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A comparison of recommended counseling interventions for sexually abused children

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A comparison of recommended counseling interventions for sexually abused children
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Leeby, Cheralyn Payton, 1966-
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English
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x, 236 leaves : ill. ; 29 cm.

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Abused children ( jstor )
Child abuse ( jstor )
Child molestation ( jstor )
Child psychology ( jstor )
Family therapy ( jstor )
Group psychotherapy ( jstor )
Incest ( jstor )
Juvenile victims ( jstor )
Parents ( jstor )
Symptomatology ( jstor )
Counselor Education thesis, Ph.D ( lcsh )
Dissertations, Academic -- Counselor Education -- UF ( lcsh )
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bibliography ( marcgt )
non-fiction ( marcgt )

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Thesis:
Thesis (Ph.D.)--University of Florida, 1998.
Bibliography:
Includes bibliographical references (leaves 210-235).
General Note:
Typescript.
General Note:
Vita.
Statement of Responsibility:
by Cheralyn Payton Leeby.

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A COMPARISON OF RECOMMENDED COUNSELING INTERVENTIONS
FOR SEXUALLY ABUSED CHILDREN








By

CHERALYN PAYTON LEEBY


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY



UNIVERSITY OF FLORIDA


1998













ACKNOWLEDGMENTS

The completion of this research project has been a true challenge to my

perseverance, commitment, and tolerance for change. Since the conception of this project, I moved three different times, and I became a mother for the first time. I also had to abandon an original study due to low response rates and initiate the current study as a second attempt. Despite these life changes and research challenges, my goals remained constant; it just took a little longer to actualize them. I am thrilled to be at a point where this acknowledgment section can be written. My gratitude extends to many individuals for all the unending support and encouragement I received as I worked towards my goals of completion.

I am particularly indebted to my committee chairperson, Dr. Larry Loesch. Dr. Loesch accepted each new phone call about my next move or my difficulties obtaining subjects with a supportive ear and wise counsel. My love of writing blossomed under the expert tutelage of Dr. Loesch. His editorial skills are unmatched in my opinion. This dissertation would not have been completed were it not for Dr. Loesch's support, guidance, and direction; I am deeply grateful.

I am also thankful to my other committee members, Dr. Peter Sherrard, Dr. Sandra Seymour, and Dr. Elizabeth Bondi. My committee members graciously accepted the long-distance correspondence and provided valuable insight and support.








I greatly appreciate the continued support and guidance provided by my friend and colleague, Dr. Marsha Wiggins Frame. Dr. Frame was always willing to give me that extra little push to say "you can do it... keep going." Her practical insight and time spent deciphering the raw data were invaluable. Dr. Frame has mastered SPSS, and I am thankful for her willingness to share her knowledge with me. I am truly grateful to Dr. Frame for her time, encouragement, and genuine interest in my educational and career endeavors.

I am thankful to the 470 participants who responded to this study. I am attuned to the myriad of requests that counselors in practice receive on a daily basis from clients, colleagues, and coworkers. I am grateful for those participants who chose to take the time to complete the surveys. Without their cooperation, this project would not have been possible.

I also thank the many child sexual abuse victims and families with whom I

worked. These survivors inspired my interest in the field of child sexual abuse treatment, and they provided the impetus for this research. I dedicate this research to all victims of abuse and neglect. I hope that the results of this study can be utilized to develop further and research effective treatment methods for child abuse victims so that they can truly become symptom-free survivors.

To my family members, who continue to support me in my educational pursuits, I am gratefil. Their faith in my abilities and the belief that one day I would successfully complete this project kept me focused. My love of formal education began at an early








age, and I thank my father, Marty Payton, for his ongoing support, encouragement, and reassurance as I pursue my educational goals.

Finally, I am grateful to my husband, Doug, and our son, Chase. My husband continually placed my research as a top priority in our lives, and when I needed to work on it, all else came second. My son allowed me to work on the computer when he would much rather that I play outside with him. My family lived through the ups and downs of this research on a daily basis yet never allowed me to "throw in the towel." My family provides me with the love, confidence, and support to succeed. I am truly blessed.













TABLE OF CONTENTS
Page

A CKN OW LEDGM EN TS ........................................................................................... ii

ABSTRACT ................................................................................................................ ix

CHAPTERS

IN TRODUCTION .................................................................................... 1

Overview .................................................................................................... 2
Scope of the Problem .................................................................... 2
Individual Effects of Child Abuse .................................................. 5
Treatm ent for Child Sexual Abuse ................................................ 9
Statem ent of the Problem ........................................................................... 10
N eed for the Study ..................................................................................... 11
Purpose of the Study .................................................................................. 16
Rationale for the Approach ........................................................................ 16
N ull Hypotheses ........................................................................................ 18
Definition of Term s .................................................................................... 20
Overview of the Rem ainder of the Study ................................................... 22

11 REVIEW OF THE RELATED LITERATURE ........................................ 23

Theoretical Constructs Underlying the Study ............................................ 24
Etiology of Abuse ........................................................................... 24
Offender Characteristics ................................................................. 27
Fam ily Vulnerability Factors .......................................................... 32
The Child Sexual Abuse Victim ...................................................... 35
Individual Effects of Child Sexual Abuse ................................................... 38
Is Sexual Abuse Detrim ental9 ......................................................... 38
M oderating Variables ..................................................................... 40
The Victim -Offender Relationship ................................................. 41
Behavioral Aspects of the Abuse .................................................. 43
Victim Characteristics .................................................................... 46








Fam ily and Environm ental Response ............................................. 49
Participation in Legal Hearings ....................................................... 51
The Psychological Effects of Child Sexual Abuse .................... 56
Em otional Reactions ....................................................................... 56
Betrayal .............................................................................. 58
Stigm atization .................................................................... 59
Powerlessness .................................................................... 61
Traum atic Sexualization ..................................................... 62
Behavioral Reactions ..................................................................... 63
Sexualized Reactions ...................................................................... 67
Psychopathological Reactions ....................................................... 69
Long-Term Effects ......................................................................... 76
Intervening In Child Sexual Abuse Cases ................................................... 79
Treatm ent for Child Sexual Abuse ............................................................ 83
Individual Interventions ................................................................ 88
Group Interventions ...................................................................... 99
Family Treatment for Incestuous Abuse .................... 102
The Structure of Incestuous Fam ilies ............................................ 105
Boundaries ......................................................................... 106
Hierarchy ........................................................................... 106
Role Im balance ................................................................... 107
Power ................................................................................. 108
Cohesion ............................................................................. 109
Adaptability ....................................................................... 111
Clarity of Expression ......................................................... 112
N egotiation ......................................................................... 113
Fam ily A ffect ..................................................................... 114
Other Therapeutic Interventions .................................................... 115
Treatm ent Studies ....................................................................................... 115
Offender Treatm ent ........................................................................ 118
Victim Treatm ent ............................................................................ 124
Fam ily Treatm ent ........................................................................... 128
Conclusion .................................................................................................. 130

III M ETHO DOLOG Y .................................................................................... 132

Research Design .......................................................................................... 133
Sam ple ........................................................................................................ 134
Instrum ents ................................................................................................ 136
Research Procedures ................................................................................... 141








Data Analyses ............................................................................................ 142
Limitations of the Study ............................................................................ 142

IV RESULTS ................................................................................................... 145

Participants ................................................................................................. 145
Results of Testing the Hypotheses ............................................................ 150
Hypothesis I ................................................................................. 151
Hypothesis 2 .................................................................................. 153
Hypothesis 3 .................................................................................. 153
Hypothesis 4 .................................................................................. 153
Hypothesis 5 .................................................................................. 153
Hypothesis 5a ................................................................................ 156
Hypothesis 5b ............................................................................... 157
Hypothesis 5c ................................................................................ 158
Hypothesis 5d ............................................................................... 160
Hypothesis 5e ................................................................................ 162
Hypothesis 6 .................................................................................. 163
Hypothesis 6a ................................................................................ 165
Hypothesis 6b ............................................................................... 166
Hypothesis 6c ................................................................................ 168
Hypothesis 6d ............................................................................... 169
Hypothesis 6e ................................................................................ 169
Hypothesis 7 .................................................................................. 169
Hypothesis 7a ................................................................................ 169
Hypothesis 7b ............................................................................... 170
Hypothesis 7c ................................................................................ 170
Hypothesis 7d ............................................................................... 170
Hypothesis 7e ................................................................................ 172

V DISCUSSION ............................................................................................ 176

Evaluation and Discussion of the Results .................................................. 177
Hypothesis 1 .................................................................................. 177
Hypothesis 2 .................................................................................. 183
Hypothesis 3 .................................................................................. 183
Hypothesis 4 .................................................................................. 184
Hypothesis 5 .................................................................................. 185
Hypothesis 5a ................................................................................ 186
Hypothesis 5b ............................................................................... 187
Hypothesis 5c ............................................................................... 187









Hypothesis 5d ............................................................................... 188
Hypothesis 5e ................................................................................ 189
Hypothesis 6 .................................................................................. 190
H ypothesis 6a ................................................................................ 191
Hypothesis 6b ............................................................................... 191
Hypothesis 6c ................................................................................ 192
Hypothesis 6d ................................................................................ 193
H ypothesis 6e ................................................................................ 193
Hypothesis 7 .................................................................................. 193
Hypothesis 7a ................................................................................ 195
H ypothesis 7b ................................................................................ 195
Hypothesis 7c ................................................................................ 195
H ypothesis 7d ................................................................................ 195
Hypothesis 7e ................................................................................ 196
Lim itations ................................................................................................. 197
Implications and Recommendations for Further Research ........................ 197
Conclusions ............................................................................................... 201

APPENDICES

A PROFESSIONAL PROFILE QUESTIONNAIRE ................................... 204

B TREATMENT RECOMMENDATIONS QUESTIONNAIRE,
FO RM A .................................................................................................... 205

C TREATMENT RECOMMENDATIONS QUESTIONNAIRE,
FORM B ..................................................................................................... 207

D LETTER OF TRANSMITTAL FOR PARTICIPATING
CO UN SELORS ........................................................................................... 209

REFEREN CES .............................................................................................................. 210

BIO GRA PHICA L SKETCH ........................................................................................ 236













Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy A COMPARISON OF RECOMMENDED COUNSELING INTERVENTIONS FOR SEXUALLY ABUSED CHILDREN By

Cheralyn Payton Leeby

May 1998

Chairperson: Larry C. Loesch
Major Department: Counselor Education

As many as one in three female children experience child sexual abuse. These child victims may seek the services of varied professionals including school, mental health, and/or marriage and family counselors. It is unknown, however, what types of treatment these particular counseling professionals recommend for female child sexual abuse victims.

The primary purpose of this study was to determine whether therapist-chosen field of practice (school, mental health, or marriage and family) was associated with the type of treatment recommended (individual, group, or family) for female child sexual abuse victims. The child's relationship with the offender (father vs. nonrelated swim teacher) was introduced as the chief moderating variable. The Professional Profile Questionnaire and the Treatment Recommendations Questionnaires were used to gather








the data. The sample included 470 professional members of the American Counseling Association (ACA).

The results of the study revealed no significant differences based on the child's relationship with the offender. In addition, there were few significant differences found among the counselor groups. Most of the counselors, regardless of their professional affiliation in ACA, chose individual counseling as the primary mode of treatment. Family therapy was considered secondary and group was rated as least essential to the resolution process. A large percentage of the population chose to refer the hypothetical clients. This may indicate that child sexual abuse treatment is becoming or should be a distinct field of counselor specialization.

While there were few differences found among the counselor groups, there were significant differences associated with particular counselor demographics. For example, White American, bachelor-level school counselors recommended group treatment most often. Therapists with more formal education were found to rate family therapy higher. School counselors rated individual counseling higher than the other two groups, and marriage and family counselors saw the most value in family therapy. It can be concluded, therefore, that child sexual abuse treatment recommendations are more counselor driven than client driven. The results of this study imply that it is essential for clients and referral agencies to know what types of counseling they request and choose a therapist accordingly.















CHAPTER I
INTRODUCTION

"I talk to you,
you make me feel much better
on the inside
and I cry on the outside"
--An 8 year old incest survivor (1993)

This statement, from a child in treatment for sexual abuse, reflects her internal sense of "feeling better" and the external manifestations of her perceived progress as evidenced by her ability to cry. What is unknown, however, is whether this sexually abused child is in fact recovering as a result of therapy and, if so, which type of therapy made the difference. Within the last decade, authors have developed and described numerous therapeutic methods for the treatment of sexual abuse (e.g., Friedrich, 1990; Giarretto, 1982a, 1982b; Madanes, 1990; Mayer, 1983; Trepper & Barrett, 1989). Professional school counselors, mental health counselors, and family therapists provide varied services to victims and their families in an effort to ameliorate and resolve the effects of abuse. These treatment providers may recommend that a particular child victim participate in individual, group, and/or family therapy. However, which treatments are most often recommended by which fields of practice is unknown. Furthermore, it is unknown whether the recommended treatment varies when the offender is related or not related to the child. Therefore, there is a need for data on which treatment methods are









most often recommended by which professionals in each of three professional categories (i.e., school counselors, mental health counselors, or family therapists) based on the child's relationship with the offender (i.e., family member vs. nonfamily member).

