Childhood sexual abuse and couples’ relationships: Female survivors’ reports in therapy groups
Pistorello, Jacqueline
Therapy videotapes from five therapy groups for female child sexual abuse (CSA) survivors were analyzed for emerging themes of couples’ difficulties reported by clients. Subsequently, the thematic categories were applied to sessions selected from an additional four groups and then correlated with CSAspecific variables. The two most frequent relationship themes were difficulties with emotional communication or intimacy, and polarized positions on control. Whereas these two themes were correlated with survivors’ CSA characteristics, sexual difficulties were correlated with survivors’ level of current traumatic symptomatology. Results are discussed in terms of implications for the treatment of CSA survivors and their partners.
The literature on childhood sexual abuse (CSA) is replete with accounts suggesting that such a history has a negative impact on survivors’ adult couple relationships (Briere, 1992; Briere & Runtz, 1991; Browne & Finkelhor, 1986; Follette & Pistorello, 1995; Herman, 1992; Johnson, 1989). The interpersonal impact observed in other types of trauma, such as war combat and adult rape, is intensified in the case of CSA by the context of the trauma. Not only does CSA take place at a time when the individual is undergoing intense developmental changes, but it also often results in an ongoing disturbance in an existing primary relationship (Cole & Putnam, 1992).
Survivors report experiencing considerable distress and dissatisfaction in their relationships (e.g., Briere, 1988; Russell, 1986). Due to the pairing of close, intimate relationships with experiences of invalidation, intrusion, or pain, survivors may come to experience a great deal of anxiety when faced with intimate contacts, which has a disruptive impact on their ability and willingness to trust others (Briere, 1992; Herman, 1992). Additionally, a wide range of problems affecting sexual performance and satisfaction have been documented among survivors (Briere, 1992; Maltz & Holman, 1987; Polusny & Follette, 1995), including more severe sexual problems (Meiselman, 1978) and lower sexual satisfaction (Waltz, 1993) than females without a history of sexual abuse. Some survivors report decreased sexual interest due to flashbacks, whereas others report heightened sexual appetite, often associated with a history of multiple, sequential, brief sexual involvements (Courtois, 1979; Maltz & Holman, 1987).
An often cited long-term correlate of child sexual abuse is revictimization in adulthood (Briere, 1988; Herman, 1992; Polusny & Follette, 1995; Russell, 1986). Compared to women who were not sexually abused in their childhood, survivors were twice as likely to experience rape as adults and were more likely to report having been physically abused and raped by their partners (Russell, 1986).
The quality of interpersonal relationships is a key factor in survivors’ recovery, because individuals in the survivor’s social environment may play a significant role in either the attenuation or the exacerbation of the impact of traumatic experiences (Herman, 1992). In a recent study, female CSA survivors reported that partner involvement in treatment was essential, particularly in dealing with related marital problems, maintaining partner support, and educating partners about CSA (Reid, Taylor, & Wampler, 1995).
These findings underscore the need for a deeper understanding of the difficulties arising within dyads comprising at least one CSA survivor. Most of the extant literature in this area has come from clinical observations made during individual therapy and from comparisons of survivors with nonsurvivors in self-report measures. However, little is known at this time about the prominence of couples’ difficulties for survivors seeking other forms of therapy.
This line of inquiry seems relevant: Studies investigating the effectiveness of group therapy for CSA survivors have found that married women were less likely to benefit from therapy (Follette, Alexander, & Follette, 1991) and were more likely to drop out (Fisher, Winne, & Ley, 1993) than unmarried women. Furthermore, marital satisfaction was predictive of initial levels of adjustment (Follette et al., 1991), and treatment attrition was linked to reports of domestic violence and partners’ objections to the survivors’ participation in therapy (Fisher et al., 1993).
The primary purpose of the present study is to identify the most frequent thematic categories of relationship difficulties discussed by CSA survivors in the context of shortterm group therapy. Although there has been an informal articulation of the problems survivors and their partners are likely to experience, the field still lacks a careful delineation of how survivors perceive these problems and how prominent couple relationship difficulties are for survivors in their recovery. Findings might be useful in informing decisions about matching survivors and their partners to different therapy modalities.
