Working with Adult Survivors of Childhood Sexual Abuse

182 Pages·2013·1.57 MB·English

Working with Adult Survivors of Childhood Sexual Abuse: Mental Health
Professional and Survivor Perspectives

Alison Barber
BSc., BA (Psych) Grad Dip Psych.

Thesis submitted in partial fulfilment of the degree of Doctor of Psychology
(Clinical Psychology)

School of Social Sciences and Psychology,
Faculty of Arts, Education and Human Development,
Victoria University
November 2012
Abstract
Childhood sexual assault (CSA) is a prevalent societal issue that can have long-term
negative effects on the survivor. Adult survivors of CSA frequently seek therapy
from mental health professionals. However, mental health professionals are not
necessarily aware of, or trained, in working with CSA. This lack of knowledge can
result in considerable negative consequences for the survivor. This study aimed to
explore the experiences and needs of CSA survivors who engage in therapy, and
identify helpful and unhelpful mental health professional practice. This was
achieved qualitatively, with data gathered by a semi-structured interviewing style
and evaluated via thematic analysis, guided by a social constructionist epistemology.
Three survivors of CSA, who had previously engaged in therapy with a mental
health professional, as well as 13 mental health professionals, participated in the
current study. This study found that despite mental health professionals’ lack of
education and training about CSA, they did not need to be particularly
knowledgeable to be considered effective. Specifically, the ability to listen was
crucial, as this indicated the professional was comfortable with the disclosure.
However, an inability to listen was commonly cited and demonstrated to the
survivor in a variety of ways. The issue of referral upon disclosure of CSA was
identified as problematic, as well as considered a professional ethical dilemma.
Whilst mental health professionals are bound by a professional responsibility of
working within their realm of expertise, it could also be perceived as negative in
terms of the messages it sent to the survivor. An ideal solution was suggested to
circumvent this problem. The implications of mental health professional practice on
CSA survivor wellbeing is discussed.

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Doctor of Psychology Declaration

“I, Alison Barber, declare that the Doctor of Psychology (Clinical Psychology)
thesis entitled ‘Working with Adult Survivors of Childhood Sexual Abuse:
Mental Health Professional and Survivor Perspectives’ is no more than 40,000
words in length including quotes and exclusive of tables, figures, appendices,
bibliography, references and footnotes. This thesis contains no material that has
been submitted previously, in whole or in part, for the award of any other academic
degree or diploma. Except where otherwise indicated, this thesis is my own work”.

Signature: _________________ Date: _______________

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Acknowledgements

I would like express my utmost gratitude to the participants of this study. Firstly, to
the survivors who provided their invaluable insights and experiences – despite being
few in number, your voices were loud. Secondly, I would like to thank the
professionals who volunteered to participate. Their passion and dedication to the
area of child sexual abuse is truly remarkable. I would also like to thank the
professionals who provided invaluable and informed contributions when designing,
and making changes to this project. Without everyone’s participation, this
dissertation would not have been possible. A special mention also is extended to
Linette Harriott, who first introduced me to the area of family and sexual violence in
2007. Learning about these often unspoken, yet prevalent issues, inspired me to
help the silenced be heard.

I would also like to thank my research supervisor, Professor Adrian Fisher. I am
grateful for his guidance and expertise that helped me navigate the challenging
aspects of research.

On a personal note, a special thanks goes out to Peter. He was unwavering in his
patience, support and encouragement throughout the very long process, of not only
this dissertation, but also my entire period of study. I look forward to finally begin
making those pipe dreams a reality.

I would also like to thank my parents, who believe education is invaluable. I have
accomplished so much due to them instilling in me this value I also hold so dearly. I
will be forever indebted to them for the support they so willingly offered when I
needed it the most.