Overview

Experts define child sexual abuse as any "sexual contact with a child by an adult, by a person who is more than five years older than the child, or by anyone with the use of force" (Berliner & Barbieri, 1984, p. 128). "Sexual contact" with children is a crime. It may be labeled as incest, rape, indecent assault, sexual battery, criminal sexual conduct, and/or indecent liberties (Finkelhor, 1979). Incest, in particular, is defined as any sexual activity between family members who are not marital partners (Mayer, 1983). By custom and law, all modem societies prohibit parent-child sexual activity (Kempe & Kempe, 1984), regardless of the degree or type of coercion by the adult or accommodation by the victim (Berliner & Barbieri, 1984). Unfortunately, however, it appears to transcend all races and socioeconomic classes in America (Finkelhor, 1986). Scope of the Problem

Current researchers who report on the extent of child sexual abuse typically

investigate both incidence (i.e., the number of cases that have occurred over a period of time ) and prevalence data (i.e., the number of victimized individuals) (Finkelhor, 1979). There are difficulties in accurately estimating the numbers of child victims due to limitations in definition, access to personal (usually "shameful") data, methodological research biases, and reported verses nonreported cases (Mayer, 1985). Thus, it is









estimated that only 2% of intrafamilial and only 6% of extrafamilial child sexual abuse cases ever get reported to authorities (Russell, 1983).

While exact incidence and prevalence data are not available, it is known that reports of child sexual assault are increasing. Unfortunately, it is unclear whether the numbers reflect an increase in the actual occurrence of abuse or in "mandatory" reporting due to widespread media attention to the subject. Within the last 10 years, the American media have taken great strides to direct public attention to this "secret" trauma. The common thread for child sexual abuse is secrecy and silence. However, more and more stories about child sexual abuse are being reported in American newspapers, magazines, and on television. This increased recognition of the problem, along with mandated reporting laws in every state, has likely had a significant impact on the numbers of reported child sexual abuse cases and the numbers of individuals seeking treatment. Regardless of the reason for this increase, however, the scope of the problem is alarming.

It has been suggested that incidence of child sexual abuse has quadrupled since the early 1900s (Russell, 1986). Estimates of cases of child sexual abuse have increased from one child in a million in 1955 (Weinburg, 1955) to one child in three in 1980 (Herman & Hirshman, 1981). National estimates of all forms of child maltreatment (including physical abuse, sexual abuse, and neglect), which have more than tripled since 1980, range from 100,000 to 500,000 cases per year (National Center on Child Abuse and Neglect, 1988). Mayer (1985) indicated that a child rape occurs every 15 minutes in the United States. According to other published data, anywhere from 19% to 45% of adult women report having experienced child sexual abuse (Bagley & Ramsay, 1986; Conte, 1984;









Finkelhor, 1979; Fromuth, 1986; Lewis, 1985; Miller, Johnson, & Johnson, 1991; Russell, 1983; Timnick, 1985; Wolfe, Gentile & Wolfe, 1989; Wyatt, 1985). In addition, it is estimated that one of every three girls and one of every six to ten boys is sexually victimized at least once during childhood (Finkelhor, 1979, 1986; Russell, 1984b; 1988). There also are at least 2 million known (i.e., adjudicated) pedophiles in the United States, and it is projected that each can victimize an average of 50 children over a lifetime (Mayer, 1985). Furthermore, Russell (1986) found that, in 32% of the known cases of intrafamilial child sexual abuse, the offender abused one or more other relatives but that abuse was never reported.

It is apparent that a large number of child sexual abuse cases are incestuous.

Approximately one in six children and one in ten families are affected by incest, although this is considered a conservative estimate (Finkelhor, 1984; Russell, 1986). It also is estimated that 60% to 70% of all child molestations occur within the family, and the offender is known to the child in 80% of all reported cases (Dixon & Jenkins, 198 1; Finkelhor, 1984; Peters, 1976). Father-daughter and stepfather-stepdaughter incest accounts for three-fourths of all the reported cases (Kempe & Kempe, 1984). It also has been estimated that 17% of adult women raised by a stepfather were sexually abused by him by age 14 (Russell, 1984b). Father-son, mother-son, and mother-daughter incest also are being reported more often than in previous years (Miller, Johnson, & Johnson, 199 1; Trepper & Barrett, 1989). Along with the increased numbers of reported cases, inevitably there are more and more victims entering therapy to relieve the resultant psychological effects.









Individual Effects of Child Abuse

Several researchers have focused on the psychological effects of sexual abuse for child and adult survivors (e.g., Alter-Reid, Gibbs, Lachenmeyer, Sigal, & Massouth, 1986). The individual effects vary in terms of the symptomology, intensity, and duration. However, there are "typical" specific, short-term effects (Friedrich, Urquiza, & Beilke, 1986; Gomes-Schwartz, Horowitz, & Sauzier, 1985; Mannarino & Cohen, 1986) and long-term traumatic symptoms found in abused children (Bagley & Ramsay, 1986; Briere & Runtz, 1988a; 1988b; Conte, 1987; DeYoung, 1982; Finkelhor, 1984; Finkelhor & Browne, 1985; Mrazek & Mrazek, 1981; Tufts New England Medical Center, 1984: White, Halpin, Strom, & Santilli, 1988). In a study conducted at the Tufts New England Medical Center (1984), between 20% to 40% of child victims displayed clinical problems immediately after the abuse. Between 46% and 95% of child victims eventually exhibit problematic symptomology related to the trauma (Browne & Finkelhor, 1986; Friedrich, Urquiza, & Beilke, 1986; Gale, Thompson, Moran, & Sack, 1988; Mannarino & Cohen, 1986; Mian, Wehrspann, Klajner-Diamond, LeBaron, & Winder, 1986).

Two commonly reported psychological symptoms following child sexual abuse are anxiety and depression (Murrey, Bolen, Miller, Simensted, Robbins, & Truskowski, 1993). With child victims, anxiety may be evidenced by fear, somatic complaints, intrusive thoughts, impaired impulse control, enuresis, sleep disturbances, hyperactivity, and socially inappropriate behaviors (Gomes-Schwartz, Horowitz, & Cardarelli, 1990; Kiser, Heston, Millsap, & Pruitt, 1991). Symptoms of depression may include low selfesteem, impaired self-concept, depressed affect, suicidal ideation, social withdrawal,









difficulties with interpersonal relations, and feelings of helplessness (Adams-Tucker, 1984; Browne & Finkelhor, 1986; Conte, 1987; Conte & Schuerman, 1987; Kendall-Tackett, Williams, & Finkelhor, 1992; Kiser et al., 1991; Mrazek & Mrazek, 1981; Wolfe, Gentile, & Wolfe, 1989; Wolfe & Wolfe, 1988). Victims also may experience disorganized thought, avoidance of certain places/people, aggressiveness, selfdestructive behaviors, eating disorders, substance abuse, and intense feelings of guilt, shame, and/or anger (Finkelhor, 1986; Greenberg, 1979; Trepper & Barrett, 1989).

In addition to these commonly reported symptoms, "two-thirds of all (victims)

suffer identifiable emotional disturbance and 14% become severely emotionally disturbed" following sexual abuse (Weiss & Berg, 1982, p. 515). The most common diagnosis for abuse victims is Post-Traumatic Stress Disorder (PTSD) as described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 1994; Mayer, 1985). In fact, in one clinical sample of sexually abused children, as many as 55% met the criteria for PTSD (Kiser et al., 1991; McLeer, Deblinger, Atkins, Foa, & Ralphe, 1988). For these children, the symptoms included (a) flashbacks or recurrent and intrusive recollections of the abuse, (b) distressing dreams related to the abuse, (c) reenactments of the abuse through play or overt behavior, (d) psychological distress and physiological reactivity when exposed to aspects of the abuse,

(e) persistent avoidance of stimuli associated with abuse, and (f) symptoms of increased arousal which were not present before the abuse (American Psychiatric Association, 1994).









Researchers also have identified the presence of PTSD symptomology in child

sexual abuse victims to include phobic/avoidant behaviors (Fromuth, 1986; Wilbur, 1984), affective numbing (Wilbur, 1984), nightmares (Burgess & Holstrom, 1975; Goodwin, 1982), and repetitive or inappropriate sexual behaviors (Friedrich, Urquiza, & Beilke, 1986; Tufts New England Medical Center, 1984). These symptoms are considered temporary but causally related to the abuse. In addition, the PTSD response may be acute, chronic, or delayed. Several researchers have documented a relationship between childhood sexual abuse and chronic adult PTSD (Briere & Runtz, 1993; Craine, Hensen, Cliver, & MacLean, 1988; Donaldson & Gardner, 1985; Goodwin, 1984; Lindberg & Distad, 1985). Therefore, it is evident that for some child survivors, the psychological effects continue for many years, even into adulthood (Gold, 1986; Herman, Russell, & Trocki, 1986).

In addition to PTSD, there are more serious dysfunctions that may surface or become pronounced following childhood sexual abuse. Sixty-six percent of adult survivors reported that at the time of the abuse the experience was severely emotionally distressing, and 50% continued to report at least some on-going difficulties related to the trauma (Finkelhor, 1979, 1986). As many as 40% of women seeking outpatient mental health therapy for other related difficulties eventually reveal child sexual abuse (Gordon & Alexander, 1993; Leahy, 1991). Consequently, adult survivors of abuse demonstrate more symptoms of psychological distress and dysfunction when compared with nonabused control groups (Browne & Finkelhor, 1986).









The resultant symptomology for adult survivors has been clustered into three areas: (a) symptoms of anxiety, (b) symptoms of depression and lowered self-esteem, and (c) symptoms of social and sexual dysfunction (Browne & Finkelhor, 1986; McLeer et al., 1988; Murrey et al., 1993). For some adult survivors, these symptoms contribute to the development of other maladaptive personality styles and self-destructive behaviors. Adult survivors also represent a significant proportion of individuals with dissociative disorders, multiple personality disorder, and borderline personality disorder when compared to community controls (Gordon & Alexander, 1993). Giarretto (1978) estimated that nearly 90% of all women who were treated for sexual dysfunction were raped during their childhood. In a study of 118 female substance abusers, 44% were victims of incest, and 75% reported having been sexually abused before the age of 9 (Densen-Gerber, 1977). Elias (1983) reported that 75% of his sample of 200 "street prostitutes" had been raped as children. Sexual abuse also is one of the three main reasons why children run away from home (Mayer, 1985; McCormack, 1986). However, for the most part, individual psychotic or psychopathological disorders are rarely experienced by victims, offenders, and/or nonoffending parents (Finkelhor, 1979).

Researchers indicate that the long-term, negative effects of child sexual abuse are associated with (a) type of relationship the child had with the offender, (b) length of time the abuse occurred, (c) type of assault and whether violence was involved, (d) extent to which the child was involved in legal proceedings, (d) reactions of others, and (e) whether the child was believed and supported following disclosure (Fromuth, 1986; Katz & Mazur, 1979; Kelly, 1990; Russell, 1986). More specifically, if the child had a close







9

relationship with the offender and if the sexual abuse occurred over several developmental stages, then the resulting symptomology is both more severe and more lasting (Russell, 1986). Similarly, if the offender was initially a "positive" person in the child's life, then the resolution of the abuse is more difficult. With more violent and violating abusive acts (i.e., forced penetration), there also is an increased likelihood for long-term emotional scarring (Russell, 1986; Trepper & Barrett; 1989). Finally, if a child victim testifies in court and feels victimized by the process, then the child's recovery may be temporarily disrupted or permanently compromised (Brownmiller, 1975; Kelly, 1990; Symonds, 1980). However, family support, especially maternal validation, can lessen the effects of these significant factors for the child victim (Fromuth, 1986). Treatment for Child Sexual Abuse

An alarming number of families in the United States have suffered the shame, secrecy, and destruction caused by child sexual abuse (Finkelhor, 1986; Mayer, 1985; Russell, 1986). Due to the widespread nature of this problem, mental health counselors, medical practitioners, legal professionals, educators, researchers, and the general public are recognizing the need for effective interventions to prevent, treat, and heal child sexual abuse. "When incest was considered a one-in-a-million occurrence, the few people working in the field had little disagreement as to the causes, effects, and treatments" (Trepper & Barrett, 1989, p. xiii). However, since the establishment in 1974 of the National Center on Child Abuse and Neglect, varied theoretical and clinical developments have emerged in the field (Elmer, 1977). Mental health practitioners have created numerous and diverse specialized programs to provide comprehensive services to victims.









"Whereas 20 years ago, there were none, today experts estimate the number of programs (for child and adult victims of abuse, assault, and other crimes) to be in excess of 5,000" (Davis & Henley, 1990, p. 157).