The marital therapy field has recently noted the importance of including individual and historical factors as contributors to current relationship functioning (Jacobson & Addis, 1993). If CSA is a crucial contributor to couples’ difficulties among survivors in treatment, then one might expect a significant relationship between couple functioning, as reported in the course of group therapy, and CSA-related variables.
Therefore, a secondary goal of this study is to explore the relationship between couples’ difficulties reported in group and current trauma symptoms, as assessed by means of a self-report measure, and characteristics of the child sexual abuse itself. Based on the literature (e.g., Briere, 1988; Browne & Finkelhor, 1986; Meiselman, 1978; Wind & Silvern, 1992; Wyatt & Newcomb, 1990; Wyatt, Newcomb, & Riederle, 1993), the following CSA characteristics were investigated: parental figure as perpetrator; occurrence of penetration (vaginal, anal, or oral); duration, frequency, and onset of the abuse; and the survivor’s belief that a nonoffending parent knew of the abuse and did not intervene.
METHOD
Participants I
Females who had experienced CSA were recruited through media announcements and community referrals for participation in 12-week therapy groups designed to deal with abuse problems.2 A total of 55 female survivors participated in nine groups (7 individuals participated in two different groups). Members ranged in age from 19 to 52, with a mean of 33. Most participants were Caucasian (93%) and had some post-high school education (77%), although only 28% had a college degree. The average family income was $21,375 (SD = 16,164). Approximately half were married or currently living with someone, 28% were single, and the remaining 22% were separated or divorced.
Participants mostly reported having been sexually abused by their father (32%), stepfather (29%), or brother (11%), followed by other family members (10%), an acquaintance (9%), or an unknown perpetrator (9%). Half of the sample reported experiencing some form of penetration (vaginal, anal, or oral) during the abuse. Approximately 40% of the women reported that the sexual abuse started when they were between 2 and 7 years old and lasted between 6 and 10 years, and that they currently believed a nonoffending parental figure knew of the abuse but did not intervene. Materials
This study relied on data collected from nine 12-week therapy groups for female adult survivors of CSA. The materials included videotapes of 1 l- hour group therapy sessions, a paper-and-pencil measure, group progress notes, sex history notes, and notes taken by coders paraphrasing problems described by survivors. Groups had an average of 7 members each, were facilitated by two female therapists, and relied on different therapeutic approaches.3
Assessment
Sex history interview. Each group participant underwent an in-depth sex history interview regarding the onset, duration, and severity of the child sexual abuse, as well as the identity of the perpetrator and the reaction of the nonoffending parents. The most severe abuse was coded for these variables.
A paper-and-pencil measure of trauma symptoms. The Trauma Symptom Checklist 40 (TSC-40, Briere & Runtz, 1989) was administered at pretest in order to measure symptoms specifically associated with the long-term impact of CSA. This instrument has demonstrated criterion-related validity in relation to CSA and adequate reliability and internal consistency (Elliot & Briere, 1992; Zlotnick et al., 1996). Although the TSC-40 is composed of six subscales, only the Sexual Abuse Trauma Index (SATI) predicted child sexual abuse within an inpatient female sample (Zlotnick et al., 1996). Thus, this subscale was used as a parsimonious measure of long-term trauma associated with CSA. Procedure
In view of the relatively early stage of understanding of couples’ difficulties among dyads comprising at least one CSA survivor, a descriptive approach rather than a hypothesis-testing approach seemed warranted. The method utilized generally followed a fourstep discovery-oriented approach to psychotherapy research (Mahrer, 1988). These steps include identifying the target events, obtaining instances of such events, developing an instrument to describe the phenomenon, and finally, gathering data by applying the instrument to instances of selected target events, preferably not those utilized in the development of the instrument. Below is a description of these four steps as applied to the present study.
