“alienated” partner: Responses to traditional therapies for adult sex abuse survivors, The
Reid, Kary S
Childhood sexual abuse affects both survivors and partners; however, the common therapy modalities for survivors (individual and individual group therapy) exclude their partners. In-depth interviews with the husbands of survivors were used to examine partner issues around the survivor’s therapy. Several themes, both positive and negative, emerged from the qualitative analysis of the in-depth interviews. The authors suggest that therapists should consider integrating conjoint couple therapy as an adjunct to, not a replacement for, the traditional modalities of individual and individual group therapy for adult survivors.
Therapists have found that most adult survivors of childhood sexual abuse tend to seek help as individuals, regardless of their marital or relationship status. Research and clinical reports indicate that many clients are reluctant to divulge their sexual abuse history in any kind of therapy and may avoid this issue altogether (Josephson & Fong-Beyette, 1987; Sheldon,1988). Perhaps because of survivors’ tendency to view childhood sexual abuse as an “individual” issue, therapeutic strategies for working with adult survivors have tended to center around individual therapy and group therapy for individuals.
Feinauer (1989) suggests that individual therapy may be more conducive to in-depth exploration of personal issues than any other treatment modality for adult survivors. Once the sexual abuse issues have been appropriately identified, a progression toward group therapy becomes the treatment of choice for many practitioners (e.g., Bergart,1986; Blake-White & Kline,1985; Deighton & McPeek,1985; Faria & Belohavek,1984; Forward & Buck, 1978; Goodman & Nowak-Scibelli, 1985; Herman & Schatzow, 1984; Tsai & Wagner, 1978).
The accepted treatments for survivors of childhood sexual abuse involve focus on the abuse, its aftereffects, and any resulting personality manifestations in the individual (Courtois, 1988). A primary focus of therapy has been on understanding the sex abuse experience from the survivor’s perspective without paying much attention to the survivor’s current relationship status. Ignoring current relationship issues when treating childhood sexual abuse ignores how the abuse issues are played out in the relationship. Intense focus on the survivor as the “identified patient” with limited attention to the partner’s role in the dyadic process of recovery is common in the current literature.
The important supportive role of a relational partner has been discussed in other, primarily self-help, works (e.g., Bass & Davis, 1988; Courtois, 1988; Davis, 1991; Dolan, 1991; Engel, 1991; Gil, 1992; Graber, 1991; Kritsberg, 1990; Maltz, 1988, 1991; Maltz & Holman, 1987; Westerlund, 1992). Other roles for the partner in therapy for the sexual abuse survivor and the partner’s own needs in therapy have not been widely researched. A computer search for “child(hood) and sexual abuse and couple (marital) and therapy” covering current PsychInfo(tm), ERIC, and Medline databases yielded a total of 36 journal articles. Of these 36, only 16 actually addressed couple therapy for sexual abuse survivors. Two reported survey research on women in treatment for childhood sexual abuse (Feinauer, 1989; Gelster & Feinauer, 1988); one was a literature review (Wilson & James, 1992); 11 were either applied theory (e.g., models of therapy for survivors involving their spouses) or single case studies or both (Barnett, 1993; Buttenheim & Levendosky, 1994; Follette, Alexander, ec Follette, 1991; Golden, 1988; Ingram, 1985; Maltz, 1988; McCarthy, 1986, 1990; Mennen & Pearlmutter, 1993; Nadelson & Polonsky, 1991; Weiner, 1988); one described a group therapy program for partners of survivors (Brittain & Merriam, 1988); and one was presented as a program for five women and their partners that focused on “relaxation training, the women’s erroneous beliefs about sexual victimization, and treatment of the sexual dysfunctions [with the partner directly involved only in the last component]” (Gazan, 1986, p. 85).
Clearly, there is not a substantial research literature on this topic beyond reports that survivor clients who seem to benefit most from therapy are those with outside supports, typically from an ongoing relationship (Goodman & Nowack-Scibelli, 1985; Herman & Schatzow,1984), and these case study reports. A personal search through a research library’s holdings produced 14 books addressing treatment of adult survivors of childhood sexual abuse (Library of Congress code RC569.5.A28…). Ten of these did not mention “partner” or “spouse” as part of treatment interventions. The remaining four addressed the issue of partner involvement as a very limited topic within another chapter, typically 4-6 pages in a 200-300 page book (Dinsmore,1991, pp.141-147; Dolan,1991, pp. 141-147; Dolan, 1991, pp. 41-47; Nichols, 1992, pp. 42-48; Sanderson,1990, pp. 246-251). For these authors, the answer to the question of whether the partner should be included in dealing with recovery from sexual abuse is, simply, “It all depends” (Nichols, 1992, p. 42).