To treat sexually abused children today, counselors utilize varied techniques,

including those found in individual, group, and family therapy (Friedrich, 1990; Mayer, 1983; Trepper & Barrett, 1989). The recommended course of intervention may depend upon several factors, including the relationship with the offender and the child's age, developmental level, gender, diagnosis, and family situation (Boatman, Borkman, & Schetky, 1981; Trepper & Barrett, 1989). The type of treatment provided also varies according to the availability of services, treatment center philosophy, and therapist training and style (Trepper & Barrett, 1989). In most cases, therapy with child sexual abuse victims addresses the following issues: (a) immediate effects of disclosure, (b) physical and emotional damage to the child, and (c) prevention of long-term dysfunction and future abuse (Bentovim, Boston, & Van Elberg, 1987). Consequently, treatment is considered to be effective if further abuse is prevented and dysfunctional and distressing symptomology are alleviated.

Statement of the Problem

As noted, researchers have presented significant data on the extent of child sexual abuse (Finkelhor, 1979, 1986; Finkelhor & Hotaling, 1984; Herman & Hirshman, 1981; Lewis, 1985; Russell, 1988; Sarafino, 1979) and the resultant psychological effects (Bagley & Ramsay, 1986; Briere & Runtz, 1988a, 1988b; Conte, 1987; DeYoung, 1982; Finkelhor, 1980; Finkelhor & Browne, 1985; Friedrich, Urquiza, & Beilke, 1986:









Gomes-Schwartz, Horowitz, & Sauzier, 1985; Herman, Russell, & Trocki, 1986; Mannarino & Cohen, 1986). Theorists and practitioners have, in response, created specialized treatment methods and programs for recovery from childhood sexual abuse (Friedrich, 1990; Giarretto, 1982b; Madanes, 1990; Mayer, 1983; Rencken, 1993; Trepper & Barrett, 1989). However, a particular child victim may begin counseling with a school counselor, mental health counselor, or family therapist without knowing which type of treatment will be recommended. That is, there is a relative dearth of empirical data on which types of treatment are currently being recommended and utilized with this population. Furthermore, it is unknown whether the type of treatment recommended varies according to the practitioner's chosen field of practice (i.e., school counseling, mental health counseling, or family therapy). Therefore, the problem addressed in this study is that the differences in professional treatment recommendations for child sexual abuse victims are unknown. For purposes of this study, individual, group, and family therapy modalities were examined for victims abused by either a family member (e.g., father) or a nonrelative offender (e.g., swim teacher).

Need for the Study

The intent of this study is to collect data from a large, random sample of

counseling professionals in order to determine which methods of intervention are most often recommended for female child sexual abuse victims. The most significant influences on treatment recommendation are delineated. The results of this study have implications for the mental health professions and for social policy.









In the mental health arena, this research provides clinicians with information on the most common therapeutic practices for this population. If specific treatments are recommended more often because they are believed to produce more positive changes in child victims, other clinicians will be more apt to utilize these interventions. In addition, clinicians may determine when alternate treatment modalities can be most successfully implemented. For example, if a majority of professionals recommend that a child begin in individual treatment and later enter group or family therapy, this may be helpful to other clinicians encountering similar clients. Furthermore, it may be found that different treatment methods are recommended based on the child's relationship with the offender. Clearly, this information will aid counselors in effective treatment planning, program development, and service delivery.

In this study, data were collected on the types of interventions most commonly utilized today by representative treatment providers from the three professional counselor groups. While a large number of mental health professionals treat sexual abuse victims, most report feeling undertrained in this area (Dietz & Craft, 1980). The need for specialized training in child sexual abuse treatment may be further realized in light of this research. If it is determined that specific modalities are chosen more often, then it may be recommended that clinicians be trained to provide these services. For example, if family therapy sessions are shown to be utilized most often, then counselors may need further education in systemic therapy. Similarly, clinicians may have more information about when to refer a client to a counselor with a particular expertise (e.g., group counseling).









Finally, the content for professional seminars and training manuals on the subject of abuse may be expanded to include data on these recommended therapies.

In regard to specialized training, most credentialing boards have instituted mandates for mental health professionals, with the exception of psychiatrists, to complete continuing education in child sexual abuse (Powell, 1988). Future credentialing boards may expand this requirement to include psychiatric and other health practitioners including professionals in pediatrics, family practice, education, and emergency health. Accordingly, professionals who are hired and reimbursed by third-party payers will most likely be those individuals who are recognized as competent and knowledgeable in this specialized field. Surveying professionals in each of the three fields of practice, therefore, will provide information that may assist credentialing boards, educators, trainers, and insurance providers in developing standards of care and practice for this specific client group.

Several theoretical implications could evolve from the findings of this study. If it is found that one method of intervention is clearly utilized more often than other modalities, then theorists can utilize these data to study and develop further these methodologies. Consequently, specific recommendations about how clinicians might implement these modalities can be proposed. In addition, theories related to the course of recovery and symptom relief may be expanded. Theorists may proffer that different interventions are necessary at different stages in the recovery process. Theorists also may further define how mediating variables, such as the child's relationship with the offender, alter the recommended course of treatment. On the other hand, if it is shown







14

that neither individual, group, nor family therapies are recommended as the primary form of treatment, then alternate theoretical formulations will need to be explored.

There will be implications for research as well. Future inquiry may focus on

which particular aspects of each treatment methodology and which techniques (e.g., art or play therapy) are most often recommended with these clients. Then, better research on the efficacy of these treatment methods can be initiated. The results of this study also can be compared with studies that include male victims as well as other age groupings. Furthermore, test developers may create measures specific to child abuse which identify trauma symptomology and treatment variables. Data from such measures can be compared to measures of therapist knowledge, training, style, and theoretical orientation.

The implications of this study are not limited to counselors and the counseling

professions. Child sexual abuse is not only a crime but also a mental health, medical, and social problem in America (Conte, 1984). Therefore, professionals in the legal. educational, medical, and social service arenas are faced with the tasks of treating and preventing child sexual abuse. In order to advocate successfully for child sexual abuse victims, these professionals must know what treatment alternatives are available and most often recommended. In addition, these professionals must know who provides these services for victims. For example, do only "family therapists" provide only family counseling services for victims? Professionals in these related disciplines can utilize these data to make the appropriate and necessary treatment referrals. With a clearer understanding of therapeutic processes and expected outcomes, professionals across disciplines also can cooperate better to provide comprehensive victim services.









There also are important implications for the American society as a whole in regards to the prevention of sexual victimization. If there is a consensus regarding the most appropriate form of treatment for child victims of abuse, then it may be presumed that this treatment is in fact working to lessen the effects and prevent future abuse. It is estimated that only 13% of sexually abused children and their families participate in treatment for sexual abuse (Alter-Reid et al., 1986). Yet, as adults, 40% of child sexual abuse survivors seek mental health treatment (Browne & Finkelhor, 1986). Therefore, the problems most likely do not diminish over time, and the cycle of victimization continues.

As child sexual abuse becomes "a way of life," some child victims learn to become adult offenders. Current studies indicate that anywhere from 32% to 57% of incarcerated adult sex offenders and 18% of adolescent offenders report a history of childhood sexual victimization (Fehrenbach, Smith, Monastersky, & Deisher, 1986; Groth, 1979; Owen & Steele, 1991; Rosenfeld, Nadelson, Krieger, & Backman, 1979). In addition to a proclivity to offend, adult survivors are prone to further victimization. In fact, 63% of female adult survivors of childhood sexual abuse report being assaulted as adults compared to 36% of women who were not victims (Russell, 1986). It is unclear, however, whether these adult offenders and/or victims were treated as children and which types of therapy were introduced.

In summary, there is great need for accurate data on the recommended course of treatment with child sexual abuse victims. The results of this study broaden the existing research in the field of child sexual abuse treatment. Ultimately, with improved service









delivery of effective treatment interventions, child sexual abuse victims may become symptom-free survivors.

Purpose of the Study

In this study the recommended course of treatment for female child sexual abuse victims was investigated. The purpose of this study was to determine whether therapistchosen field of practice (school, mental health, or family counseling) had an effect on the type of treatment (individual, group, or family therapy) these providers typically recommend for a female child sexual abuse victim. In addition, the child's relationship with the offender (i.e., family member vs. nonfamily member) was examined as a variable.

Data were gathered about which types of treatment are recommended by which of the three professional counselor groups. In particular, the following questions were addressed: "Is there a difference in the type of treatment recommended (i.e., individual, group, or family therapy) for a female child sexual abuse victim based on the professional counselor's chosen field of practice (school, mental health, or family therapy)?" Secondly, "Is there a difference in the type of treatment recommended based on the child victim's relationship with the offender (i.e., family member vs. nonfamily member)?"

Rationale for the Approach

Data were collected to compare the outcome results for school, mental health, and family counselors and therapists who are current members of the American Counseling Association. A random sample of 1,000 professional ACA members in each of these three groups was generated. A total of 470 ACA members chose to participate by returning the completed surveys (N = 470). Data from the participating counselors were









used to examine whether individual, group, and/or family therapy modalities are recommended for a typical female child sexual abuse victim as described in a hypothetical client profile (Appendices B and C). The counselor groups were chosen because they are the professionals who most often come in contact with child sexual abuse victims through their chosen fields of practice. The treatment modalities were chosen because they are the ones most often cited in the child sexual abuse treatment literature (Friedrich, 1990; Madanes, 1990: Mayer, 1985; Rencken, 1993). A detailed explanation of the theoretical constructs underlying the chosen treatment methods is described in Chapter II.

The random sample of 1,000 ACA members was sent a research packet of materials including the Professional Profile Questionnaire (PPQ) and the Treatment Recommendations Questionnaire (TRQ) (Form A or B). The PPQ contained questions related to the participating therapist's ACA affiliation, age, gender, ethnicity, and education (Appendix A). The TRQ contained a description of a 10-year-old female child sexual abuse victim entering treatment (Appendices B and C). Also contained in the TRQ child victim scenario were demographic data and information on the child's current level of functioning. The offending individual was depicted as either the child's father (Form A) or a nonrelative male swim teacher (Form B). The participating therapists were asked to read the scenarios on the TRQ and respond as if this were an actual client coming to them for treatment. Counselors were then asked to answer questions about their recommended course of treatment. Specifically, they were asked whether they would recommend individual, group, or family therapy for each particular child victim. The information from the completed TRQs was compared with data collected from the PPQ.









Null Hypotheses

The following null hypotheses were evaluated in this study:

1. There is no association between counselor type, the form for the Treatment Recommendations Questionnaire, and the primary counseling intervention type recommended.

2. There is no difference in the rating for individual counseling based on form.

3. There is no difference in the rating for group counseling based on form.

4. There is no difference in the rating for family counseling based on form.

5. There is no difference in the rating for individual counseling based on counselor type.

5a. There is no difference in the rating for individual counseling based on gender.

5b. There is no difference in the rating for individual counseling based on ethnicity.

5c. There is no difference in the rating for individual counseling based on highest degree held.

5d. There are no significant interactions among counselor type, gender, ethnicity, and degree for the ratings for individual counseling.

5e. There is no relationship between age and the rating for individual counseling.

6. There is no difference in the rating for group counseling based on counselor


type.










6a. There is no difference in the rating for group counseling based on gender.

6b. There is no difference in the rating for group counseling based on ethnicity.

6c. There is no difference in the rating for group counseling based on highest degree held.

6d. There are no significant interactions among counselor type, gender, ethnicity, and degree for the rating for group counseling.

6e. There is no relationship between age and the rating for group counseling.

7. There is no difference in the rating for family counseling based on counselor type.

7a. There is no difference in the rating for family counseling based on gender.

7b. There is no difference in the rating for family counseling based on ethnicity.

7c. There is no difference in the rating for family counseling based on highest degree held.

7d. There are no significant interactions among counselor type, gender, ethnicity, and degree for the rating for family counseling.

7e. There is no relationship between age and the rating for family


counseling.









Definition of Terms

For purposes of this study, child sexual abuse is defined as any sexual contact between someone who is at least 5 years older than the child and who has permanent or temporary care and custody of the child. Sexual contact includes a range of abusive acts with or without the use of force (i.e., fondling, oral copulation, or vaginal or anal intercourse) (Downs, 1993; Friedrich, Urquiza, & Beilke, 1986). Incest means sexual activity by anyone who is 5 or more years older and has a preexisting familial relationship with the child (Gelinas, 1983). In this study, only abuse by male offenders to female children was investigated because this is the most common situation (Finkelhor, 1979; Rencken, 1996). For ease in reading, the child victim is referred to as "she" and the perpetrator as "he" throughout the study. This does not in any way imply that abuse is perpetrated only by males or that victims are always female. Finally, the terms incest and child sexual abuse are used interchangeably when the material applies to both.

There are several terms frequently used in the literature to identify and describe

the family members affected by abuse and incest. In particular, the nonoffending parent is the parent or guardian who did not abuse the child. Conversely, an offender or perpetrator is the person who has committed the crime of child sexual abuse. A pedophile is an individual who is sexually attracted to children (Groth, 1979); an offender may or may not be considered a pedophile. There are two types of pedophilia: (a) fixated (a persistent pattern) or (b) regressed (a new activity that is situationally induced) (Groth, 1979). The fixated pedophile has a chronic compulsion to abuse children through which his needs for affirmation and affection are met (Groth, 1979; Mayer, 1983). The









regressed pedophile has a primary sexual orientation toward adults, yet, due to precipitating stressors, displaces his sexual impulses onto children (Mayer, 1983). In this study, no differentiation is made between types of offenders and the specific motivations for abuse.