Selecting target events. The events of interest in this study consisted of statements made by CSA survivors regarding couples’ difficulties brought up in the course of shortterm group therapy. Based on precoding discussions, the following operational definition of couples’ problems was derived: verbalizations made by a survivor that describe events, concerns, thoughts, attitudes, or feelings which are connected by the client to past or current difficulties arising within romantic involvements, or that relate to difficulties within couple relationships or sexual relating in general. Although survivors also reported at times strengths in their relationships, for the purposes of this paper, the focus was on difficulties reported by survivors.
Obtaining instances of the target events. Session sampling was based on intensity sampling (Patton, 1990). After reviewing group progress notes, two raters independently selected the most information-rich session, in terms of couples’ problems, from each phase of each of the five groups: beginning (sessions 1-3), beginning middle (sessions 46), ending middle (sessions 7-9), and end (sessions 10-12). There was almost perfect agreement between the two raters. Every session was watched in its entirety in order to provide a broader context for the couples’ issues discussed within sessions. Developing an instrument to describe the phenomenon. Developing an instrument to describe the phenomenon involved developing a category system describing the relationship difficulties articulated by CSA survivors in the course of group therapy. Unlike more quantitative analyses, the type of methodology utilized in this study views category systems as means to an end rather than ends in themselves (Mahrer, 1988).
The procedures for category development relied on methodological recommendations outlined in the literature (Dey, 1993; Patton, 1990; Rennie, Phillips, & Quartaro, 1988). The principal investigator (PI., first author) watched all tapes selected and wrote down verbatim couples’ difficulties voiced by each group member during the selected sessions and concurrently assigned each instance a short term to describe the issue (e.g., “pulls back when close”). These notes were routinely analyzed for emerging themes. Investigator triangulation was utilized (Patton, 1990). After the P.I. developed a preliminary description of categories, the second author and two other raters reviewed and applied the provisional system independently. All four coders met repeatedly to discuss the category system, which was constantly reevaluated based on incoming data, until all issues had been coded by two raters.
Although the identification of one or two core categories, as suggested by grounded theory (Rennie et al., 1988), would be useful in terms of theoretical formulations, it conflicted with the secondary goal of this study. Therefore, a choice was made to keep the category system comprehensive and sex-related themes separate.
Applying the instrument to new instances of target events.4 As recommended by Mahrer (1988), the categories were then applied to selected sessions from four previously uncoded groups.
The selection and viewing of therapy videotapes for the application of the thematic categories followed the same methodology as outlined above. For coding purposes, sessions were divided into 5-minute segments, and coders were asked to indicate the occurrence of any of the issues within each segment for each client.
All selected group therapy sessions were watched by two coders: The “criterion” coder was a therapist in that particular group, whereas the second coder, the “noncriterion” coder, was not. Category assignments by the criterion coders were utilized in the quantitative analyses and later compared to those of second coders to check for interrater agreement.
After the coding was completed and the frequency of occurrence of couples’ difficulties and interrater agreement were computed, the most salient couples’ issues reported in session, including the three most frequent sexual concerns, were correlated with a selfreport measure of traumatic symptomatology (SAn subscale of the TSC-40) and with characteristics of the CSA itself.
RESULTS
Development of Categories
Several categories were generated to describe the themes emerging from the data. The final category system, after the splitting and splicing of original themes, consisted of 23 categories whose content revolved around sex-related (e.g., dissociation), survivor-specific (e.g., confusing partner and perpetrator), partner-specific (e.g., personal difficulties), relationship-specific (e.g., difficulty expressing emotion), and attitudinal (e.g., negative attitudes toward men) themes. Table 1 provides a brief description of these thematic categories.
Application of Categories
The second component of the study consisted of applying categories developed to four, yet uncoded, short-term therapy groups for CSA survivors. Frequency of couples’ issues. According to the criterion coders’ endorsement of occurrence of couples’ issues, 168 of the 293 5-minute segments (58.4%) included at least one reference to couples’ difficulties made by survivors in the group. The most frequent themes brought up by the 28 survivors included difficulties with emotional communication and intimacy (n = 18), control issues within the relationship (n = 18), lack of boundaries (n = 15), blaming of the survivor’s history (n = 15), and negative attitudes (n = 15). Difficulties with emotional communication/intimacy and relationship control were not only reported by the most clients, but also were reported the most frequently: More than half of all segments coded for couples’ issues included references to one or both of these themes. In contrast, the participants’ concern that their partners might molest their children and disagreements over contact with family of origin were assigned only once each.