Finally, my sisters, Diane and Gillian, have provided hours of patient listening,
advice and encouragement over the years, which I am so grateful for. I would also
like to thank my fellow thesis traveller, Chelsea Dolan, who shared this journey and
gave me unconditional support.
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Table of Contents

Abstract…………………………………………………………….………………... ii
Doctor of Psychology Declaration….……………………………………………… iii
Acknowledgements ………………………………………………………………… iv
Table of Contents …………………………………………………………………... v

Chapter 1 Introduction an Overview …………………………………………...… 1
1.1 Background ……………………………………............................................1
1.2 Aims of the Study ……………………..........................................................2
1.3 Significance of the Study ………………….................................................. 2
1.4 Structure and Overview of the Study …………………................................ 4

Chapter 2 Literature Review Part One: Childhood Sexual Assault and the
Effects on Survivors in Adulthood ………………………………………………… 5
2.1 Introduction ………………………………………………………………... 5
2.2 Childhood Sexual Abuse ..…………………………………………………. 5
2.3 Traumatogenic Model of Childhood Sexual Abuse ……………….………. 6
2.3.1 Traumatic sexualisation ………………………………………..…….. 7
2.3.2 Betrayal ………………………………………………………………. 7
2.3.3 Powerlessness …………………………………………………………8
2.3.4 Stigmatisation ………………………………………………...……….8
2.4 The Neurobiology of Trauma ……………………………..……………… 10
2.4.1 Brain structures affected by trauma …………………………………. 10
2.4.2 Neurochemicals affected by trauma …………………………………. 11
2.5 Common Presenting Difficulties …………………………..……………... 12
2.5.1 Relational difficulties ………………………………………...………13
2.5.2 Sexual difficulties …………………………………………….…….. 14
2.5.3 Revictimisation in adulthood ……………………………………..… 16
2.5.4 Pregnancy and parenting issues …………………………………….. 18
2.5.5 Intergenerational transmission of abuse ……………………………. 19
2.6 Mental Health Issues …………………………........................................... 21
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2.6.1 Factors that moderate the effects of CSA on adult survivors ..……... 21
2.6.2 The psychiatric label …………………………………………...…… 23
2.6.3 Depression …………………………………………………………... 23
2.6.4 Anxiety ……………………………………………………………….24
2.6.5 Posttraumatic stress symptoms ……………………………………... 24
2.6.5.1 Intrusive recollections ………………………………………… 25
2.6.5.2 Avoiding stimuli ……………………………………………… 25
2.6.5.3 Hyperarousal …………………………………………………...25
2.6.6 Borderline Personality Disorder ……………………………………. 26
2.6.7 Gender differences ………………………………………………….. 27

Chapter 3 Literature Review Part Two: Disclosure of Childhood Sexual Abuse
and Mental Health Professional Practice ………………………………………... 29
3.1 Introduction ………………………………………………………………. 29
3.2 Adult Survivors Disclosing Childhood Sexual Abuse …………………… 29
3.2.1 Childhood non-disclosure of sexual abuse ………………….......…. 30
3.2.2 Adults disclosing childhood sexual abuse ………………………..… 30
3.2.3 Positive social reactions to the disclosure of CSA …………………. 31
3.2.4 Negative social reactions to the disclosure of CSA …………….….. 31
3.2.5 Gender patterns of disclosure ……………………………………..... 32
3.3 Adult Survivors Disclosing to Mental Health Professionals …………...… 33
3.3.1 Triggers for seeking help ……………………………………….…... 33
3.3.2 Asking about CSA in therapy …………………………………..…... 34
3.3.3 Barriers for mental health professionals asking about CSA ………... 35
3.3.3.1 Lack of knowledge or training ……………………………....... 35
3.3.3.2 Fear of inducing previously unreported traumatic memories … 35
3.3.4 Survivor opinions about being asked by mental health professionals..36
3.3.5 Is disclosure of CSA useful for survivors in therapy? ……….……... 37
3.3.6 Factors facilitating disclosure of CSA ……………………………… 37
3.3.6.1 Quality of the therapeutic relationship ……………………….. 38
3.3.6.2 Normalising …………………………………………….…..… 38
3.3.6.3 Psychosocial assessment ……………………………………… 39
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3.4 Working with Disclosures of CSA in therapy …………………………..... 39
3.4.1 Helpful practice when working with CSA survivors ………..……… 39
3.4.1.1 Basic counselling skills …………………………………......... 40
3.4.1.2 Listening ……………………………………………………… 40
3.4.1.3 Not replicating the abuse dynamic …………………………… 41
3.4.1.3.1 Transparency ……………………………………….... 41
3.4.1.3.2 Empowerment ………………………………….……. 42
3.4.1.3.3 Meta-dialogue ……………………………………..… 42
3.4.1.3.4 Education ……………………………………………. 43
3.4.1.4 Longer treatment ……………………………...………………. 44
3.4.2 Benefits of disclosing CSA in therapy ……………………...……… 44
3.4.2.1 Being heard …………………………………………………... 45
3.4.2.2 Understanding and developing one’s identity ……….……….. 45
3.4.2.3 Making meaning or a different meaning ……………………... 45
3.4.3 Risks of disclosure of CSA in therapy ……………………………… 46
3.4.3.1 CSA survivor being distressed by disclosure ………………… 46
3.4.3.2 Mental health professional appearing uncomfortable ……..…. 47
3.4.3.3 Mental health professional assuming a ‘blank’ therapeutic
stance …………………………………………………………. 47
3.4.3.4 Mental health professional terminating therapy ……………… 48
3.4.3.5 Negative reaction of the mental health professional and
secondary victimisation …………………………………….… 48
3.4.4 Possible reasons for unhelpful practice ………………………….…. 49
3.4.5 Consequences of unhelpful practice on survivors ………………….. 50
3.5 Summary …………………………………………………………………. 51