The term adult survivor is utilized in this study to identify a male or female adult who has experienced abuse as a child. This term captures and encourages the individual's ability to move beyond the sexual victimization as a survivor. To describe children who are sexually assaulted, the terms child "survivor" and "victim" are used (interchangeably). Identifying a child as a victim is not intended to discount the child's ability to survive. Instead, this term is used to acknowledge who was victimized and that the responsibility for the offense lies with another person (Russell, 1986).

The American Counseling Association (ACA) is the primary representative professional organization of counselors in the United States (Vacc & Loesch, 1987). American Counseling Association members can choose affiliate membership from a list of 17 divisions including school, mental health, or family therapy affiliate groups. The sample for this study included members from three specific ACA divisions. The American School Counselors Association (ASCA) enlists members who promote professional school counseling activities that affect personal, educational, and career development decisions of students (ACA, 1995). Members of the American Mental Health Counselors Association (AMHCA) administer and advocate for quality mental health services within the health care industry (ACA, 1995). The International Association of Marriage and Family Counselors (IAMFC) represents members who







22

promote the health of family systems through prevention, education, and therapy (ACA, 1995).

In this study, individual therapy is used to describe sessions with an individual client alone using individual techniques and theories of counseling. Group therapy usually involves three or more clients and a counselor. Group members work towards growth through their interactions with the counselor and each other (Belkin, 1980). The term family therapy is used to describe a variety of counseling approaches in which family members are brought together to address issues collectively (Belkin, 1980). Family therapy in a broad sense extends beyond family members to include other significant persons who have an impact on family functioning and areas of difficulty.

Overview of the Remainder of the Study

Presented in Chapter II is a review of the related literature, including an overview of child sexual abuse and the known psychological effects. Also, individual, group, and family therapy treatment modalities are discussed as they apply to the population. Presented in Chapter III is a description of the methodology for the study, including the research design, sample, instruments, and data analysis. In Chapter IV the results of the study are presented. Finally, Chapter V contains a summary of the results, discussion, implications, and recommendations for further research.














CHAPTER II
REVIEW OF THE RELATED LITERATURE Following sexual abuse, most child victims face a potential traumatic aftermath plagued by distressing and dysfunctional symptomology (Browne & Finkelhor, 1986; Friedrich, Urquiza & Beilke, 1986; Gale et al., 1988; Mannarino & Cohen, 1986; Mian et al., 1986). In fact, according to Finkelhor and Browne (1986), between 46% and 66% of sexually abused children exhibit these distressing symptoms following abuse. As a result, child victims are encouraged to enter mental health treatment in order to heal from the trauma, alleviate long-term dysfunctional symptomology, and prevent future abuse (Finkelhor, 1979, 1986; Giarretto, 1978; Madanes, 1990; Trepper & Barrett, 1989).

When a child victim enters treatment, the child may participate in individual, group, and/or family therapy lasting anywhere from 12 sessions to over two years (Friedrich, 1990; Jones, 1986; Madanes, 1990; Mayer, 1983; Trepper & Barrett, 1989). While these children may be involved in therapy for a year or more, it is unclear which type of therapy is most often recommended to alleviate symptomology. Furthermore, there are limited data available on how treament recommendation varies according to the counselor's chosen profession and the child's relationship with the offender. The numbers of victims, along with the required length of treatment and the rising costs of mental health care, require that these areas be examined.









This chapter contains a literature review highlighting the theoretical constructs underlying the study and current research in the field. Included is information on the nature and causes of child sexual abuse as well as the particular characteristics found in offenders, families, and child victims. Next, research on the mediating factors and the psychological victim effects following sexual abuse are described. Both the child sexual abuse "Accommodation Syndrome" (Summit, 1983) and Post-Traumatic Stress Disorder (DSM-IV, 1994) in relation to abuse victims are addressed. Also included is a discussion of the social service intervention processes and the prevailing methods for child sexual abuse treatment. In this section, individual, group, and family therapy modalities are illuminated. Finally, an examination of the research on treatment outcome is presented.

Theoretical Constructs Underlying the Study Etiology of Abuse

American theorists and researchers have attempted to understand the nature and causes of child abuse since the 19th Century (DePanfilis & Salus, 1992). Following this quest for understanding, it was concluded that there is no one cause for sexual abuse and no one victim typology (Rencken, 1996). According to the literature on all forms of abuse and neglect in America, there are four major theories about the etiology of abusive parenting practices (Burgess & Conger, 1978; Parke & Collmer, 1975). While these are not specific to sexual abuse, they can be applied to it readily.

The first model, the psychiatric approach, focuses exclusively on the personality characteristics of the offender and examines how these contribute to abusive acts (Kempe, 1973; Spinetta & Rigler, 1972). This model has its roots in traditional psychoanalytic









theory. However, when traditional psychoanalysts examined incest, they placed greater emphasis on the child victim and nonoffending parent (i.e., the mother). In fact, it was thought that incestuous abuse was the result of oral deprivation experienced by the child during the preoedipal stage so that the abuse satisfied the child's oral needs while revenging the nonattentive mother (Gordon, 1955; Tompkins, 1940). Furthermore, according to this view, "the daughter incorporates the father's penis as a substitute for the mother's breast, which she has been denied" (Raphling, Carpenter, & Davis, 1967, p. 506). This conceptualization is not accepted widely today. Instead, followers of the modem psychiatric view focus more on the psychopathology and sexual deviance of the offender.

In a second approach, the sociological model, the social and environmental contexts which foster abusive patterns, are examined (Burgess & Conger, 1978). According to this view, abuse is the result of environmental stressors, especially for parents who lack efficient coping skills (Gelles, 1973; Gil, 1970). This is similar to a behavioral perspective in which specific environmental factors, such as early sexual modeling and spousal nonresponsiveness, are thought to contribute to incestuous abuse (Harbert, Barlow, Hersen, & Austin, 1974). Other behaviorists have postulated that sexual abuse is not a result of individual sexual deviation but rather a product of cultures in which the behavior is accepted (Lukianowicz, 1972).

A third model, the social-psychological approach, examines the patterns of

interactions among family members in the context of external environmental events or stressors (Burgess & Conger, 1978). In this view, everyday family interactions and







26

dysfunctional patterns of relating are carefully examined as precursors of abuse (Brant & Tisza, 1978; Meiselman, 1978; Weinberg, 1955). According to Meiselman (1978), a crisis in the family that disrupts the equilibrium provides the impetus for sexual abuse. This crisis may take the form of injury, disease, relational strain, or financial loss (Meiselman, 1978). This theory is supported by Weinberg's (1955) finding that in the year or two before incestuous acts began, a family disruption was noted which left the offender in a state of tension and restlessness.

In the fourth approach, feminist family therapists argue that the power structure for the family, set up by society, leads to incestuous abuse (Butler, 1978). The patriarchal family structure is thought to perpetuate men's dominance over women and children and create the conditions for incest to occur (Rush, 1980). In this sense, fathers abuse their children because they are socialized to use sex as a way to express emotion, obtain power, and feel a sense of adequacy (Butler, 1978; Ward, 1984). The child victim is rendered powerless by society who expects her to love and trust her father (James & MacKinnon, 1990). Similarly, mothers feel that they are supposed to "honor and obey" their husbands at all costs (Butler, 1978). Therefore, feminist family therapists contend that incest becomes representative of an extreme version of the normal sexual arrangements in American society (Rush, 1980).

As described above, a variety of factors may predispose or cause abuse. Most likely, a combination of these factors motivates an offender to abuse a child. Therefore. children are at risk for abuse as a result of the patterns of interaction between themselves, the offender, their families, and the environment (DePanfilis & Salus, 1992; Holder &









Corey, 1987). While there is no one etiological explanation for abuse, researchers have validated the presence of common characteristics for offenders, families, and child victims (Finkelhor, 1984, 1986; Friedrich, 1990; Groth, 1979; Mayer, 1983; Mrazek, Lynch, & Bentovim, 1983; Summit, 1983). These characteristics, or vulnerability factors, are addressed following.

Offender Characteristics

Finkelhor (1984) described four preconditions which are specific to the offender and must be overcome in order for sexual abuse to occur. These include (a) the motivation to abuse, (b) overcoming internal inhibitors, (c) overcoming external inhibitors, and (d) overcoming resistance by the child (Finkelhor, 1984).

As delineated above, initially the offender must have the motivation to abuse a

child. This may be manifest in an arousal to children, stress, and/or the need for mastery and control (Groth, 1979). Sexual offenders are identified as either "fixated" or "reactive" based on their individual motivations. Groth (1979) described the "fixated offender" as having deviant sexual patterns manifest in sexual arousal to children rather than adults. On the other hand, the "reactive offender" responds to nonsexual problems and stress by sexually abusing a child which provides the offender with a sense of power and mastery (Groth, 1979). While both types of offenders have a predisposed arousal to children, most sexual offenders abuse children to serve emotional needs, especially the need for power and control, rather than for sexual gratification (Sgroi, 1982). Often these motivational patterns are learned behaviors supported by the offender's family history and early modeling.









With the second precondition to abuse, the offender must overcome internal

inhibitors. Internal inhibitors activate both conscious and subconscious processes that attempt to convince the offender not to proceed (Finkelhor, 1984). If the offender is unable to empathize with the child and suppresses any internal inhibitors, then he finds ways to rationalize the behavior of engaging the child's trust and eventually abuse occurs (Groth, 1979). To rationalize this behavior, the offender may adhere to stereotyped beliefs about sex roles and power over children. According to Finkelhor (1986), if the first two preconditions are not present (i.e., the offender is not motivated or inhibits desires to abuse), then the two remaining factors are not sufficient for sexual abuse to occur.

Once the first two preconditions are met, then the offender must overcome

external inhibitors. Usually, these include the child's mother and other caretakers as well as social and legal agencies who are commissioned to protect children (Larson & Maddock, 1986). Friedrich (1990) contended that the degree to which the family members are able to protect and care for a child is the degree to which a child is safe from abuse. Likewise, a physically or emotionally absent and overwhelmed parent allows an offender greater access to a child. In fact, Rhinehart (1961) found that a high-risk time for incest is when a mother has gone to the hospital to give birth to another child. Therefore, if a motivated offender has unsupervised access to a child and that child has a limited support network, the opportunity for sexual abuse is increased greatly (Finkelhor, 1984).

Finally, the offender must overcome the resistance of the child. If the primary

caretakers discuss sexual abuse and prevention openly while monitoring the child's safety









at all times, there is a decreased likelihood for abuse (Horton, Johnson, Roundy, & Williams, 1990). Similarly, a child who is aware of the warning signs and feels supported by caretakers is more likely to seek help before abuse occurs or to disclose immediately (Finkelhor, 1984). Often times, victims do not disclose because of threats, fear, intense feelings of guilt, trust in the offender, dependence on the offender, and/or feeling powerless (Russell, 1986). Therefore, if the offender has the motivation and opportunity to abuse and the child maintains the "secret," then the sexual abuse will continue over a period of time (Finkelhor, 1984).

While these four preconditions are necessary for abuse to occur, other

psychosocial elements contribute to abusive patterns including cultural, familial, environmental, and personality factors (Faller, 1993). These contributing factors alone do not cause abuse, but if they are present, they increase the risk for abuse to occur (Faller, 1993). According to Finkelhor (1984), there are four basic ingredients to the making of a child molester that correspond with the preconditions for abuse. These are found in (a) the offender's need to relate to someone on his emotional level identified as a need for emotional congruence, (b) a predisposed sexual arousal to children, (c) the inability to satisfy sexual or emotional needs in an appropriate manner, and (d) the ability to overcome social norms that would prohibit sexual activity with children (Finkelhor, 1984). These ingredients are influenced by male cultural socialization factors including

(a) a tendency for males to be raised to sexualize their emotions such that sex becomes a means to meet their emotional needs, (b) a tendency for men to be attracted to younger, smaller, and less powerful partners as portrayed in the media, and (c) a tendency for men







30

to be exempt from primary child care concerns so that victim empathy is reduced and the abusive behavior is rationalized (e.g., "she needed to learn about sex anyway, why not from me?") (Finkelhor, 1984).

While the above factors contribute to abusive patterns, the most common

characteristics for offenders are (a) poor impulse control, (b) low frustration tolerance, (c) sexual and/or emotional immaturity, (d) an absence or a questionable degree of guilt or remorse, (e) substance abuse, (f) frustrated dependency needs, (g) passive-aggressive expression of affect, (h) low ego strength and low self-esteem, (i) powerlessness and passivity outside the home, (j) rationalization and denial of acts (i.e., projection of blame), and (k) manipulative behavior patterns (Mayer, 1983, p. 29). Offenders commonly report feelings of hostility, isolation, loneliness, anxiety, depression, apathy, rigidity, fear of rejection, narcissism, distrustfulness, and/or neuroticism (DePanfilis & Salus, 1992; Holder & Mohr, 1980). While many offenders report having experienced emotional and behavioral difficulties, severe mental illness is not apparent in most cases (DePanfilis & Salus, 1992; Garbarino, 1985). However, the most common diagnosis for sexual offenders is narcissistic personality disorder (Leahy, 1991).