Almost universally, the authors of these articles and books see the therapy for the survivor as paramount and would exclude the partner from involvement under a number of circumstances. For example, Nichols asks, “Are the spouse and the marriage being negatively affected by the unresolved effects of the abuse and the client’s current difficulties?” (1992, p. 43) as if the question were moot. Presumably, if there were no effects, the partner could be left out. Although Dinsmore (1991) recommends couple therapy, she makes no suggestions about how to carry out such therapy or what should be covered beyond the most general topics and focuses primarily on helping the partner become more supportive of the survivor and the survivor’s therapy (as does Sanderson, 1990). Dolan (1991) takes much the same stance, although she offers “general therapy directions” (p. 45) for a solution-focused approach for the partner that is directed toward support for the survivor. In their approach, these authors do not differ remarkably from that in the popularized, selfhelp book for partners, Allies in Healing (Davis, 1991), in their focus on the survivor’s needs as paramount and the partner as distinctly secondary. Only a few authors, primarily sex therapists, insist that couple therapy is the treatment of choice for adult survivors (e.g., McCarthy, 1986, 1990; Schnarch, 1991), and fewer still perceive the partner as a co-victim of the abuse (e.g., Maltz, 1988, 1991; Maltz & Holman, 1987) who may be in need of specialized services, including couple therapy, as much as the survivor.
The participants in this study (N = 17) were men recruited as part of a larger study which addressed couples’ perspectives on therapy effectiveness for adult survivors of childhood sexual abuse (Reid, 1993). Couples were recruited through a letter sent to married, female adult sex abuse survivors by seven therapists specializing in treating adult survivors. Three specific selection criteria were presented to the cooperating therapists in order to assist them in identifying potential participants. First, the wife must be receiving individual, couple, and/or individual group therapy for childhood sexual abuse issues, or, if terminated, must have terminated therapy within the previous 3 years. The 3-year limit was selected with the recognition that much of the data to be collected would be based on retrospective recall of past experiences. Placing a 3-year limit on such recall helped to decrease problems with accuracy and thoroughness which might emerge with a longer recall period. Second, the survivor had to be married to or cohabiting with the same partner throughout the targeted interval of therapy. Finally, for the purpose of consistency, only married heterosexual couples were recruited.
Couples willing to participate were asked to contact their therapist, who then provided the investigators with a name and telephone number. Of 53 couples contacted by their therapists, 23 responded; 6 of these did not meet the selection criteria or later declined participation. Couples completing the interviews were provided with a voucher for dinner at a local restaurant. Most of the couples lived within a Southwest urban area with a population of about 200,000; however, 3 couples traveled up to 120 miles for the interview. Nothing is known about the couples who did not respond to their therapist’s letter. Several clients did offer to participate, but their husbands were unwilling to be interviewed. This may have been true in other cases as well.
The participating couples had been married an average of 11.8 years (range = 1-43 years). The average age of the partners was 38 years (ranging from 26 to 65 years). Fourteen of the men were European-American, one was Mexican-American, one was AfricanAmerican, and one described himself as being of Amerasian descent. Thirteen of the 17 men had some college; of these, 2 had finished bachelor’s degrees; 3 had master’s degrees; and 3 others had doctoral degrees. Ten of the men were in their first marriage. Eleven of the 17 men reported that they had participated in some form of therapy themselves; 8 of the 11 had received individual therapy for their own issues. Only one of the men was aware of being a victim of childhood sexual abuse; and he was himself an adjudicated perpetrator of sexual abuse of his children. Five other participants reported physical abuse in their family of origin. Thirteen did not know that their wives were survivors of childhood sexual abuse until after they were married. All of the survivor-wives had been abused by male perpetrators. Only one survivor-wife reported being abused solely by a nonfamily member; in other cases in which a nonfamily member was involved (n = 4), an immediate family member also participated (e.g., the survivor’s brother and his friend).
