be affected by memory impairment, discomfort with the subject matter or by the change in perspective given the changes in the subject's developmental level. The 58 subject is also the only source of the background data as there was no contact with other family of origin members who may have offered different or at least supplementary perspectives on the past events. There are also problems in the areas of validity and reliability. Validity refers to the accuracy of the findings of the study while reliability refers to whether the findings could be replicated by another researcher (Walker, 1985). It would have been preferable for the data to be analysed by others besides the investigator but the confidential nature of the material precluded this. However, in the course of the writing of this report several discussions occurred between the investigator and the members of the committee who were monitoring the development of this report. These discussions raised questions which helped the investigator maintain a clear perspective on the work and ultimately aided in the accuracy of the findings. The inclusion of the counsellors was also an attempt to increase the validity and reliability of the data. A unique feature of this study which is significant for the type of data that was generated is the character of the client. The client, although a young woman of 20, has the ability to be quite insightful concerning her own history and in relation to events that occur in daily life. A colleague who is familiar with this client stated that the client has a unique ability to take everyday experiences, integrate them and turn them into learning experiences for herself. It has been the investigator's experience with this client that she has the ability to do a great deal of the therapeutic work in and outside of the therapy sessions. This is not to deny that the client has a number of psychosocial developmental delays, but in contrast to other clients in their 59 30's and 40's she displays a maturity beyond her years and this has facilitated the type of rich data the client raised in the therapy sessions. A final feature that influences the data and findings of this study is the investigator's own biases. The investigator's theoretical approach to therapy with survivor's of sexual abuse is a systemic one in which the abuse is viewed in the context of family of origin, family systems and general systems theory. The investigator's view of incest is that the perpetrator is responsible for his actions. Although the mother/daughter relationship may be enmeshed and conflicted, the blame for the sexual abuse does not rest with the mother. The investigator also brings the perspective of feminist theory to the incestuous family situation to highlight the position the mother and child find themselves in, in the family of origin dynamics. The abuse and family dynamics are also viewed against the larger context of the differences in power and status of the male and female roles as defined by society. The check on the investigator's biases was the weekly supervisory sessions with the supervising social worker at the agency. Summary As stated previously, the theoretical model being used as a framework for looking at the data is Erikson's model of psychosocial stages of development and Bowlby's theory of attachment. Particular reference was made to the stage of intimacy versus isolation which refers to the ability or inability to form lasting relationships, the main developmental task in young adulthood. Since the client is in her twenties this stage seemed the most salient. However, as will be shown in the discussion of the study findings, other features of the developmental stages proved to be significant as well. 60 CHAPTER 111 RESULTS OF THE STUDY The presentation of the findings of this study will cover a number of areas. Prior to presenting the actual findings a biographical/social assessment of the client, together with the therapist's clinical impressions, will be presented to provide a context for viewing the findings. The findings of the study will then be presented and will include examples of indicators from the therapy sessions which illustrate the nature of the client's relationships. These include relationships with herself, her mother, her stepfather, her father and male peers. Two themes that emerged from the work with the client will also be identified. The basic social process that evolved in therapy will be described. Following the presentation of the findings from the case study, the findings from the interviews with the counsellors will be provided. These findings include themes, attachment and developmental implications and specific effects of incest. Biographical/Social Assessment Christina, nicknamed Nina, age 20, was born in Melbourne, Australia. She is the oldest of three children and the only girl, the two younger siblings being twin boys. Nina's parents were working class people who had emigrated from Scotland shortly before Nina was born. Nina's mother was 19 when Nina was born. The pregnancy was unplanned and unwanted. Apparently Nina's mother made several unsuccessful attempts to self-abort the pregnancy by falling down stairs and abusing alcohol while carrying Nina. 61 This information was conveyed to Nina by her father when she was quite young, giving her the message that she was unwanted. When Nina was between three and four years of age, her father abandoned the family and left the country. Nina was not to see him again until she was a teenager. Nina recalls spending most of her younger years away from home, first in nursery school and daycare and later in boarding school. She often spent holidays with friends. Having little access to her mother during this time Nina built up an idealized image of her mother, in Nina's words "I put her on a pedestal." Nina describes her mother as being "everything" to her. As an adult Nina is starting to become aware of how much she idealized her mother and is starting to ask herself questions such as, "Where was my mother during my developing years?" She also describes her mother as "always having nervous breakdowns." This suggests she was unable to care for the children during those years. Nina recalls that she herself was often ill at boarding school with colds and bronchitis and used this as a means of getting attention, as she felt lost among the 1500 students. Nina also recalls receiving negative attention concerning her body as she was very thin as a child. At boarding school there was a lot of fuss made about her eating which caused Nina considerable anxiety. This has contributed to a self-consciousness about her body. When Nina was nine, she and her brothers were called home from boarding school to live with their mother and her new husband. The children had not been informed of the new marriage so no attempt had been made to prepare them for this change in their lives. Nina recalls feeling betrayed and let down by her mother for not having been informed of the marriage earlier. Nina remembers the abuse by her stepfather occurring from 62 the beginning of the family living together. She states that she was physically, emotionally and sexually abused between the ages of nine and thirteen. The physical abuse from the stepfather took the form of severe beatings and resulted in physical damage being done to her body, the effects of which are still with Nina today and which further contribute to her self-consciousness about her body. In the area of emotional abuse, Nina received considerable criticism from both parents concerning her physical size and eating habits. Nina recalls that her mother was embarrassed by her thinness and forced Nina to wear clothes that were large or bulky in order to hide her body. As punishment for not putting on weight Nina was withdrawn from favourite sports and recreation activities. This curtailed contact with peers and adults outside the family. The sexual abuse was initiated by the stepfather and occurred between the ages of nine and thirteen as well. There is some indication that Nina's mother knew the physical and sexual abuse was occurring. Nina recalls her mother refusing to take her to receive medical attention for the bruising from the beatings. Her mother said she was afraid the doctors would recognize that the bruises came from physical abuse and that a physical exam might also reveal the sexual abuse. Her mother's words were, "The doctors will know what's going on." During the time the abuse was occurring Nina's mother was attempting to become pregnant and suffered several miscarriages. On one of these occasions Nina's mother asked to be allowed to die if the child could live. This has left an impact on Nina who felt shocked, betrayed and abandoned. Nina felt devastated by the idea that her mother, whom she loved and needed, could consider abandoning her in this way. Eventually, when Nina was thirteen, her mother had a baby girl. 63 Over the years Nina also saw her mother repeatedly physically abused. After these incidents, she would promise Nina that she would leave the marriage and take the children with her but she always returned. To deal with her abuse and difficult home life, Nina began to drink and act out at school. Once, having told a school counsellor about the physical and sexual abuse, Nina was forced to recant by her mother for the sake of the family. At age thirteen Nina asked to go and live with her father. With her mother's help they were able to locate him in Canada two years later. At age fifteen Nina left Australia to join her father in Canada. She lived with her father in Toronto for the next year or so. Nina suffered physical and emotional abuse from her father almost from the beginning. He beat her and criticized and ridiculed her because of her thinness. Nina recalls feeling rejected because of the criticism. She eventually left school and ran away to the streets. She spent the next year or so on the streets of Toronto where she survived by squatting in abandoned buildings. Nina did not want to prostitute herself so in order to protect herself from unwelcomed attention while on the streets, she adopted a punk style of dress, which included a mohawk hairstyle and outlandish make-up and clothing. In her own words, "I wanted to make myself ugly so no one would bother me." During this time Nina also used alcohol to dull the pain of the past. After a period of time on the streets, Nina connected with a street worker who eventually helped her find accommodation and she returned to school. Nina developed a strong sense of trust in the street worker and described him as being from another planet because she had never met a male before who was so caring. In referring to the street worker Nina said "he was the first man I had ever respected as a person and liked as a friend and as a father." A few years later 64 when Nina finished high school she moved to British Columbia and began attending a business skills course sponsored by Employment Canada. At the time Nina came into therapy she was living on her own and continuing her education. Clinical Impressions Prior to presentation of the findings from the tapes, several possible clinical implications are suggested by the biographical information already presented. In the light of the description of attachment theory and development theory a number of factors from Nina's background emerge as salient. First, Nina's attachment to her mother is of concern. From the description of the ambivalence displayed by Nina's mother towards her pregnancy and the birth of her first child, as well as the messages that Nina received as a young child from her father concerning not being wanted, it can be hypothesized that the attachment process may have been inadequate. In considering the categories of attachment identified by Ainsworth (1982) it is possible that Nina would fall into the category of resistant/ambivalent attachment, group C of the strange situation test. It also seems that Nina's mother displayed a high degree of insensitivity to her daughter's needs throughout her life, putting her own needs and the needs of the family before those of her daughter. Given Nina's abandonment by her father at an early age, the developmental issues of trust and autonomy would be severely affected. If a basic sense of trust is not established, basic mistrust and feelings of anxiety and estrangement may develop. We might expect Nina to have difficulty trusting 65 males in later relationships. What foundations would Nina have upon which to establish trust and gain a sense of autonomy? At the developmental stages of initiative and industry, Nina was in boarding school where she received little individual attention, with only an idealized image of her mother to sustain her. The tasks of the stage of initiative are for the child to learn through interacting with her environment, what is permitted and what is not. A sense of the child's own abilities is emerging through language development and physical development. The child at this stage needs encouragement from significant others, that is mother and father, to develop a sense of initiative. Too much criticism can lead to feelings of guilt. When Nina was home again she was withdrawn from activities such as sports in which she was having success and her contact with peers was severely restricted. These actions further undermined the tasks to be achieved in the stage of industry versus inferiority. "Unpleasant school experiences and lack of family support in school endeavours contribute to feelings of inadequacy and inferiority" (Phares, 1984, p. 119). Today Nina struggles with