According to Gentry (1978), the offender's poor self-concept and limited sexual identification are important predictors of abuse. "If the individual's negative self-concept sustains even one ego-deflating crisis, he or she may seek approval through sexual means from someone who cares, even a child" (Gentry, 1978, p. 362). This "ego-deflating" crisis may surface from a variety of stressors. In fact, 48% of the offenders in one study reported marital problems; 47% reported sexual problems; and reported 22%







31

unemployment problems (Bentovim, Boston, & Van Elburg, 1987). The high incidence of reported marital problems is significant because some experts (e.g., Browning & Boatman, 1977; Gentry, 1978) contend that marital dysfunction is at the root of incestuous abuse. In addition, the risks for abuse are increased if the offender experiences any conditions that reduce his impulse control, including substance use/abuse or any psychopathological disorders (Brant & Tisza, 1978; Browning & Boatman, 1977; Dixon & Jenkins, 1981; Meiselman, 1978). In many cases, alcohol is used to suppress the offender's internal inhibitors. In fact, Crewdson (1988) found that nearly 70% of incest victims reported that their father was drinking at the time of their first abusive experience.

In addition to crises in the offender's current family, there are significant aspects of his family of origin that contribute to this proclivity for sexual abuse. Often times, parents who (sexually, physically, and/or emotionally) abuse their children report experiencing similar abuse or neglect in their own childhood (DePanfilis & Salus, 1992; Garbarino, 1985). Previously, experts believed that 80% of all pedophiles were themselves molested as children (Groth, 1979). However, other research has surfaced discounting the idea that sexual abuse encourages child victims to become adult offenders. Researchers have since documented the fact that false claims about being victimized as a child are common and enable offenders to relieve themselves from the responsibility for the abuse (Goldstein, Keller & Eme, 1985). With the use of polygraph testing, data indicate that there is actually only a 30% rate of intergenerational abuse (Groth, 1979; Goldstein, Keller, & Eme, 1985). If this finding is accurate, then over two-thirds of all victims will not re-offend in adulthood.







32

While some data indicate that sexual abuse does not always lead victims to offend future generations of children, researchers have found that particular "family styles" can lead to vulnerability for abuse (Trepper & Barrett, 1989). A "family style" contains generational patterns for relating to and parenting children. As such, a man who was exposed to rigid sexual guidelines and stereotypes, the use of power and control for selfworth, and the use of sex for affection is more prone to become sexually abusive (Trepper & Barrett, 1989). In addition, an adult who did not have his own developmental needs met as a child may find it difficult to understand and meet the needs of children (DePanfilis & Salus, 1992; Maslow, 1970). Family Vulnerability Factors

Along with the characteristics of the offender and the preconditions for abuse, there are family vulnerability factors. These vulnerability factors are cumulative, and with each additional factor, the risk for child sexual abuse increases between 10% and 20% (Friedrich, 1990). The specific risk factors for incestuous abuse include (a) the presence of a stepfather, (b) a mother or primary caretaker who is passive and emotionally or physically absent due to work or illness, (c) an acceptance of male supremacy and power, (d) a dominant male figure in the family who feels a sense of entitlement over the children, (e) a sexually repressed family environment, (f) an unsatisfactory or dysfunctional marital relationship, (g) a past history of incestuous abuse in either parent's family of origin, (h) social isolation for the family and the child,

(i) chronic stress in the family, (j) a father or father-figure who performed little nurturing to the child during the growth process, (k) strict role stereotypes and a rigid adherence to









traditional sexual attitudes, (1) living in a community that tacitly accepts incest or other forms of child abuse, (m) secrecy in family communication that is modeled, tolerated, and encouraged, and (n) a child who is particularly needy of affection, has strained relations with the mother, or is estranged from siblings (Brant & Tisza, 1978; Dixon & Jenkins, 1981; Finkelhor, 1984, 1986; Finkelhor, Hotaling, Lewis, & Smith, 1990; Friedrich, 1990; Gentry, 1978; Justice & Justice, 1979; Meiselman, 1978; Parker & Parker, 1986; Trepper & Barrett, 1989).

With incestuous abuse, the family as a whole presents a dysfunctional closed system which perpetuates member dependence and possibly cyclical abuse patterns (Sgroi, 1982). Characteristics of the incestuous family have been found to include (a) the blurring of generational boundaries, (b) family isolation or rigid boundaries with those outside the family, (c) role imbalances and rigidly assigned or inappropriate family roles,

(d) an imbalance of power contributing to a dysfunctional marital dyad and/or a fragmented or nonexistent parental dyad, (e) a deteriorated marital sexual relationship, (f) strained or disturbed sibling relationships, (g) difficulties with cohesion marked by excessive separateness or connectedness within the family, (h) muffled, distorted, or ignored affect, (i) the predominance of secrets and denial, () difficulties with trust and intimacy, (k) problems with dependency, and (1) difficulties with effective negotiation and conflict resolution (Friedrich, 1990; Larson & Maddock, 1986).

The presence of these family vulnerability factors is supported by research with both child victims and adult survivors of sexual abuse. For example, when adult survivors of incest (N = 20) were asked to describe their family history, most often they reported









family secrecy and the blurring of generational boundaries (Justice & Justice, 1979). In addition, these survivors reported that their fathers were overpossessive, jealous of any peer relationships and dating, and showed favoritism to the victim over other siblings (Justice & Justice, 1979). In a larger study of sexually abused children in London (N 41), 63% of the nonoffending mothers reported marital problems; 32% reported sexual problems; and 34% reported that the offender was violent towards them in the past (Bentovim, Boston, & Van Elburg, 1987). Furthermore, 14% of these mothers had a recent or long-term physical illness, and another 14% had a previously diagnosed psychiatric disorder (Bentovim, Boston, & Van Elburg, 1987). Similarly, other researchers found that 56% of abusive families in London were severely disturbed, with 34% reporting marital dysfunction, 14% reporting parental mental illness, 13% unemployment, and 10% alcoholism (Mrazek, Lynch, & Bentovim, 1983).

According to the literature, the overall family atmosphere and the level of

systemic distress are related to child sexual abuse. In fact, in a study comparing young, sexually abused children (N - 37) with nonabused controls (N = 130), the abusive families displayed higher levels and greater rates of stress than the nonabusive families (Gale et al., 1988). In another study with adult survivors (N = 2,626), it was found that "growing up in an unhappy family appeared to be the most powerful risk factor for abuse" (Finkelhor et al., 1990, p. 24). In fact, individuals who described their families as "unhappy" had a 50% higher risk for abuse (Finkelhor et al., 1990). Most likely, this is related to the fact that an offender is more apt to overcome the resistance of the child if her home life is not supportive (Finkelhor, 1984).









If the sexual abuse is perpetrated by a father or a father-figure, there are commonly found characteristics for the nonoffending parent as well. These characteristics include (a) poor self-image, (b) feelings of inadequacy as a wife and mother;

(c) strong dependency needs, (d) the inability to take responsibility and cope with everyday problems, (e) passivity, (f) emotional immaturity, (g) sexual dysfunction, (h) denial as a defense mechanism, and (i) guilt (Mayer, 1983, p. 30). The combination of these factors, along with the offender's motivation to abuse and the child's natural vulnerability, engender incestuous abuse.

In contrast to the family and individual vulnerability factors, there are protective factors which prevent sexual abuse. These protective factors are found in the child's disposition and self-esteem, healthy external support systems, and family cohesion and warmth (Ratnor, 1990). Other findings indicate that adequate social and cognitive skills, an internal locus of control, and at least one positive adult identification figure decreases the likelihood of child sexual abuse (Garmezy, 1983). The Child Sexual Abuse Victim

It is difficult to describe a portrait of the typical child sexual abuse victim due to variations in age, personality, family experience, coping skills, and preabuse knowledge and functioning (Mayer, 1983). While a typical victim portrait is not defined clearly in the literature, Summit (1983) identified the presence of an "Accommodation Syndrome" in many female victims of sexual abuse. According to Summit (1983), a child victim adopts and acquiesces to the characteristics of this syndrome for protection and immediate survival. The five conditions of the Accommodation Syndrome are (a) secrecy,









(b) helplessness, (c) entrapment and accommodation, (d) delayed, conflicted and unconvincing disclosure, and (e) retraction (Summit, 1983).

The first two variables of this syndrome, secrecy and helplessness, are necessary components of child sexual abuse. According to Summit (1983), when an adult sexually abuses a child, "the child has no choice but to submit quietly and keep the secret" (p. 193). The offender uses promises, bribes, and threats of harm to coerce the child and prevent disclosures (Mayer, 1985). In fact, in one study of sexually abuse adolescents, 100% of the victims reported that threats were made by their offenders (Hart, Mader, Griffith, & deMendonca, 1988). Feelings of helplessness are fostered by these threats and the realization that the child cannot match the offender's power. If the abuse continues, eventually the child learns to accommodate in order to survive. Accommodation techniques include denial, martyrdom, splitting of reality, altered consciousness, dissociation, delinquency, sociopathy, projection of rage, and selfmutilation (Summit, 1983).

In time, some child victims tentatively reveal aspects of the abuse to a trusted person. Usually, this is not the child's mother, but it may be a friend, teacher, or other relative (Mayer, 1983; Russell, 1983). "Disclosure is an outgrowth either of overwhelming family conflict, incidental discovery by a third party, or sensitive outreach and community education by child protective agencies" (Summit, 1983, p. 186). However, due to the child's fear and guilt, usually she does not intend to disclose the abuse fully. In fact, most child victims never disclose sexual abuse or disclose only later in adulthood to members outside the immediate family (Herman, 1981; Russell, 1983;









Summit, 1983). In one study of female adult survivors (N = 1,481), 33% reported that they had never disclosed the abuse to anyone prior to the study (Finkelhor et al., 1990). Similarly, in another study, 42% of the respondents told someone about the abuse within a year; 21% told someone at some point after a year; and 36% never told anyone (Crewdson, 1988). On the other hand, even when abuse is disclosed or discovered, it is not always reported to the local child protection agencies. Russell (1983) found that of the mothers who were told or discovered the abuse of their child (which constituted a minority of mothers in these cases), few of them reported it to outside agencies.

Following a delayed, conflicted, or tentative disclosure, often there is a retraction of allegations (Summit, 1983). According to Summit (1983), whatever a child victim discloses, she is likely to retract if she feels a strong sense of guilt or responsibility for maintaining the family stability. Similarly, many children retract their statements because the consequences of disclosure seem worse than enduring further abuse (Gentry, 1978). This final aspect of the Accommodation Syndrome renders the child at risk for further maltreatment and consequently more severe psychological disturbance.

As described, the offender's predisposition to abuse, based on his personality and family history, along with specific victim and family characteristics, lead to a greater probability for abuse. When sexual abuse occurs, these individual, interactional, and environmental factors impact the victim's experience and the resultant psychological effects. The extent of psychological hann and the research on the mediating factors are discussed following.









Individual Effects of Child Sexual Abuse

Is Sexual Abuse Detrimental?

Professionals in the field differ in their views about the effects of sexual abuse.

Some believe that sexual abuse has only minimal (Gagnon, 1965; Henderson, 1983) or no effects for the child victim (Lempp, 1978). Yet, other experts believe that sexual abuse is extremely detrimental to child development, evoking adverse emotional and behavioral symptomology (Finch, 1982; Finkelhor, 1979; Haugaard & Reppucci, 1988; Koch, 1980). In a study of 200 child psychiatrists, a majority believed that sexually abused children experienced psychiatric difficulties (LaBarbera, Martin, & Dozier, 1980). However, it is important to note that the psychiatrists who had the most experience in the field were the least likely to support this finding (LaBarbera, Martin, & Dozier, 1980). This seems reminiscent of Sgroi's (1975) statement regarding sexual abuse as the "last frontier" in child abuse:

Recognition of sexual molestation in a child is entirely dependent on the
individual's inherent willingness to entertain the possibility that the
condition may exist. Unfortunately, willingness to consider the diagnosis of suspected child sexual molestation frequently seems to vary in inverse
proportion to the individual's level of training. That is, the more advanced
the training of some, the less willing they are to suspect molestation. (p.
21)

Despite this debate, there is evidence of a range of distress and dysfunction for child sexual abuse victims. In Russell's (1984b) study of adult survivors, 53% of the subjects reported being affected by the abuse at least moderately. With child victims, the results from two studies indicate that between 33%-50% of abused children exhibit significant behavioral problems following disclosures of sexual abuse (Friedrich, Urquiza,







39

& Beilke, 1986; Tufts New England Medical Center, 1984). In another study comparing young sexually abused children (under age 7, N = 37) with nonabused controls (N =130), only two of the sexually abused children (5%) were thought to have no demonstrated emotional or behavioral difficulties (Gale et al., 1988). Consequently, 95% of the sexually abused children displayed at least one symptom, and 61% demonstrated at least three symptomatic effects (Gale et al., 1988).