Given the high level of sensitivity inherent in researching childhood sexual abuse, a qualitative methodology was employed for collection of data in this study. Qualitative methodology has been defined as “research that produces descriptive data: people’s own written or spoken words and observable behavior” (Taylor & Bogdan, 1984, p. 5). This methodology enables “us to enter and explore the inner world of the individual, and allow[s] us to describe individual experience in depth” (Westerlund, 1992, p. 181).
Given the limited sample sizes inherent in clinical studies, sophisticated quantitative analysis of data collected from clinical populations often suffers from weak reliability and validity. Qualitative research is, in some respects, more practical when researching clinical populations, especially those projects which specify adult survivors of childhood sexual abuse as the target population. Due to the stigma and shame associated with sexual abuse, this population is somewhat “invisible,” making it difficult to sample systematically or randomly. Therefore, a qualitative methodology is better suited to capture the rich experiences of a size-/access-limited, yet very important, sample.
In-depth interviewing was the primary method of data collection for this study. Each interview required an average of about 1.5 hours to complete. A series of possible questions was developed by the authors; however, the interviews were conducted as conversations. When the interviewer felt that all topics had been exhausted, she/he asked for feedback from the participant regarding possible omissions, discussed any points raised by the participant, and then reviewed the previously developed list of questions with the participant to ensure that all topics had been adequately addressed.
The audiotaped interviews were first reviewed to ensure that all pertinent information had been obtained and clearly recorded. The tapes were transcribed by a professional transcriptionist. The completed transcripts were then checked for accuracy by the authors using the audiotapes for comparison.
The three authors independently reviewed four randomly selected transcripts to identify emerging themes. Following this initial review, the remaining transcripts were reviewed independently by the interviewers, coded for thematic content, and jointly discussed and classified. Several major themes relevant to the partners of adult survivors of childhood sexual abuse were revealed. To be classified as a major theme, the theme had to be reported by at least 9 of the 17 men. All themes reported in the Results section meet this criterion. The quotations presented in the Results section were selected as illustrative of these men’s comments on each topic.
Content analysis of the interview transcripts yielded several major themes regarding the partners’ perception of the survivors’ therapy process, their experiences on the periphery of that therapy, and the effects of the survivors’ history of abuse and the survivors’ therapy on their marital relationship. When asked what specific advice they would give to therapists who work with survivors, the partners emphasized their need for knowledge regarding the likely course of therapy and the effects of a history of abuse on the marriage, their need for some access to the therapist, and a desire for couple therapy as part of the therapy process.
Perceived Benefits of Therapy
An opportunity to share. According to the partners interviewed for this study, the greatest benefit of individual therapy for their survivor-wives was that therapy offered a place for the survivor to talk about the sex abuse.
Partner #12: I guess finally just having a safe place to go and talk about it…. I see that as the biggest part. Just finally being able to talk about it.
Explaining past behaviors. Partners, at times, expressed relief at learning that previously unexplained behaviors demonstrated by their wives could be attributed to their wives’ abusive past. Merely knowing that a reason existed for the behaviors made the behaviors appear less confusing and, usually, easier to deal with.
Partner #16: It was just like she flat out didn’t care. And there wasn’t a reason except that’s how she was and she wasn’t gonna change the way she was for me…. At least I understand [now] a little more of why she’s like she is.
Reducing isolation. Group therapy was recognized by the partners as providing an opportunity for the survivors to identify with other survivors, thereby reducing feelings of singularity.
Partner #12: The knowledge of knowing that there are other people like her, to actually be able to talk to somebody, and they know the feelings you’re going through.
Negative Aspects of Therapy
Alienation from the process of therapy. While acknowledging benefits of the survivors’ therapy experiences, the negative aspects were frequently the focus of the partners’ comments in the interview. The negative aspect of the survivors’ therapy most often mentioned was the partners’ feeling of alienation from the therapeutic process. The partners reported that, at times, this alienation was instigated by the therapist.
Partner #6: I wanted to be there, to sit and listen. But most of the therapists said, “No, because he’d interfere or be an influence.” Whereas, all I wanted to do was learn…. I felt rejected because I couldn’t be there.
Partner #7: That’s the sad part. I’ve been kept in the dark. The therapy is not shared with the spouse . . . the therapist isn’t inclined to help [the survivor] share, either. This is not an issue that’s dealt with well.