a sense of doubt and inferiority about her own capabilities. She tends towards a perfectionist, all or nothing approach to learning and to life's tasks which sometimes cause her to take on too much and which make it difficult for her to set limits for herself. The key task of the adolescent years of identity versus identity confusion is the successful transition from childhood to adulthood. This is a very stressful period and involves the search for identity. During this time Nina was searching for a resolution to her home situation and began the search for her father. This culminated in her joining him in Canada. Nina's life during her adolescent years was in great turmoil and the issue of identity is an area that has been a source of much struggle for her. 66 Nina at present is gaining some clarity in this area. As mentioned earlier the life stage of intimacy versus isolation is an area that Nina is actively engaged in at this time. However, her moves towards heterosexual closeness raise the old unresolved issue of trust and fear of males as well as the insecurity and feelings of shame that Nina carries with her about her body. Heterosexual closeness also brings back memories of the sexual abuse by her stepfather which Nina has yet to resolve. These clinical impressions from Nina's biographical history suggest some areas that may be raised in therapy. It can be anticipated that Nina may have problems with trust, that her sense of self, her identity may be diffused, and that intimacy may be a problem. It can also be anticipated that her relationships with her family of origin may be strained and difficult if not cut off completely. It might also be anticipated that Nina may have some difficulties in the area of sexuality and intimacy in heterosexual relationships. Presentation Of The Findings Presenting Problem With so much happening in her life since coming to Canada all of Nina's energy went into survival. Once her life stabilized somewhat she began to experience some of the pain that had been suppressed. At age 19 Nina began to experience bouts of depression and was having suicidal ideation due to being overwhelmed with the feelings that were emerging. At one point in an effort to give the pain some focus Nina slashed her arm. She later described this as being a very hypnotic experience but she didn't repeat it. In the six months between Nina's self-referral for therapy and starting 67 counselling, she coped with her feelings of being overwhelmed, by extreme busyness. She was involved with her studies and with a number of social and political concerns. A month or so before entering therapy a very close, supportive friend of Nina's moved away. Her usual coping methods were no longer sufficient to keep the feelings of being overwhelmed at a distance and Nina's suicidal ideation increased. On coming into therapy Nina appeared to be having difficulty in three main areas. First, intrapsychically she seemed to be at a point where the effort to maintain a sense of personal identity was becoming increasingly difficult. Second, related to this was a lack of a sense of personal boundaries. Nina was often unclear about where she began and ended as an individual. She often became overwhelmed by world events and her sense of personal responsibility towards them. Incest families often have boundaries that are either too rigid or too permeable. Their rigid boundaries may be displayed by the family isolation which keeps the outside community at a distance; Inside the family, boundaries may be enmeshed where the roles between different members of the family and between the generations are not clear. Often the children assume caretaking roles that would normally belong to the parents. Growing up in this kind of environment, family members often have difficulty with self-definition and self-regulation (Courtois, 1988). Third, Nina expressed a great deal of anxiety and concern regarding heterosexual friendships and extreme difficulty in experiencing physical closeness with a male. Up to this point she had been unable to establish an intimate heterosexual relationship. Nina's stated reason for seeking sexual abuse therapy was to "be rid of these feelings once and for all so they do not continue to affect my life." 68 Findings Having looked at a biographical sketch of Nina, and anticipated what the fmdings of the taped sessions may reveal, these findings will now be presented. It is important to recall that what is unique and valuable about this study is the authenticity of the material that emerged in the counselling sessions. The client is not responding to a questionnaire about the possible effects of incest on her life and the request to use the tapes of the sessions for research purposes was not made until after the fifth month of therapy so the content of the tapes is the natural flow of the therapy sessions. The focus of this study, the "effects" of incest, is used to analyse the natural content that the client brought forward as the areas of difficulty she was having. The fmdings from the study can be divided into three main areas. First, the client's experiences in relationships to key people in her life. Second, two overall themes, trust and authenticity, emerged which characterized the focus of the client's work in therapy. Third, a basic social process emerged which characterized the client's progress through therapy over the five month period. These findings will be presented successively. Relationships Nina has experienced difficulty in a number of important relationships. These include her relationship with herself, her relationships with her family of origin members and relationships with males. In her current life Nina displays the ability to form close peer relationships with women friends and also tends to attract as friends, people who are older than herself and who can provide a source of support, guidance and nurturance. The client also displays a strong sense of independence and strength. In the first therapy 69 session she said, "I need guidance through the process, if I could do it myself I would, but I realize I can't do it alone." Each of the client's key relationships will be presented separately for clarity purposes. Relationship With Self Nina's perception of herself as a strong person enabled her to survive the abuse in her family, travel half way around the world to reconnect with her father and when that failed she survived life on the streets. Along with this external strength however, is an internal sense of self that is extremely vulnerable. "I'm really strong, I know how to fight but I don't love myself, I don't know how to be real. I can take care of other people but I can't take care of myself, I'm burning out." When Nina came into therapy, she was physically, mentally and emotionally very tired. "I'm sick of fighting, I'm sick of being positive and negative, of complaining and feeling weird or ugly. I'm just sick of everything." To survive the extensive stresses in her life, Nina had had to develop a strong external self. Once these stresses diminished somewhat, the inner feelings and doubts which had been suppressed started to emerge. Nina realized that the energy and effort required to survive had left her depleted. She realized she needed help in making some sense of the conflicting messages and experiences she had received from her family. One of the areas Nina had difficulty with was accepting care and support from others. I don't know why my friends care about me as much as they do. It's hard for me to understand, I react differently when people have confidence in me and in what I say. I need someone to say "yes, I 70 believe in you," which seems strange, I should be able to do that for myself. Just a little bit of encouragement makes so much difference. I never got any positive messages until I came to Canada. Here I'm treated like a person. My parents were just the opposite, always criticizing me. They took me out of things I was doing well in because I wasn't putting on weight. They were ashamed of my body and how thin I was. In Australia when I was put back a year in school they made me feel like a failure. But I'm not a failure. I guess what I'm fighting is who I've been told I am and who I really am, it's confusing. I've never really felt accepted but at school in Canada I decided I didn't need to be accepted, I was going to school for me. Nina also has difficulty with a sense of personal boundaries and not being sure how to balance the needs and demands of friends and activities with her own needs. She sometimes becomes emotionally overwhelmed with events outside of herself. This is reflected also in a feeling of non-connectedness to her body. Once when I tried to draw an outline of my body I could only draw half, I didn't know where the other half was. ...There are so many different things going on in the world that I guess I get lost in them. It's almost like you have to be selfish, to put yourself first just to survive. I feel so disconnected in my body but my yoga class is helping me feel more connected, like the parts belong together. Anger was another area of difficulty for Nina. "I'm afraid to show anger, I'm not sure how to handle feelings of anger." In the area of male relationships Nina expressed feelings of being different and feelings of fear and anxiety. 71 Because I don't have a male relationship I feel out-of-step with other people my age, I feel so different. When I was younger my stepfather threatened to shoot me if I was friends with a boy so it's made forming male relationships very difficult. When asked if she thought there was any connection between her abuse and her personal reactions to males Nina said she had not thought of that. In describing how she viewed her whole family after she arrived in Canada, Nina said that she used to talk about them in positive terms. "I was still protecting my mom and my stepdad by saying everything was wonderful back home." Overall Nina suffers from considerable lack of self-esteem but is able now to make some connections between her present difficulties and her experiences in her family of origin. When it comes right down to it I'm still afraid. I don't have any confidence in me as a person. ...The influence my parents had on me has a big effect on the way I feel about myself. What they did communicate to me was all negative and the part that hurts is that they are still denying it. I think it would really help me for my parents to admit it but I guess they won't. Relationship With Mother Next to her relationship with herself, the client's relationship with her mother was the most conflicted. The client was desperately trying to integrate conflicting emotions of love/hate, anger/sadness and loss, as she struggled to 72 make sense of her love for her mother and the reality that in many ways her mother was not able to protect her. The ambivalence Nina experiences concerning her mother is reflected in the material from the counselling sessions. My mom was a real great person. When I was younger she was God-like, she was everything. I didn't see a lot of her so I made-up things, she had to be perfect. I think it was really unhealthy both for my mother and for me, especially for me, to put her on a pedestal, to create her into a superperson, but I had to to survive. ...I really thought I knew my mom, but I didn't, I didn't know her at all really. Sometimes I was like my mother's mother, I listened to her cry. She told me about the family finances when I was five, so I never asked for toys because I knew we couldn't afford them. ...She really confused me lots of times, she was my friend then my enemy, I got conflicting messages from her. ...You can't afford to be realistic, cause it'll kill you, so you need the strength of the fantasy. ...I'm angry at the reality that she was just as much my abuser as my stepdad. ...I feel very detached from my mother, I don't love her anymore. ...I was always proud of my mom because she was my mom, she was such a beautiful person inside, always laughing. ...I never want to see her again. Relationship With Stepfather While the client continues to fear the stepfather and has not been able to move towards resolving some of the feelings concerning the stepfather, she is actually less conflicted in her feelings about him because there is not the push/pull of the love/hate dichotomy as there is in the client's relationship 73 with her mother. The client hates the stepfather and is struggling with the ways the abuse she received from him is affecting her life. He started hitting me right away. He's the only person I'm really scared of, if he was in this room I'd get really upset. I was angry when my mom almost died when I was twelve because I would have to be with my stepfather. When he got close to me it was in such a gross way. It doesn't sound like a big deal but it was a big deal. Nina also expresses a sense of self blame and feelings of powerlessness about the sexual abuse. I don't know what I could have done wrong, I was just a normal child. I used to wear long pants in the summer so as not to attract him. It makes me ask what did I do to make this happen? I still fear him, that somehow he'll take me back home and I won't be able to escape. The impact of the sexual abuse is described in the client's words about loss. I feel like I was robbed of something, something was taken away from me I don't know what it is. It feels like I'm missing something other girls or women have. The freedom of being me has been taken away. Relationship With Father The client's father was not present in her life for a number of years. The client was