Another study by Einbender and Friedrich (1989) compared 45 sexually abused females (aged 6-14) with nonabused controls matched for age, race, family income, and family constellation. In this study, 95% of the abused children received prior therapy compared to only 4% of the nonabused controls (Einbender & Friedrich, 1989). The researchers found that the abused sample of children reported more stressful past histories and demonstrated more behavioral problems, lower cognitive abilities, and lower school achievement (Einbender & Friedrich, 1989). Other researchers found that sexually abused children demonstrated more behavioral problems than nonabused children and yet less severe psychopathology than nonabused psychiatric outpatient samples (Cohen & Mannarino, 1988; Friedrich, Urquiza, & Beilke, 1986; Tufts New England Medical Center, 1984). However, it is important to note that, overall, the abused children exhibited more sexual problems than the clinical comparison groups (Friedrich, Urquiza, & Beilke, 1986).

From the research described, it is clear that there are significant differences found between sexually abused and nonabused controls. While numerous studies document the presence of psychological distress following sexual abuse, the nature of this distress and









any resultant dysfunction is distinct and variable (Burgess, Hartman, McCausland, & Powers, 1978; Finkelhor & Browne, 1986). This finding may be the result of individual differences before the abuse or the result of research studies which utilize varied instruments and differing methodologies. Because none of the studies described above utilized random sampling techniques, the results should be interpreted with caution. In addition to sampling problems, the child sexual abuse research is limited by other methodological and empirical deficiencies.

Moderating Variables

Following a traumatic event, the psychological effects are influenced by a variety of factors including the victim's pretrauma history, the nature of the trauma, the broad socio-cultural and political contexts, and the interpersonal and institutional response the victim receives (Figley, 1985; Lebowitz, Harvey, & Herman, 1993). According to an ecological theory of trauma, the particular aspects of the person, event, and the environment must be examined; these variables interact and influence how individual victims respond to traumatic situations (Lebowitz, Harvey, & Herman, 1993).

Similarly, for child sexual abuse, a victim's response is dependent upon the interactions among several variables. Of particular importance are (a) the offender's relationship with the child and the child's feelings toward the offender, (b) the behavioral aspects of the abuse (i.e., the type of sexual contact, degree of force, and the duration of the abuse), (c) the victim's age and psychosocial development, (d) the reactions of significant others following disclosure and whether the child is believed and supported, and (e) the extent to which the child is involved in legal proceedings following disclosure









(Basta & Peterson, 1990; Benedek & Schetky, 1986; Downs, 1993; Goodman, 1984; Groth, 1978; Katz & Mazur, 1979; MacFarlane, 1978; Mrazek & Mrazek, 1981). "Taken together, the strength and interaction of these variables must be considered in order to evaluate the degree of harm to the child and the subsequent behavioral, emotional, and sexual problems which may result" (Basta & Peterson, 1990, p. 556). The Victim-Offender Relationship

Several researchers have found that the child's relationship with the offender has a significant impact on the resulting symptomology (Adams-Tucker, 1982; Finkelhor, 1986; Russell, 1984b). In most sexual abuse cases, the perpetrator is a known and trusted male adult who may be a family member (Conte & Berliner, 1981 b; Finkelhor, 1984). In fact, 98% of the offenders of female child sexual abuse are male (Gelinas, 1983; Finkelhor et al., 1990; National Center on Child Abuse and Neglect, 1978), and in 80% of the cases, the offender has some preexisting relationship with the child (Peters, 1976).

Because 60%-70% of all child sexual abuse occurs within the family, parents and parent surrogates constitute a substantial portion of offenders (Burgess et al., 1978; Peters, 1976). According to Russell (1984), a female child who is raised by a stepfather is

6 times more likely to be sexually abused by him than a child who is raised by her biological father. In one study of young sexually abused children under age 7 (N = 37), 50% of the perpetrators were related to the child and 28% were biological fathers (Gale et al., 1988). Similarly, Adams-Tucker (1982) found that 50% of the sexually abused children in an outpatient clinic (aged 2-15, N = 28) were abused by fathers or father-figures.







42

In most cases, sexual abuse is not a violent, one-time attack but rather progresses through a persuasive seduction process over time (Brownmiller, 1975; Horowitz, 1983; Morrow & Sorell, 1989; Vander Mey & Neff, 1982). If the offender was a once loved and trusted adult in the child's life, the child may have difficulty defining who is to blame, and she may experience more self-blame. Similarly, adult rape victims were found to be less symptomatic when the rape was less forceful and the responsibility more ambiguous (e.g., date rape) (Becker, Skinner, Abel, & Treacy, 1982).

The effects of abuse appear to increase when the offender is an adult who is close to the child. For example, Finkelhor (1986) found that victims who were abused by adult offenders suffered more long-term traumatic effects than victims who were abused by adolescents. Children abused by their fathers or father-figures are especially at risk for traumatic effects due to family loyalty issues and feelings of betrayal following disclosures (Adam-Tucker, 1982; Burgess, Holstrom, & McCausland, 1978; Everson, Hunter, Runyan, Edelsohn, & Coulter, 1989; Herman, Russell, & Trocki, 1986; Summit, 1983). Adams-Tucker (1982) found that children who were abused by father figures had more severe diagnoses, including symptoms of depression and withdrawal. In fact, 50% of the children abused by their natural fathers were placed in an inpatient facility for severe maladjustment problems (Adams-Tucker, 1982). In this study, the emotional disturbances were more pronounced when (a) the offender was a father-figure, (b) the child was abused by more than one person, and (c) the abuse began at an early age and continued over a long period of time (Adams-Tucker, 1982).









From a review of the research, it appears that the child's relationship with the offender correlates with the severity and duration of the abuse which in turn affects victim symptomology (Phelan, 1986). Father-daughter cases tend to involve more intrusive and violating acts over longer durations, rendering the abuse more traumatic for the child (Finkelhor, 1979; Phelan, 1986). In a study of 102 families referred to an outpatient clinic for treatment, 54% of the cases of abuse by a natural father involved full intercourse in comparison to 27% of the stepfather abuse cases (Phelan, 1986). Furthermore, in 80% of the biological father cases, the abuse continued for over a year, while 64% of the stepfather cases lasted over a year (Phelan, 1986). On the other hand, the frequency of the abuse did not appear to be affected significantly by these relational distinctions (father vs. stepfather). For example, in 66% of the father cases and 71% of the stepfather cases, the abuse occurred from once a week to more than once a month (Phelan, 1986).

Behavioral Aspects of the Abuse

In addition to the relational factors, victim outcome is affected by particular

behavioral aspects of the abuse. More specifically, the type of abuse, the degree of force, and the duration are shown to impact the victim's experience. According to Morrow and Sorell's study (1989) of 101 female adolescent incest victims, the severity of the abusive acts (ranging from exposure to intercourse) was the "single most powerful predictor of distress levels" (p. 677). In fact, "greater severity of abuse was associated with lower self-esteem, greater depression, and a higher frequency of negative behaviors," including antisocial and self-injurious behaviors (Morrow & Sorell, 1989, p. 681). Similarly, others









have found that actual vaginal penetration was associated with more distressing and dysfunctional traumatic symptomology than with other forms of abuse (Friedrich, Urquiza, & Beilke, 1986; Russell, 1984a; 1984b; 1986). When the abuse involved intercourse and the child's mother was nonsupportive, the effects on self-esteem were found to be even greater (Morrow & Sorell, 1989).

From the available data, anywhere between 32% and 77% of child victims

experience penetrating forms of abuse (Gale et al., 1988; Shapiro, Leifer, Martone, & Kassem, 1990). According to Crewdson (1988), 55% of abuse cases involve intercourse; 36% fondling; 7% exhibitionism; and 1% sodomy. In another study (N = 112, mean age=10 years), 28% of the abused children experienced vaginal or anal intercourse, and 38% experienced other forms of penetrating abuse, including oral-genital contact or object penetration (Gomes-Schwartz, Horowitz, & Sauzier, 1985). In a third study of sexually abused children (N = 37, aged 0-7 years), 68% of the cases involved molestation (fondling or exposure), and 32% penetration (26% vaginal penetration, 3% sodomy, 3% oral-genital contact) (Gale et al., 1988). In a large study of female adult survivors of childhood sexual abuse (N = 1,481), 49% of the respondents said that their abuse involved either attempted or actual intercourse (Finkelhor et al., 1990). The highest rate of penetrating abuse was found in a study of 53 African-American sexually abused girls (aged 5-16) in which 77% experienced some form of penile penetration (Shapiro et al., 1990). Most likely, these results vary due to differences in each participant's willingness to report on these severe sexual acts. Most child victims disclose sexual abuse in stages, saving the "worst" for last, and full disclosure occurs only in the context of a trusting relationship







45

(Mayer, 1983). The development of a trusting relationship that endures over time is not possible in most research methodologies.

Along with the type of abuse, the degree of force has been shown to have an

impact on the victim's psychological distress. Nearly half of all victims report that the abuse was accompanied by force or coercion (Finkelhor, 1979; Russell, 1986). Finkelhor (1979) found that abused children exhibited greater traumatic reactions with increased force. Others have found that trauma was increased when penetrating acts, aggressiveness, and physical injury were combined (Elwell & Ephross, 1987; Friedrich & Luecke, 1988). In a study by Cohen and Mannarino (1988) (N = 24), abused children who experienced physical force or vaginal penetration demonstrated higher scores for aggressive behavior when compared to other victim control groups.

The effects of the sexual abuse duration and frequency are inconclusive. Some research data suggest that these variables affect victim outcome greatly while other suggest that these variables are irrelevant (Finkelhor & Browne, 1986; Morrow & Sorell, 1989; Tufts New England Medical Center, 1984). In a study of African-American female victims (N = 53) aged 5-16, the median duration for the abuse was 5 months, and 53% were abused at least once every 2 weeks or more (Shapiro et al., 1990). Russell (1988) found that 73% of adult survivors labeled their abuse as "extremely traumatic" when it lasted more than 5 years in comparison to 62% when the abuse lasted 1 week to 5 years, and 46% when the abuse occurred one time. Others have found greater traumatic reactions with longer durations when the offender was closely related to the child (Burgess et al., 1978).







46

In another study, however, the duration and frequency of abuse were not related to victim distress (Morrow & Sorell, 1989). Yet, the duration and the frequency of the abuse were positively related to the severity of the abuse which has been found to affect victim distress significantly (Cohen & Mannarino, 1988; Morrow & Sorell, 1989). In many cases, sexual abuse progresses along a continuum of acts beginning with fondling and leading to actual intercourse (Groth, 1979). Therefore, there is an increased risk for the abuse to proceed to intercourse if the offender has regular contact with the victim and the abuse continues over a period of time (Finkelhor, 1979). In one study, 72% of the offenders were living in the child's home at the time of the abuse (Shapiro et al., 1990). This may account for why 77% of the victims in this study experienced penetrating abuse (Shapiro et al., 1990). In summary, it may be concluded that the frequency and duration are significant to an extent because they are related to the severity of the abuse (Morrow & Sorell, 1989).

Victim Characteristics

The most significant moderating variable for the child victim is the age at which the abuse began (Jackson, Calhoun, Amick, Maddever, & Habif, 1990). According to a Los Angeles Times poll (1985), 14% of victims were first abused between 0-6 years old; 61% between 7-12; and 25% between 13-18 (Timnick, 1985). Accordingly, the average age during which a child is first abused is 10 (Crewdson, 1988; Finkelhor, 1986; Finkelhor et al., 1990). While the impact of child sexual abuse is thought to vary with the stage of development during which the abuse occurs (Jackson et al., 1990), there is disagreement about which stage has the most deleterious effects (Downs, 1993; Gomes-Schwartz,









Horowitz, & Cardarelli, 1990). In fact, some studies have found that younger children show greater symptomatic effects (Meiselman, 1978; Wolfe, Gentile, & Wolfe, 1989) while others demonstrate that older children are affected more deeply (Conte & Schuerman, 1987; Gomes-Schwartz, Horowitz, & Sauzier, 1985).

Young children may experience more adverse effects because early abuse disrupts a greater number of developmental stages (Downs, 1993). Some researchers have found that a young age at the time of the abuse was predictive of serious long-term psychological disturbance (Meiselman, 1978; Wolfe, Gentile, & Wolfe, 1989). Younger victims were more prone to have difficulties with self-esteem, intimacy, and adult heterosexual relationships (Courtois, 1979). Coping with the traumatic effects may be more difficult for these young victims because they have fewer cognitive and language skills with which to understand the abuse and communicate their feelings. Likewise, younger victims may have difficulties negotiating sex-role expectations as adults because they were introduced to adult sexual behavior at such an early stage in their development (Morrow & Sorell, 1989; Simmons, Rosenberg, & Rosenberg, 1973). On the other hand, some adults who were abused as young children may be less symptomatic because they have had more time to recover and heal (Friedrich, 1988).

Gomes-Schwartz, Horowitz, and Sauzier (1985) found that sexually abused

school-aged children exhibited more clinically significant symptomology when compared to preschool victims. In this study, 40% of the school-aged victims had disturbances in one or more areas of functioning (Gomes-Schwartz. Horowitz, & Sauzier, 1985). School-aged victims may have more pronounced traumatic reactions following sexual









abuse because they are more likely to understand the interpersonal and psychological ramifications (Gomes-Schwartz, Horowitz, & Cardarelli, 1990). In addition, school-aged children may experience more severe abuse for longer durations because they are not monitored as closely as preschool children or infants.