Partner #11: [Therapist] did not want me in there. She said there was so much that [my wife] had to work on, that she wanted her to focus on her issues.
Feeling blamed. Partners also expressed confusion and helplessness with regard to feeling they were being treated by their wives as if they were the perpetrator(s). This “object transference” by the survivor toward her partner is not uncommon (Davis, 1991; Graber, 1991); however, it can cause the partner to feel hurt, angry, and unjustly accused. Some partners opposed therapy for their survivor-wives because they felt blamed for the abuse. The emotional distance in the couple’s relationship is increased by such interactions.
Partner #2: There were times in our relationship that I would tell her [wife], “I’m not your perpetrator.” And it would show up especially in our sexual relationship.
Exclusive focus on survivor issues. Once the therapeutic process toward recovery began, it seemed to the partners that the entire focus of life for themselves as well as their wives became the survivor’s sex abuse issues. Partners expressed impatience with the process, wanting to “get this behind us.”
Partner #1: There are many points where I get frustrated with, well . . . it’s time for this to be over, isn’t it?
One of the systemic consequences of childhood sexual abuse for survivor couples is that personal issues often become relational issues. The nonabused partner becomes a secondary victim of the original abuse (Maltz, 1988, 1991). Although the participants in this study were in unanimous agreement on the benefits of individual therapy for the survivor, they also agreed that marital issues for survivor couples had not been adequately addressed.
Communication. Given the magnitude of the issues inherent in the topic of childhood sexual abuse (e.g., distrust of others, feelings of shame and guilt, and low self-esteem), marital communication often becomes problematic for adult survivors and their partners. Partners reported feeling betrayed if information that they viewed as vital was not shared by their wives. Consequently, a dysfunctional communication pattern often developed as a residual effect of the survivor’s past sexual abuse.
Partner #11: We were in college dating. And on one of our dates she just asked me if I knew she had been sexually abused as a child…. It really didn’t pop up again until after we had been married for about 8 years.
Partner #16: It was my brother-in-law who ended up telling me. And that didn’t make me happy because I didn’t understand why she [wife] wouldn’t tell me. … That made it kinda harder to be there for her [later] when she didn’t think enough of me to tell me.
As reported earlier, some of the partners in this study also felt alienated and/or angry when the survivor would not share her therapy experiences, especially if this refusal to disclose was encouraged by her therapist.
The sexual relationship. As in other studies (Maltz, 1988,1991), the participants in this study reported that their sexual interaction was a major issue. Often, the distinction between physical and sexual intimacy becomes blurred for survivors and their partners.
Partner #15: From the start, she [wife] always thought I had other motives any time sex was brought up…. I could always tell that there was just a little bit of hesitancy there . . . that she didn’t totally trust me.
The confusion about how, when, and where to interact sexually with their wives was exacerbated for partners who reportedly received mixed messages around sexual and other forms of interaction. From the partners’ perspective, their wives displayed inconsistent behaviors from one interaction to another, not only in relation to sex. Partners reported feeling as if they could do nothing right, that the rules changed continuously.
Partner #1: She [wife] has her ups and downs, and those are very fluid. Where she told me not to touch last week is gonna be different than where she told me I could or couldn’t touch this week. It requires a constant understanding of where her boundary is.
Physical contact. A recurring theme among the partners of this study centered around the ways in which a couple communicated through tactile contact. Issues of touch and the effect they can have on relationships are almost always referenced in the literature on childhood sexual abuse (e.g., Blume, 1990; Courtois, 1988; Maltz & Holman, 1987; Westerlund, 1992). Examples of the significant role touch played in the marital relationship of the partners in this study reveal the feelings of confusion and frustration which were often reported.
Partner #17: Touching . . . I’m a real touchy, feely, huggy person. And that was a problem. Initially, it wasn’t a problem, but when she started going to therapy, then it became a problem.
Extended family relationships. The partner’s awareness of the sexual abuse sometimes produced negative reactions, including blaming the survivor, expressing disgust and anger toward the survivor, and feeling threatened by the survivor’s continued relationship with her perpetrator(s). Such reactions were perceived by the participants as contributing to a dysfunctional marital system.
Partner #3: I kept bringing it [sexual abuse] up `cause I wanted to know. Because she stayed with them [parents] all of the time whether her mother was there or not. And it really went through my mind, “She’s still doing it [having intercourse with her father].”