physically abused by her father when she reconnected with him in Canada. The client expresses feelings of longing for a father. I remember really hating other kids who had dads in the park, when their dads would pick them up and throw them in the air and things like that, cause I wanted a dad too, and a mom can't be a dad. 74 Although mention of her father did not arise often there was a sense that Nina had built up an idealized image of him as she had her mother. This may have been due in part to the abuse by the stepdad which may have led to the belief or hope that her own dad would treat her better. When I came to Canada I guess I had great expectations of my dad, like everything would be great. He started hitting me right away and criticized what I wore and the way I looked. It was awful so I ran away, there was nothing else to do. Nina's present feelings towards her father were revealed when he called just before Christmas to invite Nina to spend Christmas with him and his new wife in Toronto. Nina said the unexpected call was very upsetting and brought back a number of memories and fears. He was drunk and it really upset me, hearing from him. I got really scared and I didn't know what to do. It brought back all the memories of what it was like living with him. I'm afraid of getting sucked back into a bad situation. Relationship With Males The client experiences a great deal of anxiety and physical reactivity in relation to male friends and is very conflicted over issues of intimacy. The client experiences considerable confusion concerning her own sexuality. This does not include conflict around her sexual orientation which is heterosexual, but it does appear in difficulties with her body image, "I always feel so ugly." Nina also has a poor sense of personal boundaries and how to interact with men, "I don't know what I'm supposed to do. I fear rejection. I'm afraid if they see me (naked) they'll reject me and that would really hurt." Nina also 75 experiences difficulties with her self-concept as a female person. As long as no one's attracted to me, I'm fine, then those feelings won't come to the surface. I always get so anxious, it's hard to be relaxed and casual. I feel afraid of men, of relationships, of getting close, of sex, of everything. I know I'm so vulnerable inside, I'm very delicate. Nina expresses a lack of awareness of her own power and rights in a relationship. "I don't know what you're meant to do." Nina also speaks of the reactions of her body which has stored old memories of the abuse and reacts with a "mind of its own". Sometimes I don't mind an arm around me but the old part of me doesn't want an arm around me or anybody to look at me or be close or anything, it's very confusing, my body doesn't know what to do. The issue of trust comes up, I can only be near someone after I trust them and that takes time, time is trust. I trust women faster than I trust men. Even though my mom was as much an abuser in a way, I was never afraid of her. Nina refers to the mind/body split and connects it to the incest by the stepfather. "When I'm near men my body shuts off automatically. I think I developed this as a way of protecting myself from my stepfather. I'm more aware of it now but I still can't stop it." Nina also refers to her overall sense of self and lack of self-esteem. "I really feel like I'm not good enough for somebody else." Having looked at the client's key relationships it is possible to see a number of areas where the client experiences unresolved conflict. Nina struggles with her sense of herself as both a strong yet vulnerable person. She is also struggling with the conflicting feelings of love/hate she has towards 76 her mother. In relation to her father and stepfather, Nina has difficulty in connecting with the feelings that are related to the abandonment and abuse she has received from them. In the area of male relationships the unresolved issues from her abuse are triggered by the prospect of an intimate relationship and therefore, make achieving intimacy difficult. In the next section we will look at two themes which evolved from the therapy work. Themes Two overall themes emerged from the material the client was working on. One was the theme of trust and the other was the theme of authenticity. Trust The theme of trust emerged from the first session with the client. "You can't trust that those you love won't abandon you." The client is engaged in a struggle to establish a sense of trust from which she can engage in relationships and be in the world. A basic sense of trust seems to be missing and seems to be one of the results of the client's background which gave her little cause to trust. The client is moving towards a basic sense of trust in herself and in others. "I'm starting to let myself be cared for by others when I need it." Authenticity The client is seeking to ground herself in reality, in something real. She characterizes herself as strong and as a fighter but internally she is very vulnerable. Her struggle is to find her own authentic self so she can be real in the world and be honest. "I need to be honest with myself (about her 77 feelings). ...I need to start being really honest and dealing with things. ...I can't live a lie anymore." (by pretending everything is fine). These two themes continue throughout the sessions and provide a powerful impetus for growth and change. Basic Social Process In the course of analysing the tapes three separate stages of the client's work in therapy emerged. These may be called Stages of Adjustment and can be seen as a Basic Social Process as referred to in Glasser (1978), because they describe change that occurs over time. While the three stages are not finite and each contains elements of the other two stages, they each contain distinctive characteristics of the client's adjustment to her life situation and problems. The three stages are Cognitive Confusion, Emotional Expression and Integration. Cognitive Confusion This stage occurred in the initial two months of therapy and was characterized by the client being overwhelmed by her feelings and life situation. Nothing made any sense yet the client desperately wanted to cognitively understand what was happening to her that made her feel so confused. The general feeling may be summarized in a paraphrase of the client's thoughts, 'if only I could understand what I'm feeling then everything would make sense, everything seems so crazy, the world's crazy so I must be crazy too.' Other indicators from the client were "everything seems so pointless, there's always been abuse. ...I have to deal with everything now or I just can't be here. ...Everything's so wishy-washy, I can't make decisions. 78 ...What am I meant to do?" This stage was also characterized by physical and emotional exhaustion in the client. In summary, the client was in crisis. Emotional Expression Gradually as the relationship between the client and the therapist developed, the client began to experience feelings she had formerly kept hidden from herself. This stage was characterized by a move away from the client's desperate attempts to cognitively understand everything to a more comfortable state in which feelings could emerge. "I feel sad about my parents and about everything that happened." This stage roughly corresponded to the third and fourth months of therapy. This stage was indicated in the client's growing awareness that she had something to offer "my friend said I was really special, I know some really special people, maybe I can be real and special too. ...I'm angry at my mom for not being there for me, I've never been angry at her before." Integration This stage was characterized by the client beginning to make connections between her thoughts, feelings, behaviours and beliefs. Although the client had experienced moments of integration in the first two stages, this emerged strongly in the fifth month as the client made great strides in her ability to start to make sense of the confusion and the contradictory feelings she was experiencing. The following examples present some indicators of this stage. Recently the client was able to get in touch with her feelings of anger over being treated unfairly by an employer and rather than staying hurt, was able to access the anger and then decide on a course of 79 action. In the client's words "I don't want to be a victim anymore." The following quote gives another example of when the client became aware of changes that were occurring. She said in therapy, "I'm changing and transforming, I've let lots of things go, it's scary not to plan everything." It is important to note that the movement within these stages was not consistent in all areas of the client's life and relationships. In her relationship with herself, the client has begun to do some integrating as well as in the area of her relationship with her mother. In the relationships to her stepfather, father and male relationships in general the work of being able to experience the feelings around these areas and then to move towards integration is still to be done. This may be due to feelings of fear that Nina has towards her father and stepfather and the intense emotional reactions she has to any reminder of the abuse. At present it seems safer to Nina to talk about the painful relationship she has had with her mother. Interviews With Professionals The interviews with professionals were held to augment the material from the single case study. Each professional was interviewed separately and the interviews lasted for a period of from one to two hours. The format of the interviews was semi-structured in that each counsellor was asked the same set of ten open-ended questions and supplementary probes were used to elicit additional information. The professionals all have experience with adult survivors of incest, as noted in Chapter H The findings from the counsellors tend to confirm much of what the literature has to say on the effects of incest. They addressed issues related to developmental effects and also addressed many of the issues the client herself 80 raised in therapy. The findings from the counsellors will be presented in three parts. First, the overall themes that emerged as areas common to all sexual abuse survivors will be presented. Second, the developmental implications that the sexual abuse has for the victim's life will be discussed. Third, specific effects that victims suffer as a result of the incestuous abuse will be dealt with. Themes The material from the interviews with the counsellors focused on four themes: trust, intimacy, context of abuse and the need for the reparenting of the abuse survivor. The overall theme that emerged from all the interviews with the counsellors was that of trust. Without exception, very clearly and strongly stated and without any reference in the interview questions to the issue of trust, this theme emerged. The counsellors felt that a sense of trust was a foundation principle which is severely disrupted by incest and by other dynamics in incestuous families. "Trust is the primary issue." "The issue of trust emerges with men and in the area of intimacy." "There is a basic lack of trust, of men and women, of self." The issue of trust affects the survivors relationships with males, females and with self. One of the counsellors described this as "a basic impaired ability to trust others and to trust oneself, a lack of trust of your feelings and their validity, and a lack of the safety type of trust, that is, trust in your personal safety, trust in being vulnerable and trust in expressing feelings." It affects the survivors sense of her own "worthwhileness and sense of self esteem." Related to the issue of trust is the theme of intimacy. All the counsellors felt that survivors have problems in the area of intimacy. "Since 81 the abuse occurred in a relationship, the feelings connected to the abuse will be triggered by other relationships." "Incest compounds the difficulties with intimacy and sexuality." "The survivor may have trouble achieving closeness since her ability to trust has been impaired." A third theme that all five counsellors agreed on was that incest occurs in a context. "Incest occurs in incestuous, dysfunctional families." The families are characterized by an imbalance of power between the mother and the abuser. There is doubt in the child's mind that the mother will be able to protect her from the abuse. There is a sense of isolation and disorganization. The children have a different kind of function, to meet the needs of the parents. "Often these families are shame-based, that is certain things aren't talked about as other members can't deal with them. The abuser is often imbued with power." "In the dysfunctional family setting, boundaries are unclear and parentification of the child occurs." The fourth theme that emerged was for the need of reparenting for the survivor. "The survivor needs to go through a reparenting process. She must be allowed to experience the developmental stages she was denied." Attachment and Developmental Implications One counsellor specifically mentioned attachment problems in incestuous families, "conditional bonding occurs in incestuous families." Conditional means that the child does not receive unconditional acceptance. The attachment/bonding process is conditional on the child meeting the parent's needs, for example, by being good. Therefore, the child is not free to 82 express the full range of feelings from happiness and contentment to anger and distress. All the counsellors felt the experience of incest had serious developmental consequences. "A halt occurs in development when the abuse occurs." "The developmental cycle gets derailed." "The abuse affects the ability of the child to negotiate the subsequent stages of development." "The child suffers arrested development." Although the developmental process is interrupted the symptomology of this may not appear until years later. "The survivors cope by not coping, that is by not dealing with the abuse. They suppress the memory of it." "Growth gets challenged in relationships." One counsellor noted that "clients in their twenties usually do not focus on the abuse when they experience problems in relationships. When they are in their thirties they look to the abuse as the source of relationship problems." This may be explained as part of the developmental process in adulthood. Young adults are forming relationships and moving towards intimacy. When this fails later the individual may be at a stage where she is asking questions about why the relationship failed. All the counsellors identified the family as playing a key role in the child's development. "The family of origin is where we become who we are. Parents are very significant in shaping identity, cognitive and emotional development." "Once the relationship with the caregiver has been impaired the child experiences betrayal by the central figure in her life. It is difficult at a later date to recapture early development." Two of the counsellors noted that they use Erikson's developmental stage theory as a guide to the types of unfinished tasks the client may be dealing with depending on the stage the abuse commenced. "The secrecy aspect of incest results in shame and guilt." 