There were 14 themes brought up by at least 25% of the clients. These included 3 sexrelated themes (History Guilt, Avoidance, and Control), 6 survivor-specific themes (Lack of Boundaries, Blaming Survivor’s History, Control(Excess/Lack), Partner Evaluation, Partner/Perpetrator Association, and Confusion), 2 partner-specific themes (Partner Personal Difficulties and Partner’s Reaction to Treatment), 2 relationship-specific themes (Abusive Style and Difficulties with Emotional Communication/Intimacy), and 1 attitudinal theme (Negative Attitudes). Themes brought up by fewer clients will not be discussed further.
Interrater agreement. Interrater reliability was calculated for each of the 14 issues brought up by a quarter or more of the participants, using the kappa coefficient. For each theme, reliability was computed based on whether the two raters could agree that the issue had been brought up by a particular client within a particular session. Interrater reliability varied across themes, ranging between .50 and .81, with a mean kappa of .72. Although three categories (Blaming Survivor’s History, Abusive Style, and Negative Attitudes) could not be reliably coded (kappa levels below .60), the remaining categories achieved adequate levels of interrater reliability. Themes that could not be coded reliably were not utilized in subsequent analyses.
Relationship between couples’ difficulties and trauma symptoms. In order to investigate the relationship between severity of long-term trauma-related symptoms and couples’ difficulties brought up in the therapy group, the frequency of the three sex-related categories reported by at least 25% of the clients, the two categories reported the most often and by the most people, and the overall frequency of couples’ issues reported in the group were correlated with the Sexual Abuse Trauma Index (SATI) of the TSC-40. These correlations were computed using the Pearson product-moment coefficient, with one-tailed tests of significance.
Results revealed that trauma symptoms were significantly correlated with sex avoidance (r = .44, p .10). Although there were no significant correlations between the SATI and control within the relationship (r = .11, p > .10), there was a trend toward significance with difficulties with communication and intimacy (r = .35, p
Relationship between couples’ issues and CSA characteristics. Because CSA variables were coded as either dichotomous or ordinal, Spearman correlation coefficients were computed between the five themes noted above and selected CSA characteristics (parental figure as perpetrator, onset, duration, penetration, and nonoffending parent being aware). Tests of significance were again based on one-tailed tests, except for duration of the abuse. The total number of reports of difficulty with emotion or intimacy was correlated with longer duration (r = .57, p
DISCUSSION
The present findings corroborate the available literature which suggests that many CSA survivors who are in therapy experience a great deal of turmoil and dissatisfaction in their relationships: Couples’ difficulties were discussed by participants during more than one half of the time in the group sessions evaluated. Although these sessions were selected for their richness in relationship themes, this sample of sessions constituted one third of all group therapy time.
The two most pervasive themes reported by this clinical sample of survivors, in terms of both overall frequency and number of different clients reporting them, were difficulties with emotional communication and intimacy and issues related to either an excess or lack of control within the relationship. Interestingly, this finding parallels results from a recent study indicating that survivors’ primary coping strategies involved avoidance of threatening or dangerous feelings and the management of feelings of helplessness, powerlessness, and lack of control (Morrow & Smith, 1995).
The difficulties that many CSA survivors report with emotional interactions and feelings of power and control are understandable in the context of the abuse experience. A somewhat guarded and vigilant approach to close interpersonal relationships, which may have been adaptive for the child, frequently leads to issues in attaining an intimate connection with a partner as an adult. The relevance of this issue to couples in which one member is a CSA survivor was demonstrated in a recent study (Waltz, 1993). When compared to control couples’, survivor couples’ interactions were characterized by low emotional expressiveness, and the female survivors tended to report more difficulty with emotional communication within the relationship. In the present study, the particular areas of difficulty reported by survivors related to discussing aspects of the abuse history and to tolerating emotional closeness. These findings may be understood in the context of an avoidance model, which is frequently used in the trauma literature. For example, many of the long-term correlates of CSA have been conceptualized as forms of emotional avoidance, that is, behavioral attempts to avoid experiencing negative thoughts, feelings, or memories (Follette, 1994; Polusny & Follette, 1995). Thus, the relationship patterns suggested by these categories may, at least within a clinical sample of survivors, function similarly in helping the client to avoid the negatively evaluated private experiences that are associated with being in an intimate relationship.