Partner #4: I knew she’d [wife] been sexually abused, when we got married. It was a situation between her and her brother. I really blamed my wife for years. I felt like she was a participant in the whole thing.
Advice to Therapists
Need to educate partner and survivor. The partners were very specific about what they perceived to be lacking in the therapeutic process of adult survivors of childhood sexual abuse: education to improve understanding of the ramifications of childhood sexual abuse for both the survivor and her partner and information on the likely course of therapy. Partners repeatedly referred to the need to know early on what they were facing.
Partner #15: I think that would have really helped us, for [therapist] to have sat down and really explained sexual abuse to me . . . because I felt dumb. I felt, here I am, a collegeeducated man, a successful man, and I don’t know one cent’s worth of what sexual abuse is about.
The partners’ plea for more timely information is understandable given the confusion they so often reported in their interviews.
Therapist-partner contact. Another area for improvement is the need for the therapist and partner to remain in contact throughout the therapeutic process. Partners expressed the importance of feeling free to contact the therapist in times of need.
Partner #3: I can call her therapist and I can just get [an] answer and I feel 100% better.
Partner #17: There have been a couple of times when things have been so crappy, at the house, that I didn’t know what to do. And I have called [therapist] and I have gone in. I have access to her to be able to do that if I need to.
Marital therapy. Marital therapy was seen as beneficial in helping the partner become more involved with, educated about, and understanding of the survivor’s past and present experiences.
Partner #1: You’re gonna have to have somebody on the other side, the spouse, that is willing to go through it and support…. I don’t think that the survivor can recover without the spouse.
Partner #17: I think there should always be some ongoing, periodic couples therapy. It doesn’t matter how much you know, when you’re involved with a survivor, different stuff comes up. And all you know goes out the door.
The participants in this study offered explicit descriptions of the issues faced by the partners of adult survivors. The complexities of a marital relationship are magnified when recovery from childhood sexual abuse is also an issue. The demands of a committed relationship require that special attention and energy be focused on such issues as trust, communication, and physical and sexual intimacy, all of which have been shown to be problematic for the adult survivor of childhood sexual abuse (e.g., Bass & Davis, 1988; Blume, 1990; Browne & Finkelhor, 1986; Courtois,1988; Feinauer, 1989; Maltz & Holman, 1987; Westerlund,1992). The systemic consequences of the survivor’s past sexual abuse become an issue for the survivor’s partner as a secondary victim.
Survivor issues such as blame and control become paramount during the course of therapy, inside and outside the therapy sessions. Yet most partners know little or nothing about what is actually being discussed and reported in therapy. Partners are alarmed and often angry that the negative emotions released in the therapy are brought home and that they become the target of anger, rage, sorrow, and so forth. Attempts to become more involved in the therapy are typically met by the wall of confidentiality; this is frequently perceived as rejection of the partner by the therapist.
Our interview data clearly indicate a need to bring the partner in (with the survivor’s consent, unless the abuse has been revealed in conjoint therapy) for initial discussions of the likely time-frame for the survivor’s therapy, a description of likely behavioral and emotional changes that will be seen at home, information on available resources (e.g., books for the partner, partner support groups, individual therapy), and, possibly, a discussion of possible goals for conjoint therapy, including sex therapy. Early on in these discussions, mutually acceptable rules about communicating with the therapist must be set that both protect the survivor’s need for boundaries and the partner’s need for information. The therapist cannot ignore the possibility that the survivor has replicated her perpetrator in her choice of a partner and must be cautious in regulating partner involvement. To determine the appropriate level of partner involvement, the therapist must remain cognizant of both individual and dyadic variables (e.g., the survivor’s comfort with the partner’s presence, the partner’s own sexual history and attitude toward therapy, the partner’s attitude toward the spouse’s sexual abuse, and the couple’s relational dynamics). Nichols (1992) provides additional potential guidelines for this phase of partner involvement. Couple therapy alone is, in our opinion and that of others (e.g., Busby, Glenn, Steggell, & Adamson, 1993), not necessarily central to the recovery process for married adult survivors of childhood sexual abuse. The effectiveness of the traditional modalities of individual and individual group therapy for adult survivors is well-established. First, the survivor benefits from an opportunity to tell her/his story to a consistently supportive “other.” Second, the support of other survivors in a group setting appears to be of great benefit for self-acceptance and healing.