83 This refers to the incomplete resolution of Erikson's stage two, autonomy and stage three, initiative. "The process of separation from the family of origin is disrupted. The child is not able to separate from her parents and establish her own identity." This refers to Erikson's stage five, identity versus identity confusion. Specific Effects Of The Incest Abuse The five counsellors felt that there are specific effects of the incest on the future functioning of the adult survivor. They identified several factors that affect the seriousness of the impact of the abuse. These are, "the closeness of the relationship of the abuser to the victim, the sexual nature of the abuse, and the damage to the developing self depending on the age at which the abuse occurs." It is generally felt that the younger the age the more serious the effects will be. Two of the counsellors addressed the issue of the significance of the age of the child when abuse occurs. "The younger the child the 'better' victim she makes, that is, the less ability the child has to resist, protest or disclose, especially if the child is too young to know what is happening." "If the abuse occurs prior to the acquisition of language the child may suffer life-long severe impairment as she will have no language with which to cognitively conceptualize her experience." Courtois (1988) notes that there is some debate concerning the influence of the child's age on the repercussions of the abuse. Does the young age of the child predispose her to more damage or does her young age serve as a protection from the impact of the abuse. Several researchers have found that the younger the age of onset the more primitive will be the the type of defense mechanism used as protection, repression for example. This may cause younger children to 84 appear asymptomatic initially but may result in severe symptomology in adulthood. In the area of intrapsychic implications, the five counsellors identified several issues. "There is a correlation between incest and impaired functioning especially in the areas of sexuality, self-esteem and self-worth." "The survivor's internal sense of trust, intimacy, vulnerability and sense of personal security will be impaired." These areas are similar to the areas identified as effected in the area of relationships. "The survivor will experience conflict in the areas of trust, intimacy, and self esteem in interpersonal relationships." "The survivor will have problems in the area of sexuality with difficulties achieving closeness. Her sexual identity may be impaired and her sexual orientation may be effected." "The problems in any sexual relationship whether heterosexual or homosexual will be related to power issues and the client's personal sense of autonomy." "Early traumas get replicated in adult relationships." This refers to the repetition compulsion, the tendency for unresolved issues from the child's earliest relationships in the family of origin to get repeated in her adult relationships. Therefore the adult survivor may inadvertently continually become involved with partners who will in one way or another abuse her. One of the counsellors addressed the coping options of children who are being abused. "They can cope by leaving, that is, running away, by acting out, or by living with it." Four counsellors mentioned dysfunctional coping mechanisms of adults. "Adult survivors cope by continual revictimization, substance abuse, alcohol, drugs, food, by sexualizing all relationships, by self mutilation and by suicide." 85 The five counsellors also mentioned the personal and therapeutic implications for the survivors. "They suffer from continual low self-esteem and a sense of shame and guilt. They need to be believed, to have the reality of their experiences validated." Two counsellors specifically mentioned the physical reactions of abuse survivors. The body is identified as the carrier of the memories of the abuse. "Survivors often feel dead from the neck down." "They have no sense of their body." "They are very reactive to things, such as touch and smells and sounds that trigger the memories. The memories of the abuse are stored in the body." One counsellor felt that recovery from incestuous abuse is never complete. "Healing is possible but never recoverable. Some residue of the abuse remains but people can accommodate for these in a supportive relationship." Another counsellor stated, "The more the survivor can become aware of how the abuse has affected her, the more likely she will be able to resolve these issues and although still affected, will no longer be as reactive to the effects and will be more proactive in taking care of herself." Summary The findings from the individual sessions with the client and the interviews with the counsellors have a lot in common. The overall theme of trust emerged in both areas and the developmental implications identified by the counsellors reflected issues the client was raising in therapy. A discussion of the findings from the client and from the counsellors will be presented in the next chapter. 86 CHAPTER IV  DISCUSSION AND RECOMMENDATIONS Developmental Theory and Attachment Theory were proposed as a framework for discussing the client's present functioning and identifying developmental tasks that remain unresolved. The overall aim of the study was to deepen the knowledge about problems in adult functioning for individuals with incest as a feature in their background and assess the relationship of the incest experience to the later difficulties. Developmental theory addresses the issue of trust as being the first task of the new born in the first year of life, that is, to establish a trusting relationship. Without this sense of basic trust the child becomes mistrustful, not only of the wor ld around her, but also of her own feelings and abilities and is unable to form a secure base from which to bui ld relationships. The relationships with family of origin members and other factors which affected Nina's early life w i l l be discussed. The discussion w i l l first consider the developmental implications and attachment problems related to the findings from Nina's relationships wi th her mother, father, stepfather, males, peers and self. The findings from the counsellors w i l l also be considered in relation to the implications for development. Once the developmental implications of the findings have been discussed, several other theories w i l l be presented as ways of contributing to our understanding of the developmental tasks. Psychoanalytic theory w i l l address the child's relationships with her parents. Social learning theory w i l l be presented as a view of how learning affects development. Loss theory w i l l 87 look at the number of losses Nina has suffered. Feminist theory will be presented as a context in which the developmental stages and tasks as delineated by Erikson may be viewed differently. Development and Attachment Issues Nina's relationship with her mother will be discussed first since this would be Nina's primary relationship as an infant. Nina's relationship with her mother affected the first three developmental tasks, establishing trust and gaining a sense of autonomy and initiative. Nina's sense of trust was affected by the feelings she had of being abandoned and betrayed by her mother. Nina experienced a sense of abandonment on learning that her mother had tried to end the pregnancy, that she was not a wanted child. She may also have experienced a sense of abandonment in being sent away to boarding school at a young age. Later, Nina felt betrayed by her mother's unexpected second marriage. Nina also experienced a sense of abandonment and betrayal in relation to her mother's request to be allowed to die during one of her many miscarriages. Nina further experienced abandonment and betrayal in her mother's inability to protect her from the abuse by the stepfather. The role reversal that Nina experienced with her mother would have interrupted her ability to form a sense of autonomy. Nina describes herself as "her mother's mother", indicating that she had to restrict her own needs for autonomy and initiative in order to meet her mother's dependency needs. The process of attachment between Nina and her mother would also be affected by the ambivalence her mother felt about the pregnancy. Nina's attachment to her mother was very strong. She idealized her mother. We can hypothesize however, that this attachment would be insecure and of an 88 ambivalent nature, marked by anxiety on Nina's part and inconsistency and a lack of awareness of her child's needs on the mother's part. The attachment process would also have been affected by Nina's being away from her mother and in the care of others during her early years. The tasks of trust, autonomy and initiative would also have been affected by Nina's relationship with her father. Nina was abandoned by her father when she was quite young, between the ages of three and four. We can hypothesize about the nature of the father-daughter relationship during these first years and the effect on Nina. Nina's father conveyed to her that her mother had not wanted her. This indicates a lack of awareness or concern on his part for the needs of a young child and perhaps that he too did not want a child at that time. This raises some questions concerning the nature of the father-daughter attachment and suggests that this may have been tenuous. Being abandoned by her father at a young age would have severely affected Nina's trust in her father and in males. It would also threaten her ability to develop an autonomous sense of herself and develop her own sense of initiative since she would have no secure base to depart from. She may have experienced guilt if she blamed herself for his leaving. Nina expressed a longing for a father as a young child. She indicated that she was still searching for a father when she reconnected with him as a teenager. The physical and emotional abuse that she received from her father at that time further damaged her ability to trust and was a repeat of the earlier abandonment since Nina felt let down and rejected by her father's criticism and abuse. The abuse from the stepfather further affected Nina's ability to trust relationships, especially relationships with males. She incorporated feelings 89 of shame and doubt about the abuse which affected her sense of herself as an autonomous person. Nina's relationship with her stepfather occurred when she would developmentally be dealing with the tasks of industry and identity formation. The emotional abuse in the form of criticism and the physical and sexual abuse increased Nina's feelings of inferiority. Nina took responsibility for the abuse thereby affecting her identity formation. Part of her identity came to be in seeing herself as powerless in relation to males and as a victim and that something must be wrong with her or else "Why would the abuse have occurred?" In relation to males, Nina experiences physical reactivity and fear of males and intimacy. Issues of trust surface as Nina has considerable difficulty in trusting in these areas. Part of Nina's identity incorporates a poor concept of herself as a female which further inhibits interaction with males. Nina is at the developmental stage of intimacy. Her ability to form an intimate relationship at this time is significantly impaired. Part of Nina's being able to form an intimate relationship with a male will involve her having to deal with the feelings of mistrust, shame and doubt, guilt, inferiority and identity confusion that she experienced in relationship to her father and stepfather so that she can develop a health sense of her own power in relation to males. In Nina's relationships with same sex peers she is able to establish close friendships. Recalling Nina's words that" my mother was as much my abuser as my stepfather but I wasn't afraid of her", the absence of fear in this relationship is significant since it seems to have