A third age grouping encompasses adolescents. According to Conte and

Schuerman (1987), the older the child is when first abused, the greater the risks for depression and other negative effects. Some experts contend that adolescents are affected severely by sexual abuse due to their crucial stage of development (Conte & Schuerman, 1987). During adolescence, individuals attempt to form their self-concepts into a coherent psychosocial identity (Erickson, 1968). When sexual abuse occurs, this developmental process is tarnished by feelings of stigmatization, guilt, shame, and negative self-concept (Downs, 1993). Adolescents may have more difficulties openly discussing and resolving the abuse due to this intense shame and guilt. As a result, these victims may withdraw socially and may never develop healthy self-concepts (Conte & Schuerman, 1987). In fact, 36% of sexually abused alcoholic women and 33% of nonalcoholic survivors reported negative feelings about self as a long-term consequence of the abuse (Downs, 1993). In addition to difficulties with self-concept, other researchers have found a positive relationship between age and acting out or self-injurious behaviors (Morrow & Sorell, 1989). However, this does not mean that the most harmful effects occur during adolescence. Instead, this finding may be attributed to the fact that older adolescents have more opportunities and more free time to engage in self-destructive, acting-out behaviors (Morrow & Sorell, 1989).









In light of these findings, it appears that with each developmental stage there are deleterious effects. There are no data to support the notion that children at one particular stage are better equipped to cope with sexual abuse than others. According to some experts, regardless of the age at which the abuse first occurs, the behavioral effects change over time, suggesting that development alters the experience and symptomology (Friedrich & Reams, 1987). In addition, "developmental triggers" usually occurring during adolescence or early adulthood may exacerbate distressing symptomology (Downs, 1993). With each new developmental stage and the stressors of emotional growth, previously denied intense emotions may surface (Downs, 1993; Gelinas, 1983). Therefore, treatment efforts should be developmentally focused and victims may need to reenter treatment with each new developmental stage. Family and Environmental Response

Most often, disclosures of sexual abuse cause family distress accompanied by chaos, fear, and denial by family members (Everstine & Everstine, 1989; Friedrich & Reams, 1987; Mayer, 1983). Disclosures of incestuous abuse are shown to precipitate family and individual crises, leaving the child victim feeling unprotected, emotionally deprived, and personally weak (Everstine & Everstine, 1989; Simrel, Berh, & Thomas, 1979; Sgroi, 1982; Summit, 1983). The family distress following disclosures may become so overwhelming for the child that it is indistinguishable from distress that is specific to the abuse (Friedrich & Reams, 1987). Researchers investigating the effects of physical abuse found that nonabused children from distressed families had similar levels of behavioral difficulties when compared to children from physically abusive families (Wolfe









& Mosk, 1983). The authors concluded that "disturbances in the child's social and behavioral development may be more a function of family events and interaction patterns than isolated abusive episodes" (Wolfe & Mosk, 1983, p. 707). Similarly, many researchers have found that a sexual abuse victim's view of herself was highly correlated with the responses of others following disclosure (Ageton, 1983; Atkeson, Calhoun, Resick, & Ellis, 1982; Burgess & Holstrom, 1978; Burgess, Holstrom, & McCausland, 1978; Finkelhor, 1984).

In particular, the reactions of the offender and the nonoffending parent have been shown to mediate the resultant psychological effects of sexual abuse. For example, Finkelhor and Browne (1986) found that when the offender openly assumed responsibility for the abuse instead of reacting with denial and blame towards the victim, the victim distress was less. Fromuth (1986) found that the symptomology for abused children was lessened when parental supportiveness was controlled. In another study, when mothers reacted to disclosures in a punitive, angry manner, the victims demonstrated more frequent behavioral disturbances in comparison to those children whose mothers provided obvious support (Tufts New England Medical Center, 1984). Other authors found that the degree of maternal support was more predictive of psychological health than the type and length of abuse or the child's relationship with the offender (Everson et al., 1989). This may be due to the fact that children who are rejected or blamed by caretakers are removed from the home more often, thus removing them from school, friends, and family (Everson et al., 1989). Furthermore, when the child is removed from the home, there is an increased likelihood that social services will be







51

involved and the child may be asked to testify in court (Everson et al., 1989). According to Elwell and Ephross (1987), children are more at risk for traumatic effects when the disclosure process involves (a) reports or involvements of friends and neighbors outside the immediate family, (b) insensitive comments made by these individuals, (c) insensitive and repeated questioning by police and other officials, and (d) the anticipation of court appearances (Elwell & Ephross, 1987).

Participation in Legal Hearings

Experts estimate that as many as 25,000 families, or 40,000 children, may be

exposed to the legal system annually because of sexual abuse (DePanfilis, 1986). In one study, 40% of sexually abusive families were referred for prosecution in court, compared to only 13% of families involved with other forms of child abuse and neglect (Russell & Trainor, 1984). The prosecution of these cases is extremely difficult due to the nature of the crime and the fact that there are seldom other witnesses involved or corroborating physical evidence (Einbender & Friedrich, 1989). Even if the case is referred for prosecution and tried successfully, it does not always mean that the offender will be detained legally. In fact, only 10% to 12% of those offenders convicted of felony child molestation in America are actually imprisoned (DePanfilis, 1986). For those who are sentenced to incarceration, the average length of time spent in prison is 3.5 years (Mayer, 1985). Furthermore, Conte and Berliner (1981 a) reported that 14% of the convicted offenders in their study were sentenced to attend sexual rehabilitation programs as opposed to prison. If these findings are generalizable, then almost 75% of sexual









offenders remain in the community. The devastating result is that not only do offenders escape penalty, but they also have the opportunity to continue abusing children.

In sexual abuse cases, usually child victims are the only witnesses to the abuse,

and it is incumbent upon them to testify if the case proceeds to trial. The American legal system, as it stands today, however, is not attuned to the specific emotional, developmental, and physical needs of the child victim witness (Finkelhor, 1983; Whitcomb, Sharior, & Stellwagon, 1985). In fact, "when a child is called to assist the prosecution of his/her accused assailant, he/she is treated basically the same way as an adult witness" (Libai, 1969, p. 978).

In a criminal case against a sexual offender, the offender has rights guaranteed by the U.S. Constitution, including the right to confront and cross examine all witnesses, the right to a jury trial, strict adherence to the rules of evidence, and the rights to a public and speedy trial (DePanfilis & Salus, 1992). The defendant is presumed innocent until proven guilty, and in these cases, the burden of proof lies with the child victim (Dixon & Jenkins, 1981; Weiss & Berg, 1982). As a result, the child's testimony is open to direct challenge and confrontation on the grounds of incompetence or fabrication (Goodman, 1984). The child victim is placed in the middle of conflicting groups, including the offender and his supporters, the family, child protective services, and the courts (Dixon & Jenkins, 1981). Therefore, according to some experts, child victims who testify in court are at risk for increased traumatic effects and psychological distress (Benedek & Schetky, 1986; Dixon & Jenkins, 1981; Gibbens & Prince, 1963; Runyan, Everson, Edelsohn, Hunter, & Coulter, 1988).









There are several systemic factors associated with a child's involvement in the

legal system which increase the possibilities for further trauma. First, the legal assembly routinely grants continuances which prolong the process. Typically, 6 months or more elapse between the initial event and the child's court appearance (Goodman, 1984). This means that the child will be preoccupied with the anticipation of legal outcomes which will in turn delay the abuse recovery process. Second, the child is forced to remember the detailed events surrounding her sexual assault and report on this repeatedly to groups of unfamiliar adults. The child may be asked to recount the details of the abuse as many as 12 times to varied professionals at different times during the legal processes (Weiss & Berg, 1982; Whitcomb, Shapiro, & Stellwagon, 1985). Before a trial, the child victim may be interviewed repeatedly by legal, medical, social service, and law enforcement personnel. These interviews interrupt the child's daily functioning and may mean absences from school and other activities.

In addition to the abuse factors, when the child eventually takes the stand, she is generally unprepared for what is going to occur (Berstein & Claman, 1986). The responsibilities of the court personnel and the formality of the process may be confusing and overwhelming for the child. For example, judges may seem to loom large, powerful, and threatening. In addition, the child may be confused by the legal language and fearful of attorneys who appear to argue over everything said in court.

Common feelings experienced by child witnesses are (a) fears of retaliation by the offender, (b) fears that she will not be believed, (c) feelings as if she is on trial, (d) confusion about the roles of legal personnel, (e) humiliation and embarrassment about the









nature of the questions being asked, and (f) confusion about legal decisions and rulings following a hearing (Benedek & Schetky, 1986). Feelings of guilt and shame may be exacerbated by challenges to her testimony through cross examination, regardless of the verdict (Weiss & Berg, 1982; Whitcomb, Shapiro, & Stellwagon, 1985). Furthermore, the child's anxiety may be amplified by the nonoffending parent's stress and anxiety. While the child wants the abuse to stop, she may feel that testifying means that the fate of the offender is in her hands, and she may begin to empathize with the offender (Dixon & Jenkins, 1981). If the offender is incarcerated, guilt may surface from feelings that the child "sent him to jail." Finally, family members may react with anger and resentment towards the child who they feel "ruined" the family (Dixon & Jenkins, 1981). Under these conditions, it is not surprising that, while on the stand, "some children freeze and are unable to remember events that they previously recalled in great detail; some children cry or are visibly shaken; and under the stress of cross examination, some children recant their previous testimony" (Benedek & Schetky, 1986, p. 1227).

Gibbens and Prince (1963) found that child sexual abuse victims who were

involved in legal proceedings experienced greater trauma than child victims who did not participate in court. In this study, however, it is likely that the sample of cases was severe enough to warrant prosecution and the children were most likely unprepared emotionally and intellectually for their court appearances (Gibbens & Prince, 1963). In another study comparing sexually abused children who were involved in court proceedings with controls, it also was found that children who participated in court demonstrated more adverse effects (Runyan et al., 1988). In particular, the researchers









found that the children who were not involved in court proceedings (N = 33) improved 30% over a 5-month period, and, in comparison, only 17% of the children waiting for court proceedings demonstrated improvement in symptomology (Runyan et al., 1988). Of the children who had actually testified in court (N = 12), 42% showed an improvement on anxiety subscales, and 17% demonstrated overall improvement (Runyan et al., 1988). In this study, the court delays which hindered the resolution of the legal proceedings seemed to affect victim outcome greatly (Runyan et al., 1988).

While some researchers have found that court involvement was traumatic, others have found that testifying in court was therapeutic for child victims (Berstein, Claman, Harris, & Samson, 1982; Whitcomb, Shapiro, & Stellwagon, 1985). For some victims, participating in court can validate the child's credibility, encourage self-mastery, and confirm her sense of justice. The child may feel supported in understanding who was wronged and who was to blame for the wrongdoing (Mayer, 1985). In addition, the child can benefit from the experience of testifying in court as she learns self-assertion and finds a constructive means for expressing her anger about the abuse. In this sense, the child is empowered by her testimony which serves to protect other potential victims and may provide the impetus for the defendant to seek help (Benedek & Schetky, 1986). According to Berstein et al. (1982), children who experience court preparation and appropriate legal support are able to testify without experiencing undue stress or negative psychological effects.

In summary, researchers have found that specific moderating variables affect victim outcome significantly. Of particular importance are the offender's relationship







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with the child, the behavioral aspects of the abuse, the child's age, the family reactions to disclosure, and the child's involvement in legal proceedings. More deleterious effects were found when a young child experienced penetrating abuse by a father-figure over a long duration (Haugaard & Reppucci, 1988). In addition, if family members were nonsupportive and the child anticipated legal testimony without preparation, further damaging effects were observed (Benedek & Schetky, 1986; Berstein et al., 1982; Everson et al., 1989; Fromuth, 1986; Runyan et al., 1988; Tufts New England Medical Center, 1984).

The Psychological Effects of Child Sexual Abuse

It appears that a large percentage of victims experience distressing and

dysfunctional symptoms following sexual abuse. However, the percentages of children with any particular symptom vary from study to study, and there is no symptom found to be universal to all victims (Faller, 1993). In 60% to 80% of the child sexual abuse cases, the child victim is not injured physically (DeJong, 1985). Usually, child molestation does not produce physical trauma, but other emotional, behavioral, and sexual indicators are evident. Some child and adult victims even develop severe psychopathological responses that continue as long-term consequences of abuse (Browne & Finkelhor, 1986; Gold, 1986; Livingston, 1987). In the following section, research on the emotional, behavioral, sexual, and psychopathological victim reactions is addressed. Emotional Reactions

Experts in the field have identified numerous emotional consequences of child

sexual abuse, including shame, guilt, fear, depression, low self-esteem, poor social skills,







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repressed anger and hostility, impaired ability to trust, anxiety, role confusion and blurred boundaries, pseudomaturity coupled with a failure to accomplish developmental tasks, and difficulties with self-mastery and control (Browne & Finkelhor, 1986; Porter, Blick, & Sgroi, 1982). The first five of these symptoms are common to sexually abused children, and the latter symptoms are considered more specific to incest victims (Alter-Reid, Gibbs, Lachenmeyer, Sigal, & Massoth, 1986; Porter, Blick, & Sgroi, 1982).