Chapter 4 Research Methods and Procedures ………………………………..…… 53
4.1 Introduction …………………………………………………….………… 53
4.2 Qualitative Methods ……………………………………………………… 53
4.2.1 Semi-structured interviewing …………………………………….… 54
4.2.2 Thematic analysis ………. …………………………………………. 55
4.3 Participants …………………………………………………………….…. 56
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4.3.1 Adult CSA survivors ……………………………………….………. 57
4.3.2 Mental health professionals ………………………………………… 57
4.4. Gathering Data …………………………………………………………… 61
4.4.1 Developing the interview schedule …………………………………. 61
4.4.2 Recruitment process ……………………………………………...…. 61
4.4.2.1 Adult survivors of CSA ……………………………...……….. 61
4.4.2.2 Mental health professionals ……………………………..……. 62
4.4.3 Organising and conducting interviews ………………………...……. 63
4.5 Analysing the data ……………………………………………………..…. 64
4.6 Quality of the findings ………………………………………………….… 65
4.7 Ethical and Other Considerations …………………………………...……. 66

Chapter 5 Results and Discussion Part One: Survivors of Childhood Sexual
Abuse …………………………………………………………………………….. 68
5.1 Introduction …………………………………………………………….… 68
5.2 CSA Survivors’ Presenting and Associated Issues ……………………….. 68
5.2.1 Attachment, relationships and revictimisation …………………...….. 69
5.2.2 Sexual intimacy ……………………………………………...………. 70
5.2.3 Parenting issues ……………………………………………………… 71
5.2.4 Mental health presentations ……………………………………..…… 72
5.2.4.1 Depression and anxiety …………………………………….…. 72
5.2.4.2 Substance abuse ………………………………………………. 73
5.2.4.3 Insomnia …………………………………………………….... 74
5.2.4.4 Posttraumatic stress symptoms …………………………….…. 74
5.2.4.5 Borderline personality traits ……………………………..…… 75
5.3 Gender Differences ………………………………………………………. 76
5.3.1 Male survivors and shame ………………………………………….. 76
5.3.2 Male survivors and sexual identity …………………………….…… 77
5.3.3 Male survivors, anger and violence …………………………...……. 77
5.3.4 Communication style …………………………………………….…. 78
5.4 CSA Survivors Disclosing to Informal Supports ……………...…………. 80
5.4.1 Disclosing to family ……………………………………….……….. 80
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5.4.2 Disclosing to friends ………………………………………..………. 82
5.5 Summary ………………………………………………………………….. 85