generalized to a lack of fear of other females. However, the issue of trust reasserts itself when a friendship is threatened, by a friend moving away, for example. At that time Nina's 90 dilemma is evident, "How do you trust that those you love won't leave you?" which seems to resonate back to the original abandonment by her father. The developmental issues that Nina is dealing with in her relationships to others are also present in the way she perceives herself. Nina displays a sense of mistrust in herself and in her own feelings. She's not sure "what she's meant to do" in many situations especially those involving males. She exhibits shame and doubt in not loving herself and in feeling unlovable or unworthy of another's love. Her sense of guilt is evident in assuming responsibility for the abuse from the father and stepfather. Her sense of inferiority is evident in her lack of self-worth and in her difficulty in accepting care and support from friends. To accept their care and support would mean she was deserving of this which raises issues of self-esteem. Nina also has difficulty in the areas of identity as evidenced in her lack of clear boundaries between herself and people and events in her environment. Nina's difficulties in the area of intimacy have already been discussed. Nina is at different levels of resolution of the developmental tasks depending on her history and the nature of the present relationship. For example, she is able to establish trust in relationships with women but is not able to trust in relationships with men. She is also able to begin integrating her feelings concerning her mother. In contrast, Nina has yet to begin integrating the painful feelings associated with the abuse from her father and stepfather and the consequent difficulties in male relationships. The findings from the counsellors also indicated that child victims of incest would suffer a number of problems in the resolution of psychosocial developmental tasks. They indicated that as a result of the incest, trust, particularly with males and in the areas of sex and intimacy would be a 91 problem. They thought that the particular developmental delays would relate to the age at which the incest occurred as well as factors in the family of origin dynamics. The types of problems anticipated were ones of difficulty achieving a sense of autonomy and initiative because of feelings of shame and guilt associated with the abuse. Victims would also have difficulty with the stage of industry as they tend to lack confidence in their abilities. Their sense of identity would also be confused. They would tend to lack a sense of their own power and assertiveness in relationships and to sexualize all relationships. Intimacy would be a problem because they would have little experience of what a healthy, intimate relationship is like. Although the counsellors agreed that it is difficult to separate the effects of incest on the future functioning of the adult from the effects of the dysfunctional background, they did think that problems with trust, identity and mtimacy would be most directly affected by the incest experiences. Explanatory Theories Psychoanalytic Perspective Development and Attachment theories are useful as descriptive accounts of the process of development. Having identified the developmental tasks to be resolved by this client, it seems appropriate to consider other theories which might help explain how the interruptions in the developmental process occurred. For this purpose the views of several psychoanalytical theorists will be presented which look at the significance of the primary relationship between mother and child and the significance of the father-daughter relationship. The contribution from social learning 92 theory will then be discussed. Loss theory will then address the developmental significance of the number of losses Nina has suffered. Following this, an alternative view of Erikson's developmental stages, from a feminist perspective, will be presented. Development and attachment theories can provide a conceptualization of the nature of the early developmental tasks and the significance of the attachment process. One of the ways that Nina as a child coped with the absence of her mother was by creating an idealized image of her. Browne & Finkelhor (1985) identify betrayal of the victim by the mother, by the abuser and by other family members as being one of the traumagenic events that effects the victim's relationships with family of origin members. The child realizes that the mother is unable to protect, defend or believe her and is unable to be proactive in her daughter's defense. The implications of this for the child are significant as the internalization process with the primary caregiver is affected. Behrends & Blatt (1985) address the role of internalization as part of the psychological development process. Psychoanalytical theorists view internalization as the primary vehicle whereby psychological growth is accomplished. Psychological development occurs through progressive internalization of aspects of relationships with significant others. The needs of the infant include not only the gratification of basic physiological needs for food, water and warmth but also the need for stimulation through a relationship with a mothering person. The primary psychological task of infancy is separation-individuation, the emergence of self and object differentiation which becomes realized within the mother-infant relationship. Disruptions of this relationship are inevitable and necessary if individuation is to occur. These disruptions must 93 not be too great so that they don't exceed the adaptive capacity of the child. If the disruption in the mother-infant relationship is premature, or too sudden or severe, the child may not be capable of internalization and consequently will resort to other less successful means of adaptation such as anxiety or symptom formation. If the child does not successfully internalize the early familial relationships, later stages of the individuation process such as adolescence will be affected. The teenager will not have a foundation of internal object constancy on which to seek new relationships. Psychoanalytic theory may be able to explain the interruption of the developmental process, how the idealization of the mother occurred, what purpose it served and also the effect that the lack of paternal parenting and the abuse had on Nina's development. Miller (1981) addresses the consequences of the failure of the separation-individuation process in childhood. She states that the child can only successfully separate from those to whom the process of her separation and moves towards autonomy are not threatening. If the mother needs the child for her own psychological well being she will not be able to see the child as a separate individual human being with needs. The child senses this and represses those parts of herself which are unacceptable to the parent in order not to risk losing the parent, the love object. Since the child's survival is based on keeping the love object close, the child will go to great lengths to do so, even to the extent of the denial of the authentic self in order not to threaten her parent whom she must protect. Miller (1984) describes this process as splitting off and projecting. The child must split off the bad feelings of tears, pity, helplessness, fear and despair. The adult projects her needs, which stem from unresolved issues from her own childhood, onto the child. "Such a child can never go 94 beyond the stage of idealizing the parents..." (p. 83). Development of autonomy and initiative are not possible since the child's feelings must be subjugated to meet the needs of the parent. Bowlby (1979) writes about how the suppression of knowledge and of feelings in the child occurs. Similarly to Miller 1984, Bowlby states that for the child to be able to experience the complete range of feelings, her experiences must be validated by her parents. If the parents cannot tolerate painful experiences themselves, the child, to maintain the parents' love will have to suppress their own thoughts and feelings. If the bad experiences are connected to the parent, as in the case of abuse, the child is likely to internalize the 'bad' as related to herself and will create an idealized version of the parent. Kunkel (1984) used the term we-psychology to refer to the need of individuals to be bonded and connected to significant others. The we-experience is a mutuality of participation, a sharing of a total experience. Kunkel describes the original-we as between mother and child. This is a biological union with the mother's body producing the milk the infant needs for nutrition as well as a psychological union. The original-we must eventually be breached and this occurs normally as the child realizes she is an individual, separate from mother. With regard to the future form of the child's personality, it makes a difference whether the "breach of the we" occurs early or late, quickly or slowly, cruelly or mildly. A sudden "breach of the we" will be experienced as a terrifying fear, helplessness and estrangement. If the "we" is breached in this way the child experiences a betrayal by the parent. 95 In looking at the relationship between attachment theory and child abuse, DeLozier (1982) examines the generational pattern of abuse. She notes that "there seems to be convincing evidence for the probable transmission of disturbed patterns of parenting within child abusing families" (p. 96). DeLozier studied 18 child abusing mothers and 18 typical mothers, that is, mothers who were not known or suspected of abusing their children. DeLozier noted that impaired attachment can damage the developing child. She notes further that there is a correlation between poorly attached parents and child abuse. Abusing parents invert the usual parent-child relationship and inappropriately seek caretaking from their child. The child's first relationship, usually with mother, is of key importance. A premature disruption of this first relationship is very threatening to the child and is experienced as betrayal or abandonment. Betrayal interrupts the process of internalization and prevents the child from forming an internal sense of object constancy from which to develop autonomy and independence. In reference to this study, Nina's idealization of her mother may be seen as her way of protecting herself from the impact of the abandonment she was subjected to but which was too threatening to experience at the time. Miller (1984) states that the authentic self can be regained in therapy but requires the person to psychologically risk the loss of the parent's love in order to regain their lost self. The same process that led Nina to create an idealized version of her mother may have led her as a teenager to idealize a reunion with her father in Canada in the hope that someone would be able to take care of her. Although the role of the father in the personality development of sons is receiving increasing attention, the importance of the father-daughter 96 relationship has received less acknowledgement (Biller, 1971). The traditional psychoanalytic view of this relationship was that the father encouraged the daughter in her sex role development to come to accept herself as a female. The father did this by treating his daughter as a female and encouraging her to value her femininity which was described as developing the expressive qualities of warmth, sensitivity to the needs of others and good interpersonal communication (Biller, 1971). The definition of what constitutes femininity has broadened and the role of the father in the daughter's development is seen as significant especially in her ability to interact successfully with males as an adult. Variations in fathering have an important effect on the female's psychological functioning and sex role development. Father provides an additional attachment figure for the daughter. The quality of the infant-father attachment is important even in the first year of life and influences the daughter's sex role and personality development. Biller (1974) states that paternal deprivation is a highly significant factor in the development of serious psychological and social problems in the daughter. Father absence prior to age four or five is seen as having a disruptive effect on the daughter's personality development. In paternally deprived environments the child may become exclusively attached to the mother in a clinging, dependent manner. Biller (1974) notes that father absence does not necessarily lead to developmental deficits but that the child with an involved and competent father and mother is more likely to have generally adequate psychological functioning. Effects of paternal deprivation are mediated by such factors as, the reason for the paternal deprivation, the sex and the developmental status of the child, the quality of the child-mother relationship, the availability of 97 surrogate male models such as a stepfather, and so on. Nina's father was not present in her life from age three to age fifteen. Nina exhibits a longing for a father, for a "safe" male, with whom to interact and by whom she can be accepted. Nina also exhibits considerable fear and anxiety regarding males in general. Her anxiety and fear of males could also be explained by social learning theory. This perspective postulates that people are influenced by their environment and learn through observation of models and through reinforcement of their beliefs and behaviour (Deaux & Wrightsman, 1984). Nina's relationship with her father and stepfather