As therapy for the survivor continues, it is our contention that adjunctive conjoint sessions with the couple are essential to adequately address dyadic issues and to reinforce the partner’s support of and involvement in the healing process. In addition, conjoint therapy provides the survivor-couple an opportunity to deal with intensified problems in the marriage that arise as individual therapy progresses and to develop improved patterns of interaction.
Most therapists will have to struggle to maintain a balance in conjoint therapy, especially if the same therapist is serving as the survivor’s therapist. The therapist is very aware of the survivor’s trauma and possible retraumatization, her needs, and the partner’s past behaviors, and may fail to acknowledge the partner’s experience as a co-victim. The partner often has substantial personal issues, feels attacked by the survivor at home and by the survivor and therapist in conjoint therapy, and is told, explicitly and implicitly, that personal needs must be put on hold for the survivor’s sake. The therapist must explicitly acknowledge these issues with the partner and find ways to support the partner that do not violate the survivor’s needs (e.g., educating the couple about the sequelae of childhood sexual abuse, providing readings as homework for the partner and couple, allowing partner to vent in couple and/or individual sessions, assigning positive couple activities as homework, working on communication problems, scheduling couple discussions about the abuse at home). Depending on the therapist’s theory and treatment model, the works of Schnarch (1991) and Scharff and Scharff (1994), as well as the articles cited above may be helpful in developing appropriate couple interventions. Acknowledging, exploring, and working through sexual difficulties should also be part of couple therapy (e.g., McCarthy, 1986, 1990; Schnarch, 1991); however, we do not feel that it should be the sole focus of therapy. Premature introduction of “hands on” sex therapy can retraumatize the survivor.
The failure to involve and educate the partners of sexual abuse survivors ignores the resources the partner brings to the relationship. Most partners want to be helpful to the survivor and can be assisted in this through contact with the therapist, including couple therapy. The issues of childhood sexual abuse are being played out in adult relationships, and partners need support and assistance in dealing with such issues for their own sakes as much as for the survivor’s sake. Failure to acknowledge the centrality of intimate relationships to the recovery process from childhood sexual abuse needlessly limits therapy.
This study was exploratory and descriptive in nature. Although the specific goal of this study was to understand the partner’s perceptions of the therapeutic process experienced by his survivor-wife and his role in that process, the initial goal was not to prove or verify any existing theory. Although the results of this study may clarify certain theoretical issues, verification of the present results by employing different research designs could prove to be a valuable step toward understanding the ramifications of childhood sexual abuse from the partner’s perspective.
Like many qualitative studies, this study involves a small number of participants from a very restricted population. The value of qualitative analysis, however, lies in the richness of the data, not the size of the sample. Nonetheless, the results of a study utilizing such a small sample size cannot be generalized to be representative of all people who are in a relationship with someone who has been sexually victimized as a child, or the population as a whole. Researcher bias is always a concern when conducting research, whether it be qualitative or quantitative in nature and design. The researchers’ subjectivity in analyzing the data for this study is fully acknowledged here. Personal perceptions, values, and assumptions are all an integral part of the data collection and analytic process. Prior to conducting this study, our bias was strongly in favor of couples therapy as the primary mode of treatment for survivors and their relational partners. However, the results clearly did not support this bias. Instead, the participants of this study taught us that couples therapy as an adjunct to the traditional modalities of individual and individual group therapy could conceivably offer additional positive therapeutic results that are not realized from these traditional modes of treatment.
1A copy of the interview questions is available from the first author upon request.
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Kary S. Reid
Family Enrichment Associates
Richard S. Wampler Dana K. Taylor Texas Tech University
Kary S. Reid, PhD, is in private practice at Family Enrichment Associates, Lubbock, TX 79424. Richard S. Wampler, PhD, is an Associate Professor in the Marriage and Family Therapy Program, Department of Human Development and Family Studies, Texas Tech University, Lubbock, TX 79409.
Dana K. Taylor, MS, is a Doctoral Student in the Department of Human Development and Family
Studies, Texas Tech University, Lubbock, TX 79409.
Correspondence concerning this article should be addressed to Kary S. Reid, PhD, 8008 Slide Rd., Suite 17, Lubbock, TX 79424.
Copyright American Association for Marriage and Family Therapy Oct 1996
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