The present study also explored the specific difficulties faced by CSA survivors in their couples’ relationships. Current severity of trauma symptoms, as measured by a standardized assessment tool, tended to covary with the survivors’ reports of sexual difficulties and with the total frequency of couples’ issues reported across sessions. Additionally, survivors who reported in the group having more difficulty discussing emotions and being intimate in relationships had been abused at an earlier age and for a longer period of time. These findings are consistent with the hypothesis that early sexual contact, in conjunction with other contextual factors, may lead to an interference in social and self development (Cole & Putnam, 1992).
Issues of control were more likely to be discussed by group members who currently thought that a nonperpetrating parental figure was aware of the ongoing abuse and did not intervene. This finding could be interpreted, albeit with caution, as a suggestion that some of the mediating variables discussed in the literature may serve to exacerbate or ameliorate the impact of the trauma (Wyatt & Newcomb, 1990). In this case, the belief that a parental figure was aware of the abuse may have increased the sense of powerlessness and may have subsequently also increased the need for control within adult relationships.
Clinical Implications
Although there are few empirical data that directly explore couples’ issues related to CSA, individual distress has been found to have a relationship to couples’ issues in a number of clinical presentations (e.g., Gotlib & Whiffen, 1989). An exploration of the bidirectional interactions of the couple in which one member has an abuse history would help us to understand the factors that may either intensify or lessen the impact of the abuse on later interpersonal functioning. Current findings have various treatment implications for CSA survivors in therapy and their partners. The results of this study support previous findings that point to individual differences among survivors in terms of relationship functioning (Buttenheim & Levendosky, 1994; Waltz, 1993).
The long-term sequelae of a history of CSA lead many individuals to seek therapy. Some studies indicate that as many as 50/o of samples of female clients report an abuse history (Briere & Zaidi, 1989). Although it is common practice to view group or individual therapy as the treatment of choice for CSA survivors, emerging data indicate that this may not always be the most appropriate modality (e.g., Follette et al., 1991). We believe that a careful analysis of both historical and present variables that are associated with the current distress would assist the therapist in selecting the most effective therapeutic approach. When couples’ issues are in fact the primary presenting complaint, interventions specifically designed to target those issues are generally most appropriate. In view of the fact that intimacy and closeness are frequently reported issues for this population, therapies that focus on acceptance (of self and others) and emotional expression, as well as behavioral change, are particularly appropriate. Examples of such therapies include Emotionally Focused Couple Therapy (EFT; Johnson & Greenberg, 1994), Integrative Behavioral Couple Therapy (IBCT; Christensen, Jacobson, & Babcock, 1995), and Acceptance and Commitment Therapy (ACT; Follette, 1994). Whereas traditional behavioral therapy, BMT, has employed strategies that focus on behavior change, IBCT is directed more at dealing with affective experiences and acceptance strategies.
Because a partner may join his survivor partner in therapy mostly to facilitate her growth, it is important to explore issues of mutual difficulty and responsibility. It is not unusual for the survivor, as suggested by some categories in this study, and her partner to assume that the survivor’s abuse history is solely responsible for any difficulties within the dyad. This process of “benevolent blame” tends to promote the stigmatization of the survivor and may lead the couple to avoid current difficulties by focusing exclusively on historical events.
In working with the couple on their relationship, the therapist can create a new context for emotional relating that involves acceptance and validation. Prior to engaging in specific work related to dyadic conflicts, the therapist must work to enhance the empathic repertoires of both members of the couple. Helping the clients to understand and accept each other, as well as the history that they bring to the relationship, can provide the foundation for resolving difficulties.