in which she experienced abandonment and physical, emotional and sexual abuse and in which she also experienced powerlessness may have contributed significantly to her sense of inferiority as a female and to her distrust of and fear of males in general. Also, the observation of her mother's physical abuse and seeming powerlessness in relation to the stepfather, may have further influenced Nina's sense of female powerlessness in relation to males. Losses Meiselman (1978) notes that incest is not something that occurs in isolation. She views the family dynamics as affecting the incest victim as well. There are many traits which seem to characterize incestuous families. These include social isolation, role confusion and boundary diffusion both within and outside the family, parentification of the child, overly moralistic attitudes of the parents, inadequate parenting, emotional abuse related to ridicule and criticism of the children, absent parent(s) due to death, abandonment or work, unwanted children, unpredictable and intermittent 98 reinforcement of the love and care of the child, violence or the threat of violence and lack of alternative people to turn to for help (Courtois, 1988). Nina's family meets many of these criteria as follows. They were socially isolated. Nina was placed in a parental position in relation to her mother which resulted in role confusion within the family. Nina had not been a wanted child. Nina's father abandoned the family. Physical and emotional abuse were also present. One of the ways to conceptualize Nina's experience in her family and the effects that her early circumstances may be having on her young life is through loss theory (Schneider, 1984). We know that Nina has suffered a number of losses in her young life. She experienced a sense of loss when her father told her she had not been wanted. She experienced the loss and abandonment by her father when he left the family. She experienced the loss of her mother by the lack of contact she had with her during her early life and loss of her childhood by the parentification that took place. She experienced loss as a result of the physical, emotional and sexual abuse by her stepfather which she described in her own words, "I feel like I'm missing something other girls and women have. The freedom of being me has been taken away." Nina also experienced loss again in relation to her father by his physical abuse and the loss of hope she had for a better life when she joined her father in Canada. Nina has also suffered a number of what might be termed psychic losses. These are losses experienced internally in relation to events that are occurring in the environment. In connection with these early experiences, Nina has experienced a loss of childhood, a loss of innocence, a loss of power, a loss of control and a loss of choice. 99 Schneider (1984) notes that losses have potential for both positive and negative effects and that unresolved grief will make the resolution of subsequent losses more difficult. There are times of greater vulnerability when the individual is more at risk for negative consequences. Schneider states that infancy and childhood prior to age 10 is a vulnerable time because the child's abilities to adapt to and conceptualize the losses are not yet fully developed. Children are also vulnerable to difficulties in resolving losses because the losses are probably determined by factors outside the child's control. Schneider (1984) and Provence (1987) address the significance of loss on the developmental process. Normal development involves significant changes which are complicated when the individual experiences other significant losses as well. Provence (1987) found that some separation experiences facilitate psychological growth as they present new opportunities for learning and adaptation. Other separation experiences, especially those involving important persons in the child's life, can precipitate states of bereavement, grief and mourning and can be painful and traumatic. Because the child's human relationships are important and influence their physical, mental and emotional development, they exert a powerful influence in the present as well as on future development. Schneider (1984) notes that in childhood the loss of a relationship is the most important thing and results in a feeling of incompleteness. The loss of a significant relationship may constitute a developmental interference. Provence (1987) notes that the way the loss is experienced also depends on a number of factors, the nature of the child's relationships to the adults who are most important to her/him, the developmental period during which the loss occurs, previous experience with 100 loss, intensity and duration of the event and whether the loss is one that can be shared with others. Schneider (1984) addresses the losses concerning sexual abuse. The losses connected with sexual abuse are often not recognized or understood and often must be endured in secret. The child may also fear other losses if she discloses the abuse, such as, loss experienced if she is not believed or loss of a parent if the family breaks up. The child who is sexually abused, especially by a family member suffers a loss of predictability and trust and may become distrustful and fearful. Courtois (1988) in referring to loss theory in relation to the aftereffects and treatment of incest, states that in order to heal, the survivor must go through a grieving process of accepting the losses and relinquishing the hope of changing her family of origin members into the people she needs. The survivor needs to break with the family of origin in order to complete the tasks of growth and development that were interrupted by the circumstances in which she was raised. Feminist Perspective Having considered this study from the perspective of intrapsychic processes and interelational losses, the societal context of incest will now be presented. Meiselman (1978) stated that incest does not occur in isolation but in the context of a dysfunctional family. Similarly, a family, dysfunctional or otherwise does not exist in isolation but in the context of the larger society. It is this society which defines the roles and responsibilities of those in the family. In the western world the social order is dominated by the white male system which is characterized by the beliefs that this is the only system, that it 101 is innately superior, that it knows and understands everything and that it is possible to be totally logical, rational and objective (Schaef, 1985). It is from this white male system that Erikson delineated his psychosocial stages of development. Writing in the 1950's and 1960's Erikson was much influenced by the prevailing social values which arose from a male-dominated, capitalist, industrial society (Berzoff, 1989). These influences can be found not only in his choice of words to describe the developmental stages of autonomy, initiative, industry and individuation, but also in the wOrds he used to elucidate the meaning of these stages. In the discussion of autonomy Erikson (1963) mentions "the principle of law and order" (p. 254), and in discussing initiative Erikson acknowledges that this has an "American and industrial connotation" and differentiates male initiative in boys as being based on a "phallic-intrusive mode" while female initiative in girls is characterized as "catching...or making oneself attractive and endearing" (p. 255). In the stage of industry Erikson talks of this stage as a time when "the fundamentals of technology are developed" (p. 259). In addressing the stage of identity Erikson defines this as "how to connect the roles and skills cultivated earlier with the occupational prototypes of the day" (p. 261). "Developmental theory has established men's experience and competence as the baseline against which both men's and women's development is then judged, often to the detriment or misreading of women" (Belenky, Clinchy, Goldberger & Tarule, 1973). While Erikson acknowledged that there are differences in male and female development, he devalued female development seeing the formation of female identity as coming about through a relationship with a man and through bearing children, as opposed to male identity which is formed 102 through separation and individuation (Berzoff, 1989). Other writers view female development differently. They see female development occurring through connection to others rather than separation from others (Schaef, 1985). Women's psychological development begins in the context of the primary relationship between mother and child. Unlike a male child who must eventually separate from the mother and identify with the father, the girl and mother share a gender identity. "Women's psychological development is thus shaped in the mother-daughter relationship, the critical relationship in the formation of women's psychology" (Eichenbaum & Orbach, 1983, p. 36). In the establishment of a feminine identity this primary relationship with mother is never severed completely and therefore, female boundaries between self and others remain fluid and are not quite as rigid as male boundaries tend to be (Berzoff, 1989). Gilligan (1982) in writing of women in relationship noted that "women not only define themselves in a context of human relationship but also judge themselves in terms of their ability to care" (p. 17). Women's development in relationship to others is characterized by empathy, mutuality and cooperation, values which are not supported by the dominant male society. The occurrance of incest, since it occurs in the context of a relationship with a trusted person is going to have a significant impact on the victim. That which women value is assaulted by a person with whom they had a trusted relationship. Victims often lose the capacity for trust and intimate relationships and a significant part of themselves is lost in the process. The responsibility for the abuse must rest with the male who through his own socialization has come to view women and children, particularly girls, as being there to meet his needs. The neglect of the importance of relating to 103 others in male socialization may account for why abuse occurs. Men have been taught to seek emotional closeness and release of tension and anxiety through sexual contact while women have a broad repertoire of ways to achieve emotional closeness, of which sex is but one. Another feature of male socialization that may contribute to sexual abuse is that men traditionally are taught to be attracted to females who are younger and smaller than themselves. It is not difficult to see that the male who by his socialization process is taught to seek satisfaction, closeness, release and security through sex with females who are younger and smaller, could through his own lack of impulse control resort to involving children in this behaviour. This is not to provide an excuse for the incest aggressor since many males do not pursue this avenue, but rather to highlight that incest will not cease until we change our process of male socialization (Finkelhor, 1982). The purpose of discussing the findings of the study from the psychoanalytic, loss and feminist perspectives was to provide a larger context in which to view the findings and as a means of differentiating the effects of incest from other background features. It now seems appropriate to summarize the areas specifically affected by the physical and sexual abuse that Nina received from her father and stepfather. Specific Problems Related to the Incest and Physical Abuse The main difficulties that Nina has in the present are in the areas of trust, intimacy in relationships with males and her search for the authentic self. Nina experienced a sense of powerlessness and self-blame in relation to her stepfather when she was unable to stop the abuse despite her attempts to do so. This sense of powerlessness is with Nina today in a lack of a sense of 104 personal efficacy in relationships to males. She often says. "I don't know what I'm supposed to do", in relation to males. This places the authority for decision making outside of herself. On the physical level, Nina carries symptoms of nervous anxiety in relation to the sexual abuse by her stepfather. Following discussion of this in therapy, Nina often develops skin rashes. She states that her nerves are bad and she becomes anxious when discussing her experiences with her stepfather. Nina also has similar strong bodily reactions to the closeness of males. Notwithstanding the familial background factors that have been discussed, the findings suggest that there are specific areas in Nina's current functioning which seem to be directly connected to the physical and incestuous abuse she received from the stepfather. Cohen (1983) identifies incest as a specifically sexual form of abuse to differentiate it from the effects of other family pathology. The fact that Nina has not been able to establish a close friendship or intimate relationship with a male and feels blocked in doing so appears clearly related to the incestuous and physical abuse from her stepfather and the abuse and abandonment by her father. The physical reactions of skin rashes and anxiety which Nina experiences in relation to the abuse and to males in general are manifestations of the nature of these effects. Other physical effects have to do with the mind/body split that Nina describes. She is not aware of it happening but when near males her body "shuts-off." It is important to remember the cumulative effects of physical and sexual abuse as identified by Bryer, Nelson, Miller and Krol (1987). They found that the repercussions of childhood sexual abuse are compounded when physical abuse is present as well. One of the differences between physical and sexual abuse is the nature of the transgressions of the body's 105 physical boundaries. While both physical and sexual abuse affect the psyche, sexual abuse is a specific invasion of the body in a way that connects directly to the person's sense of self and power to control what happens to them. Nina also talked about feelings of being different and feelings of shame. These feelings are supported in the literature by Jehu, Gazan and Klassen (1985) and by Herman (1981). This is also related to the sense of loss that has already been discussed. The losses specifically connected to incest include the loss of body boundaries, loss of childhood, loss of innocence. As a counsellor stated, victims can survive but are never the same for there is always some residue of the abuse. Courtois (1988) in discussing this sense of loss with 50 adult survivors, described it as a sense that "the incest irreparably changed them and that they did not develop as they might have" (p. 126). The Therapeutic Relationship The therapeutic relationship can serve as a microcosym of the client's functioning in other relationships. As such, symptoms may arise in therapy which relate to problems the client is experiencing in other areas of her life. The themes of trust and the need to be authentic were the issues which provided the impetus for seeking therapy. The client was easy to engage and a sense of trust was established fairly early. It was observed however, that the therapy experience was an anxiety provoking one in which the client exhibited some concern about what she was meant to do and was she doing it right. This indicates a lack of a sense of internal control and personal power as well as a desire to please the therapist, the authority figure, similarly to how the client may have tried to please her mother. Although there was a lot of material concerning the client's relationship with her mother, the client 106 was initially only able to express ambiguous feelings towards her. In therapy when the material became too emotionally laden the client would often resort to cognitive/philosophical responses which took the focus away from the client. Over a period of time the client was able to express both positive and negative feelings concerning her mother. However, because the relationship with the mother is still enmeshed and the client would still like to receive unconditional acceptance from her, this therapist believes that this may present itself in therapy at some point in the form of transference. This might take the form of anger at the therapist. To do this the client would be risking the loss of the connection with therapist and symbolically with the mother. It would be my task at that time to provide an accepting response and also to help the client make some connections between the desire for acceptance and her own mother. In the area of the client's relationships with the father and the stepfather, very little material came up and what did, was presented on a cognitive level by the client. The lack of affect was deceiving and it was months before the feelings concerning the incestuous abuse started to come out. During this time this therapist was aware that we were talking around the abuse issues and around the relationships with males issues but was unsure of how to engage the client on the emotional level. Eventually, having spent considerable time dealing with issues concerning the mother we began doing some expressive therapy in the form of relaxation exercises and guided imagination exercises (a form of hypnosis) followed by art therapy. Through this process the feelings connected with the abuse began to emerge. However this process is far from over and indicates how difficult and painful the work of reexperiencing and resolving the losses is. One of the moments 107 that was particularity important was when this therapist used the words "I believe you" in regards to a disclosure of an aspect of the sexual abuse. Even though this therapist had been conveying an accepting manner to the client for months, the actual words were very significant for her. This was a reminder to the therapist of the vulnerability of the client and the need for her to receive concrete messages of acceptance and belief. Significant Findings There are three significant findings from this study which are not often obvious to people who are not experienced in the sexual abuse field. The first is the nature of the client's feelings about the abuse. If the client presents with a history of sexual abuse she may be aware of it on a conscious level and treat it quite factually but with little or no affect. Because it can be anticipated that the client will not like the abuser and may in fact hate him, the related affect may be expected but may not be present. It is important to be aware that the client has been betrayed many times so may not be too ready to trust the therapist. The lack of affect can be seen as a form of denial and/or protection but is not to be seen as an indication that the abuse had no repercussions. In dealing with emotional reactions it is important to go at the client's pace. When the client is ready and trust has been established, the client will indicate that there may be feelings or issues or areas in which she feels blocked. The second finding has already been discussed at some length and that is the importance of the relationship between the incest survivor and her mother. Since the abuse occurs at the hands of the other parent, problems in the relationship with the victim's mother may not be anticipated. However, 108 since the abuse does not occur in a vacuum, the child's relationship with her mother may also be disturbed. The nature of the ambivalence the child feels for her mother may remain repressed for some time and may therefore not be readily accessible to the victim. It is important to remember that even if the mother took action to protect the child, the child may still have had to bear the repercussion on the family and may have been stigmatized by the experience. Unless the child's mother was able to talk to her at the time and was able to fully protect her and help her to realize that she was not to blame, the child's relationship with the mother will be conflicted and imbalanced. In dealing with the client's relationship with her mother, it is important to help the client express her feelings of anger and loss. However, it is also appropriate at a later time when some of the issues concerning the mother have been resolved, to help the client understand her mother's position in the larger context of her role in the social order and her relative powerless and perhaps own victim status vis" a vis her own family of origin. The third finding is the difficulty Nina had in making any but the most general connections between the incest experiences and problems she was having in her adult life. Many survivors enter therapy without being consciously aware that incest or sexual abuse is a feature in their background. In Nina's case she was aware of the incest but did not make any direct connections to it besides feeling generally that she was having problems because of her experiences in her family of origin. This point is important for two reasons. First, if the incest is not the presenting problem the therapist should be aware of the indicators that might cause one to question whether sexual abuse is present in the client's history, and second, if the client is aware of the incest, the therapist must be cautious about the client "playing down" 109 the implications of this for her, since this is a form of denial. The client in both cases should be gently encouraged to explore the history of the abuse so that the feelings connected with it may be resolved. Summary and Recommendations for Further Research In the discussion of the findings a number of issues have been identified that the client is dealing with. The issues are trust, search for the authentic self and her difficulties if specific relationships, particularly, the blocked feelings associated with her relationship to her father and stepfather, her inability to establish intimate relationships with males, the ambivalence of her feelings towards her mother and her sense of being stuck and somehow different from other women. One of the strengths of this kind of research is that it takes into consideration the client's perspective and examines this in relation to information from other sources such as the literature and professionals. This information is then added to the general body of knowledge in this area. Further research in this area is indicated. It is recommended that: 1. Further single case studies such as this be conducted to add to the information that this study has generated and to provide a comparison of survivor's issues and possibly identify features in the survivor's backgrounds that had an ameliorating affect on the repercussions of the abuse. 2. Due to the sensitive nature of this subject and the risk in interviews, another style of study that should be considered is that with subjects who are survivors and who have already been through treatment. They might be interviewed to ascertain what understanding they now have as to the 110 nature of their abuse and how it is or is not affecting them in their current functioning. 3. These two types of studies could also be combined so that survivors just coming into therapy are studied. Follow-up interviews could then be done at regular intervals to ascertain how they have been able to resolve their major issues. 4. With the growing ethnic communities in Canada there is a need for studies to be done which look at the effects and repercussions of sexual abuse in different cultural milieux and the formulation of treatment programs to meet these needs. 5. Similarly to item four, there is an urgent need for studies of the needs of Canada's native population in the area of sexual abuse and in consultation with native people for appropriate treatment programs to be designed and made available. 6. The growing awareness that sexual abuse of males has also been occurring and the lack of resources for male survivors is an urgent need that also must be addressed and appropriate treatment models developed. 7. Another area where resources are lacking is in the availability of groups for adult survivors and their partners, whether these partnerships be homosexual or heterosexual. It is recommended that resources be made available to address the many issues that arise as recovered and recovering survivors attempt to establish intimate, sexual relationships. 8. Studies should be conducted in the area of female development so that the relationship of the mother to the daughter and the father to the daughter may be considered in the light of the changing roles of women. I l l 9. Studies should also be done in the ways males in this culture are socialized and recommendations made concerning a more androgenous approach to male socialization. 10. With the growing number of father absent families and single mothers who are choosing to have children on their own, the significance of father absence on the development of both girls and boys needs to be studied. 11. With the growing public awareness of sexual abuse there is a growing need for treatment resources. Therefore, a recommendation is for governments, federally and provincially to sponsor affordable and accessible programs, particularily in remote areas. 12. Related to this is the problem of the availability of trained counsellors. Because therapy with adult survivors can take years there are often long waiting lists for treatment. One solution to this would be for trained therapists in this area to be covered under the medical plan which would make them accessible to a wider segment of the population. 13. Policy changes are needed to address the needs of families for support and education in this area and in the tasks of parenting in general. 14. There is a need for more public education on the effects of sexual abuse and the costs in people's lives. 15. The final recommendation is for courses in the sexual abuse area to be part of the curriculum at Schools of Social Work and Counselling Psychology Programs. These courses would meet the need to train therapists in this area as well as educate practitioners who work in other areas, of the ramifications of sexual abuse. 112 The focus of this study, the impact of incest abuse and it's consequences for adult functioning, as well as the strength of the survivor is poignantly captured in the following poem written by a sexual abuse survivor. Stolen Innocence Like the wind That chased the clouds away, You thieved my innocence, And led my childhood dreams astray. You snatched away My laughing eyes, And placed on my features A dark disguise even I can't recognize. No longer can I play In the grass without a care, For you took the part that holds my heart. And now there's nothing there. But I refuse To let you Have all of me, For intact, I keep my dignity. Karen Tracy Kostiuk Logan Lake 113 REFERENCES Abramson, L., Seligman, M . , & Teasdale, J. (1978). Learned helplessness in humans: Critique and reformulation. Journal of Abnormal Psychology, 87,49-74. Ainsworth, M.D.S. (1982). Attachment: Retrospect and Prospect. In C M . Parkes & J. Stevenson-Hinde (Eds.) The Place of Attachment in Human Behaviour. 