Chapter 6 Results and Discussion Part Two: Mental Health Professionals
Working with Survivors of Childhood Sexual Abuse ………………………… 86
6.1 Introduction ………………………………………………………………. 86
6.2 Triggers for Seeking Therapy ………………………………………..…… 86
6.2.1 Child reaching the age of survivor’s abuse …………………...……. 87
6.2.2 Significant life events ………………………………………………. 87
6.2.3 Existing coping strategies becoming ineffective ……………..…….. 88
6.2.4 Stage of life …………………………………………………...…….. 89
6.2.5 Family occasions …………………………………………...……….. 90
6.3 Asking about CSA in Therapy …………………………………….……… 90
6.4 Barriers Preventing Mental Health Professionals from asking about CSA.. 91
6.4.1 Lack of training and knowledge ……………………………………. 91
6.4.1.1 Mental health professionals’ own training experiences …….... 92
6.4.1.2 Increasing skills for working with CSA …………………...…. 93
6.4.2 Fear of legal repercussions …………………………………….….… 94
6.4.3 Mental health professionals’ level of comfort ……………………… 96
6.4.4 Mental health professionals’ own trauma experiences ……………... 97
6.5 The Implications of not asking about CSA …………………………...….. 98
6.6 Is Disclosure of CSA Important in Therapy? ………………………..….. 100
6.7 Factors Facilitating Disclosure of CSA ………………………...……...... 101
6.7.1 Quality of the therapeutic relationship ……………………...……... 102
6.7.2 Transparency ………………………………………………………. 103
6.7.3 Conducting a thorough psychosocial assessment ……………......... 104
6.7.4 Offering a hypothesis ……………………………………………… 106
6.8 Factors Impeding Disclosure of CSA …………………………………… 108
6.8.1 Asking specifically and directly ………………………….…………108
6.8.2 Gender of the mental health professional ………………………..…109
6.9 Benefits of Disclosing CSA in Therapy ………………………...…….… 111
6.9.1 Being acknowledged …………………………………………….… 111
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6.9.2 Making meaning or different meaning ………………………...….. 111
6.9.3 Developing one’s identity ……………………………………...….. 112
6.10 Risks of Disclosing CSA in Therapy…………………………… 113
6.10.1 Mental health professional driving therapy ……………... 113
6.10.1.1 Being treatment focused ………………………….... 113
6.10.1.2 Time limits and inflexibility ……………………….. 114
6.10.1.3 Recommending inappropriate strategies ………..…. 116
6.10.1.4 Violating survivor boundaries ………………..……. 117
6.10.2 Mental health professional appearing uncomfortable ...… 118
6.10.3 Mental health professional assuming a blank therapeutic
stance ……………………………………………………. 121
6.11 Referrals and Constraints …………………………………………...….. 122
6.12 Consequences of Unhelpful Practice on CSA Survivors ………...……...125
6.13 Summary ………………………………………………………….……..128

Chapter 7 Conclusions and Recommendations ………………………………….. 130
7.1 Aims of the Study …………………………………………………….…. 130
7.2 Findings of the Study …………………………...……………………..… 130
7.3 Implications and Recommendations to Improve Professional Practice … 134
7.4 Limitations of the Study…………………………………………………. 135
7.5 Future Directions for Research ………………………………………….. 137
7.6 Conclusions ……………………………………………………………... 138

References…………………………………………...………………………………. 139

Appendix A - Semi-structured Interview Schedule (CSA Survivors) ………..… 154
Appendix B – Semi-structured Interview Schedule (MHP) ………………..…… 155
Appendix C – Expression of Interest Flyer (CSA Survivors) ………...…………. 156
Appendix D – Expression of Interest Flyer (MHP) …………………………….... 157
Appendix E – Information and Consent Forms (CSA Survivors) ...……………. 158
Appendix F – Information and Consent Forms (MHP) …………………………. 163
Appendix G – Ethics Approval and Amendment ……………………………..…. 168
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