The issue of safety in conflictual interactions is crucial. Although some couples may be able to tolerate high levels of conflict and remain mindful during the interaction, the abuse survivor frequently has a long history of using experientially avoidant coping strategies. Specifically, she may dissociate or otherwise withdraw from the interaction, which leads to increased reinforcement for avoidant responses. Therefore, the therapist has two tasks associated with doing this work. First, the therapist must ensure that the client has adequate resources to tolerate the affect involved in intense interactions. This may be best accomplished through individual work using strategies such as those suggested by Linehan (1993), in which clients are taught skills targeting emotional regulation (e.g., acting opposite to emotion) and distress tolerance (e.g., self-soothing techniques). Second, the therapist must guard diligently against repeated emotional victimization of the survivor by the partner in the therapy session. Research has clearly documented the risk of revictimization for CSA survivors (Polusny & Follette, 1995). It is incumbent on the therapist not to recreate this process in the therapy session.
The findings of this study also indicate that CSA survivors do, in fact, report a number of sexual difficulties. Engaging in sexual activity may stimulate associations that result in intrusive memories, flashbacks, and even somatic distress. Therapists working with survivor couples should always do a thorough evaluation of sexual functioning. Gradual exposure, presented in conjunction with coping strategies, can assist couples in working with sexual difficulties.
Limitations and Future Directions
The present study constitutes an early attempt to delineate the couples’ difficulties that are most salient to CSA survivors in group therapy. However, there are certainly limits to this study. Due to the small sample size, results in the quantitative analyses should be interpreted cautiously. The lack of a control group in particular warrants caution. It is not known whether themes of intimacy and control difficulties, noticed in this sample, would be just as prevalent in any other women’s group, or whether CSA survivors not presenting to therapy would complain of such pervasive relationship difficulties. Future studies might investigate the generalizability of these themes to those reported by nonsurvivors in therapy, survivors who are not presenting for CSA-related therapy, and nonclinical samples of CSA survivors.
It should also be noted that a number of these categories were reported by relatively few participants, and that some of those reported by 25% or more of the sample could not be reliably coded. Although the goal of the present study was not to develop a category system per se but rather to describe couples’ issues as viewed by CSA survivors in group therapy, the low reliability presents a threat to the validity of some of the themes described. However, it is encouraging that the categories do converge with issues described in the clinical literature.
In conclusion, although it has long been clinical wisdom that survivors will experience issues in couples’ relationships, this project provides some understanding of the specific complications that may also arise.
NOTES
Individuals were self-identified as abuse survivors, and all those accepted into treatment had at least some recollection of the abuse experience.
2 Treatment outcome findings for this study will not be presented here. Manuscript is currently under preparation.
3 The therapeutic approach taken varied across groups: Two groups followed a self-help book and discussed topics presented in the book; two groups relied on an approach encouraging acceptance of feelings, thoughts, and memories associated with the abuse, combined with a commitment to behavioral change; two groups had consisted of dyadic discussions of issues during sessions; and three groups utilized a combination of these methods. Quantitative analyses relying on paper-and-pencil measures of depression, social adjustment, and marital satisfaction indicated no differences among the four group modalities on these measures at pretest or in terms of treatment gains. 4 The original category system applied, which consisted of 31 categories, was reduced to 23 themes (see Table 1 on next page) after some of the overlapping categories were combined into more comprehensive themes. Please contact the lead author for further information.
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Jacqueline Pistorello Victoria M. Follette University of Nevada, Reno
Jacqueline Pistorello, BA, is a doctoral candidate at the University of Nevada, Reno, and is currently a Research Associate at Brown University and Butler Hospital. Correspondence concerning this article should be addressed to Dr. Pistorello at University of Nevada, Reno, Mail Stop 298, Reno, NV 89557. Victoria Follette, PhD, is Associate Professor of Clinical Psychology and Associate Dean of Arts and Sciences at the University of Nevada, Reno, Mail Stop 086, Reno NV 89557. Special acknowledgment is given to (in alphabetical order) Laura Arkowitz, Anne Bechtle, Amy Naugle, Melissa Polusny, Jill Serafin, Ethan Steever, and Robyn Walser, all of whom assisted in coding of data.
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