3-30. London: New York: Tavestock. Anderson, R.E. & Carther, I. (1984). Human Behaviour in the Social Environment: A Social Systems Approach. New York: Aldine. Bagley, C. S. McDonald, M . (1984, Spring). Adult mental health sequels of child sexual abuse, physical abuse and neglect in maternally separated children. Canadian Journal of Community Mental Health, 3 (1) 15-26. Behrends, R. S., & Blatt, S.J., (1985). Internalization and psychological development throughout the life cycle. The Psychoanalytic Study of the Child, 40,15-39. New Haven: Yale University Press. Belenky, M.F., Clinchy, B.Mc, Goldberger, N. R., & T a r u l e , J .M . (1973). Women's Ways of Knowing: The Development of Self, Voice and Mind. New York: Basic Books. Bergart, A . M . (1986, May). Isolation to intimacy: I nces t s u r v i v o r s in group therapy. Social Casework: The Journal of Contempory Social Work. 67, 266-275. Berzoff, J. (1989). From separation to c o n n e c t i o n : Sh i f t s i n understanding women's development. Affilia, 4(1), 45-58. Biller, H.B. (1971). Father, Child and Sex Role, Paternal Determinants of Personality Development. M a s s : H e a t h L e x i n g t o n B o o k s . B i l l e r , H . B. (1974). Paternal Deprivation. T o r o n t o : L e x i n g t o n B o o k s . Bowlby, J. (1969). Attachment and Loss, Vol. I. L o n d o n : H o g a r t h P r e s s . 114 Bowlby, J., (1979). On knowing what you are not supposed to know and feeling what you are not supposed to feel. Canadian Journal of Psychiatry, 24, 403-408. Browne, A., & Finkelhor, D. (1985). The Traumatic Impact of Child Sexual Abuse: A Conceptualization. Durham: University of New Hampshire, The Family Violence Research Program. Bryer, J., B., Nelson, A.B., Miller, J.B., & Krol, P. A. (1987, Nov.). Childhood sexual and physical abuse as factors in adult psychiatric illness. American Journal of Psychiatry ,144,1426-1430. Cleveland, D. (1986). Incest: The Story of Three Women.. Mass: Lexington Books. Cohen, T. (1983, Mar.). The incestuous family revisited. Social Casework: The Journal of Contemporary Social Work 64 ,154-161. Constantine, L.L. (1979). The impact of early sexual experiences: A review and synthesis of outcome research. In J.M. Sampson, (Ed.) Childhood and Sexuality: Proceedings of the International Symposium-University of Quebec in Montreal (150-172). Editions Etudes Vivantes, Montreal. Conte, J.R., (1985). The effects of sexual abuse on children: A critique and suggestions for further research. Victimology: An International Journal, 10 (1-4),110-130. Conte, J.R., & Schuerman, J.R., (1987). Factors associated with an increased impact of child sexual abuse. Child Abuse & Neglect, 11, 201-211. Courtois, C.A. (1988). Healing the Incest Wound. Adult Survivors in Therapy. New York: W.W.Norton. Courtois, C.A. & Sprei, J.E. (1988). Retrospective incest therapy for women. In L.E.A. Walker (Ed). Handbook on Sexual Abuse of Children, Assessment and Treatment Issues. 270-308. New York: Springer. Deaux, K., & Wrightsman, L.S. (1984). Social Psychology in the '80's, 4th Edition. California: Brooks/Cole. De Lozier, P.P., (1982). Attachment theory and child abuse. In C M . Parkes & J. Stevenson-Hinde (Eds). The Place of Attachment in Human Behaviour 95-117. London: New York:Tavestock. 115 Eichenbaum, L., & Orbach, S. (1983). Understanding Women, A Feminist Psychoanalytic Approach. New York: Basic Books. Erikson, E. (1963). Childhood and Society. New York: W.W. Norton. Finkelhor, D. (1982). Sexual abuse: A sociological perspective. Child Abuse & Neglect. 6, 95-102. Fromuth, M.E., (1986). The relationship of childhood sexual abuse with later psychological and sexual adjustment in a sample of college women. Child Abuse & Neglect, 10, 5-15. Gelinas, D.J. (1983). The persisting negative effects of incest. Psychiatry, 16 (4) , 312-332. Gilligan, C. (1982). In a Different Voice, Psychological Theory and Women's Development. Mass: Harvard University Press. Glasser, B.G. (1978). Theoretical Sensitivity. Mill Valley: Sociology Press. Glasser, B.G., & Strauss, A.L. (1967). The Discovery of Grounded Theory, Strategies for Qualitative Research. Chicago/New York: Aldine Atherton. Gold, E.R. (1986, Aug.). Long-term effects of sexual victimization in childhood: An attributional approach. Journal of Consulting and Clinical Psychiatry, 54(4), 471-475. Gordy, P.L. (1983, May). Group work that supports adult victims of childhood incest. Social Casework: The Journal of Contemporary Social Work. 64, 300-307. Greenberg, N.H., (1979, May). The epidemiology of childhood sexual abuse. Pediatric Annals; A Journal of Continuing Pediatric Education, 8 (5) , 16-28. Herman, J.L. (1981). Father-Daughter Incest. Harvard University Press, Cambridge, Mass. Herman, J.L., Russell, D., & Trocki, K. (1986, Oct.). Long-term effects of incestuous abuse in childhood. American Journal of Psychiatry, 143, 1293-1296. Jehu, D. & Gazan, M. (1983, Sept.). Psychosocial adjustment of women who were sexually victimized in childhood or adolescence. Canadian Journal of Community Mental Health, 2(2), 71-82. 116 Jehu, D., Gazan, M . & Klassen, C. (1985). Common therapeutic targets among women who were sexually abused in childhood. 25-45, (from) Feminist Perspectives on Social Work and Human Sexuality, The Haworth Press, Inc. Joy, L. (1988). [A Framework for Treatment of Adult Survivors & Child Sexual Abuse Victims ]. Unpublished raw data. Kerlinger, F.N. (1973). Foundations of Behavioural Research, Second Ed. New York: Holt, Rinehart & Winston. Kunkel, F. (1984). Selected Writings. New York: Paulist Press. MacFarlane, K. & Korbin, J. (1983). Confronting the incest secret long after the fact: A family study of multiple victimization with strategies for intervention. Child Abuse & Neglect , 7, 225-240. Martinson, F.M. (1979). Childhood sexuality: Trends and consequences. In J.M. Sampson, Ph.D., (Ed.). Childhood and Sexuality: Proceedings of the International Symposium-University of Quebec in Montreal. 41-55. Editions Etudes Vivantes, Montreal. Meiselman, K.C. (1978). Incest: A Psychological Study of Causes and Effects with Treatment Recommendations. San Francisco: Jossey-Bass. Miller, A. (1981). The Drama of the Gifted Child. New York: Basic Books. Miller, A. (1984). For Your Own Good: Hidden cruelty in childrearing and the roots of violence. New York: Farrar, Straus, Giroux. Parkes, C M . , & Stevenson-Hinde, J. (1982). The Place of Attachment in Human Behaviour. London: New York:Tavestock. Patton, M.Q. (1980). Qualitative Evaluation Methods. Beverly Hills, Cali: Sage. Phares, J.E. (1984). Introduction to Personality. Columbus: Charles E. Merrill. Provence, S. (1987). Psychoanalytic views of separation in infancy and early childhood. In J. Bloom-Feshback, S. Bloom-Feshback & Ass. (Eds). The Psychology of Separation and Loss, Perspectives on Development, Life Transitions and Clinical Practice. San Francisco: London:Jossey-Bass. 117 Raphling, D.L. Carpenter, B.L., & Davis, A. (1967, Apr.). Incest: A genealogical study. Archives of General Psychiatry , 16, 505-511. Reid, W.J., & Smith, A.D. (1981). Research in Social Work. Columbia University Press. Ruckdeschel, R.A., & Farris, B.E. (1981). Assessing practice: A critical look at the single-case design. Social Casework: The Journal of Contemporary Social Work, 62, 413-419. Russell, D.E.H., Ph.D. (1984). The prevalence and seriousness of incestuous abuse: Stepfathers versus biological fathers. Child Abuse & Neglect 8, 15-22. Russell, D.E.H. (1986). The Secret Trauma: Incest in the Lives of Girls and Women. New York: Basic Books Inc. Schaef, A.W. (1985). Women's Reality, An Emerging Female System in a White Male Society. San Francisco: Harper & Row. Schneider, J. (1984). Stress, Loss and Grief: Understanding Their Origin and Growth Potential. Md: University Park Press. Steele, B.F. (1970). Parental abuse of infants and small children. In E.J.Anthony, & T. Benedek, (Eds). Parenthood, Its Psychology and Psychopathology. Boston: Little Brown & Co. Steele, B.F. (1986). Notes on the lasting effects of early child abuse throughout the life cycle. Child Abuse & Neglect, 10, 283-291. Tsai, M . & Wagner, N.N. (1978). Therapy groups for women sexually molested as children. Archives of Social Behaviour, 7(5), 417-427. Walker, R. (1985). Applied Qualitative Research. England: Gower. Wheeler, B.R., & Walton, E. (1987, Dec). Personality disturbances of adult incest victims. Social Casework: The Journal of Contempory Social Work, 68, 597-602. 118 Appendix A Sample Counselling Session Client: I'm a real strong person and I'm a real fighter so it took me a long time to ask for help. I always knew I needed it, I've got to work though things. I've prepared myself mentally, emotionally and physically to deal with this stuff. Lately I've been feeling really tired, everything seems so pointless. Therapist: How did you cope? Client: I've had close friends, but some people who were really close to me have just moved away and I couldn't deal with them leaving. I cried a lot. I never knew I could care about someone so much. Therapist: Do you know what it was you were missing when they left? Client: I didn't really know what it was. Everybody I ever loved has left, there's always been a permanent separation. I guess I figured this would be the same way, but they had to leave, it was the right thing for them to do. Therapist: Can your good feelings for their needing to leave coincide with your sad feelings for yourself? Client: I guess so. I didn't see them that often but it was nice to know they were there. Therapist: Is it okay to feel the feelings you felt for them? To feel sad and hurt? Client: I think so. My feelings were so strong, I couldn't deny them so I guess they were okay. Therapist: Were you able to express them to those people before they left? Client: Yes, I did. Therapist: What kind of response did they have? Client: I think they felt the same. 119 Appendix B Interview Questions 1. From your training and experience do you believe there is a relationship between incest experiences as a child and later impaired functioning as an adult in relationships? 2. Are you able to identify specific areas of adult relationships that are affected by the incest experiences separate from any other influences in the client's background? 3. What other factors in the family of origin context do you see as being commonly present that might impinge on adult functioning? 4. What philosophical or theoretical model or models would you be basing your observations on? 5'. Generally speaking, would you say that the adult survivor's relationships with family of origin members are significantly different from those of adults without incest as a feature in their backgrounds? How? 6. Would you say that the adult survivor's ability to form satisfactory heterosexual relationships is significantly impaired? How? 7. As regards homosexuality in incest survivors, do you see this occurrence as being related to the incest in any way and/or to the difficulties the adult may be having in heterosexual relationships? 8. In referring to Erik Erikson's developmental stage model, how do you think incest affects the child's development? 9. What are the main issues the client must resolve in adulthood? 10. Are there any other comments you would like to make concerning the relationship of incest and adult functioning? 121 This project will not require any additional time on your part as our weekly counselling sessions will provide the material to be studied. I am willing to answer any questions or concerns you may have about the project now or at any time in the future. I would also be comfortable with you seeing the final report if you are interested. You are at complete liberty to refuse to allow your audiotapes to be used in this research or if you agree you are free to withdraw your permission for their use at any time. Whether you grant permission or not will in no way jeopardize our therapeutic relationship nor interrupt or in any way affect our weekly therapy sessions. I thankyou for your consideration of this project. Date Investigator's Signature Participant's Statement The above study has been explained to me and I voluntarily consent to the analysis of the audiotapes of my therapeutic sessions. I have had an opportunity to ask questions and understand that any questions or concerns I may have in the future will be answered by the investigator listed above. I have received a copy of the Consent Form which includes an explanation concerning the research. Date Participant's Signature Copies To: Participant Investigator's file 123 Confidentiality is completely assured. No identifying information nor verbatim material will be used in the final report and all tapes will be erased and related notes destroyed by June 30,1989. I am willing to answer any questions you may have about the project now or at any time in the future. I would also be comfortable with you seeing the final report if you are interested. You are at complete liberty to decline the interview or to withdraw your permission for the inclusion of your comments at any time. Thankyou for your consideration of this request. Date Investigator's Signature Participant's Statement The above study has been explained to me and I voluntarily consent to being interviewed and to the interview being audiotaped. I have had an opportunity to ask questions and understand that any questions or concerns I have about the interview in the future will be answered by the investigator listed above. I have received a copy of the Consent Form which includes an explanation concerning the research project. Date Participant's Signature Copies To: Participant Investigator's file. 

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