While there are various symptoms considered to be "common" among child sexual abuse victims, there is no one typical emotional response. According to the Tufts New England Medical Center study (1984), the most prominent symptom for sexually abused children was fear, especially for those children over 6 years old. Other researchers found that feelings of self-blame and guilt are common, especially to victims of incest (Finkelhor, 1984; Selby, Calhoun, Jones, & Matthews, 1980). In addition, a loss of normal developmental capabilities or developmental regression (e.g., enuresis/encopresis) and somatic complaints (e.g., stomachaches, headaches, or loss of appetite) are well documented with this population (Adams-Tucker, 1982; Dixon, Arnold, & Calestro, 1978; Goodwin, Simms, & Bergman, 1979; Peters, 1976). Finally, depression, withdrawal, and poor self-concept are found consistently in the child sexual abuse literature as well (Blumberg, 1981; Justice & Justice, 1979; Sgroi, 1982; Yates, 1982).

In a recent study, sexually abused children were compared with nonabused

controls (total N = 48, aged 6-10 years) using the Children's Personality Questionnaire (1972) (Basta & Peterson, 1990). The authors found that the abused children demonstrated significantly lower scores for ego strength, enthusiasm, social boldness, and









extroversion and elevated scores for anxiety, guilt, and social withdrawal (Basta & Peterson, 1990). In addition, the overall adjustment of the abused children was lower as illustrated by a predominance of somatic concerns, depression, delinquency, deficient social skills, low self-confidence, and unusual thought processes (i.e., elevated psychosis scales) (Basta & Peterson, 1990).

It is evident that abused children experience varied emotional effects following sexual abuse. In light of the existing research, Finkelhor (1986) has conceptualized four traumatogenic emotional effects identified as (a) betrayal, (b) stigmatization, (c) powerlessness, and (d) traumatic sexualization.

Betrayal. "Perhaps the most fundamental damage from sexual abuse is its

undermining of trust in those people who are supposed to be protectors and nurturers" (Faller, 1993, p. 19). If the perpetrator was considered close to the victim, a sense of betrayal surfaces (Friedrich & Luecke, 1988). Often, the child is victimized by the adults upon whom she is dependent for physical and emotional survival (Finkelhor, 1984). If the nonoffending parent rejects the child or denies the abuse, the child's sense of betrayal is heightened. These adult caretakers are supposed to nurture, encourage, protect, and care for the child in order to foster healthy development (Gelinas, 1983). As such, "incest is a profound abandonment and betrayal, a travesty of the parental love and care that is a young child's inherent right" (Gelinas, 1983, p. 319). Furthermore, with incest, "there is a profound failure of parental empathy--the centerpiece of a child's emotional well being" (Leahy, 1991, p. 392). As a result of this betrayal, victims have difficulty with trust, affective expression, and normal developmental tasks (Finkelhor, 1986; Mayer, 1983).







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The child who is reared by an incestuous system has "no perspective, no language and no experience base with which to stand outside these relational and sexual forces and form a healthy personality and set of relational templates uncontaminated by incest" (Gelinas, 1983, p. 319). Therefore, the foundation of a healthy sense of self has been damaged and replaced by various psychopathological defensive structures" (Leahy, 1991, p. 392).

The betrayal by the offender and family may be compounded by a perceived betrayal by social service, medical, or legal professionals, especially if traumatic court experiences follow disclosure (Runyan et al., 1988). Some victims respond to these feelings of abandonment and betrayal with intense anger, aggression, and mistrust (Finkelhor, 1986). These feelings may continue into adulthood as evidenced by an avoidance of intimate relationships, manipulation of others, and/or reenacting the trauma through exploitive and damaging adult relationships (Browne & Finkelhor, 1986; DePanfilis & Salus, 1992; Herman, Russell, & Trocki, 1986).

Stigmatization. For sexually abused children, a sense of stigmatization has been identified as the "Damaged Goods Syndrome" (Sgroi, 1982). The "Damaged Goods Syndrome" affects the child's sense of self both physically and psychologically (Sgroi, 1982). The child may feel that she is different from her peers or that she is damaged, dirty, or inferior as a result of the abuse. In fact, in one study of female adult survivors, 70% reported that after the abuse they felt "different" from other girls their age (Downs, 1993). Often times, the child victim experiences anger or resentment in feeling that she was robbed of her virginity and defiled by the offender (Gagliano, 1987). For sexual abuse victims, self-destructive behaviors are observed as behavioral manifestations of this









anger (i.e., substance abuse, risk-taking behaviors, self-mutilation, suicidal gestures, and provocative behaviors designed to elicit punishment) (Dixon, Arnold, & Calestro, 1978; Faller, 1993). Moreover, if there is a public report of the abuse or the child expects to testify in court, these feelings of stigmatization may be more pronounced (Runyan et al., 1988).

For many sexually abused children, feelings of stigmatization lead to guilt and low self-esteem (Mannarino & Cohen, 1986; Peters, 1974; Tong, Oates, & McDowell, 1987). Following disclosures of abuse, often the child feels guilty for having "caused trouble" for the family and the offender (Finkelhor, 1979). Many victims experience guilt for participating in the acts and/or concealing them, yet they also feel responsible for punishment to the offender (Gagliano, 1987). Guilt may surface as a result of direct statements made by the offender, convincing the child that she "wanted" or "brought on" the abuse. In addition, some child victims are told by nonoffending parents that they "should have told sooner," and they may feel guilt about not having done so. This is compounded if there was any aspect of the abuse that was pleasurable in terms of physical arousal or if the child enjoyed the offender's "special" attention (Faller, 1993).

The victim's guilt and sense of responsibility are accompanied by feelings of

shame and low self-esteem (Finkelhor, 1979). Several research studies have validated the fact that child sexual abuse victims have lower levels of self-esteem when compared to nonabused controls (Steele, 1986; Tong, Oates, & McDowell, 1987). According to Steele (1986), low self-esteem arises when the child realizes that the abuse will occur regardless of her thoughts and feelings which appear to be of no import to the offender. In one









study, 45 sexually abused children (aged 3-16) were examined over 2 years after the abuse occurred and compared with matched controls (Tong, Oates, & McDowell, 1987). The sexually abused children had significantly lower scores on measures of self-concept when compared to the control groups. In fact, the abused children demonstrated lower scores for all six dimensions on the Piers-Harris Self-Concept Scale (1984) (i.e., behavior, intellectual and school performance, physical appearance and attributes, anxiety, popularity, happiness and satisfaction) (Tong, Oates, & McDowell, 1987). Overall, the abused group exhibited more aggressive behavior, poor school performance, difficulties with friendships, and lowered self-confidence and self-esteem (Tong, Oates, & McDowell, 1987). As a result, "formally maltreated children tend to have in greater or lesser degree an impairment of a cohesive integrated sense of identity" (Steele, 1986, p. 286).

Incest survivors appear to be affected greatly by low self-esteem. In fact, in a

study of 101 adult survivors of sexual abuse from clinical populations, the authors found that incest victims experienced more negative feelings about themselves when compared to nonincestuous abuse survivors (Hartman, Finn, & Leon, 1987). In addition, adult incest survivors exhibit higher current levels of depression and anxiety (Hartman, Finn, & Leon, 1987) and reduced coping abilities (Steele, 1986).

Powerlessness. In addition to a sense of betrayal and stigmatization, sexual abuse victims experience a sense of vulnerability and powerlessness (Finkelhor, 1986). Often times, these feelings of powerlessness are amplified by social service investigations, legal proceedings, and placement decisions over which the child has no control (Runyan et al.,









1988). In addition, researchers have found that when the abuse involved physical force, the child's experience of powerlessness was more pronounced (Friedrich & Luecke, 1988). As a result, victims may experience intense anxiety, manifest in phobias, sleep problems, elimination problems, and/or eating problems (Jones & Emerson, 1994). In some cases, these feelings of powerlessness may be manifest in avoidant behaviors such as dissociation or running away. These anxiety problems and phobias can become debilitating and continue into adulthood (Faller, 1993).

In some cases, this sense of vulnerability leads to revictimization. On the other hand, abused children who are rendered powerless may identify with the offender over time and develop a desire to control or prevail over others (Freund & Kuban, 1994). Often, this desire to control others is manifest in aggressive or exploitive behaviors. As described by Miller, Johnson, and Johnson (1991),

To have one's helplessness preyed upon by a person one loves leads to the interlinking of feelings of love and hate. This later becomes a central
dynamic in one's adult object relationships. (p. 160)

Traumatic Sexualization. Following child sexual abuse, victims may develop aversive feelings about sex and sexuality; they may overvalue sex; or they may have difficulties with their sexual identities (Finkelhor, 1986). Therefore, the behavioral manifestations of traumatic sexualization range from hypersexual behaviors (i.e., sexual acting out or exaggerated interests in sexuality) to avoidant behaviors or negative sexual identification (Finkelhor, 1986). For many victims, the effects of this traumatic sexualization become more pronounced with insensitive and forceful medical examinations or repeated questioning about the abuse (Runyan et al., 1988). The behavioral









manifestations of this phenomenon are described in detail in an upcoming section delineating the sexualized reactions to abuse. Behavioral Reactions

In addition to the emotional reactions following abuse described above, anywhere from 33% to 95% of all victims will exhibit significant behavioral problems (Friedrich, Urquiza, & Beilke, 1986; Gale et al., 1988; Tufts New England Medical Center, 1984). Mannarino and Cohen (1986) found that 69% of the children in their sample (N = 45, aged 3-16) exhibited psychological and behavioral symptoms over an 18-month period as reported by the parent/caretakers. Most often, these symptoms included nightmares, bedwetting, clinging behavior, inappropriate sexual behaviors, anxiety, and sadness (Mannarino & Cohen, 1986). Others have observed dysfunctional behaviors manifest in aggression, irritability, truancy, and/or running away (Adams-Tucker, 1981; Bess & Janssen, 1982; Browne & Finkelhor, 1986; DeFrancis, 1969; DePanfilis & Salus, 1992; Friedrich & Einbender, 1983; Meiselman, 1978; Orr & Downes, 1985; Tufts New England Medical Center, 1984; Vander Mey & Neff, 1982). In addition, researchers have found that abused children exhibited lower cognitive abilities, lowered school achievement, and poor academic performance when compared with controls (Browning & Boatman, 1977; Einbender & Friedrich, 1989; Elwell & Ephross, 1987; Peters, 1976). More specifically, in a small study of sexually abused children referred within 1 month after disclosure (N = 20, aged 5-12), 90% had some physical symptoms (i.e., sleeping or eating difficulties) and 85% experienced school problems (Elwell & Ephross, 1987).









In a study of 152 female adult survivors of childhood sexual abuse, nearly 100% of the respondents reported feeling "upset" by the abuse at the time it was occurring and 35% described themselves as "extremely upset" (Herman, Russell, & Trocki, 1986). Researchers have found that many sexually abused children demonstrate heightened anxiety or "upsetness" as evidenced by hypervigilence, impaired impulse control, enuresis, eating disorders, sleep disturbances, and socially inappropriate behaviors (Browne & Finkelhor, 1986; DePanfilis & Salus, 1992; Jones & Emerson, 1994; Kiser et al., 1991). In one study (N = 130), 68% of the abused children exhibited anxiety. and 62% had difficulties with compliance (Gale et al., 1988). In addition, over one-third of the abused group demonstrated symptoms of depression, social withdrawal, and inappropriate sexual behavior (Gale et al., 1988). To cope with the anxiety and trauma, some children engage in reenactive behaviors including fantasy or aggressive play, selfdestructive behaviors, and/or delinquency (Kiser et al., 1991). According to Faller (1993), some of these behavioral problems, such as difficulties with sleeping, eating, toileting, and being alone, "may be acute after disclosure but diminish over time and eventually disappear" ( p. 70). On the other hand, some symptoms continue as long-term effects of sexual abuse (i.e., anxiety, social dysfunction, poor self-concept, fear, distrust, sexual difficulties, depression, and/or guilt (Browne & Finkelhor, 1986; DePanfilis & Salus, 1992; Finkelhor, 1979; Herman, 1981; Russell, 1986; Summit & Kryso, 1978).

In a study of 103 children in an inpatient setting (mean age= 10 years old), parents of the sexually abused children reported more symptoms of hypersexuality, fear, mistrust, and withdrawal compared to nonabused patient control groups (Kolko, Moser,









& Weldy, 1988). From an examination of medical records, it was confirmed that the abused children exhibited more sexual behaviors, fears, anxieties, and sadness while in the hospital (Kolko, Moser, & Weldy, 1988). The behaviors associated with fears and anxiety were found to include fears of being alone, discomfort in the bathroom, and hypersensitivity to touch (Kolko, Moser, & Weldy, 1988). The sexualized behaviors included seductive behaviors, discussions of sexual matters, sexualized gestures with objects, sex play, and inappropriate physical touching (Kolko, Moser, & Weldy, 1988).

In another study of 72 abused children, 67% demonstrated dysfunctional

symptomology including depression, fearfulness, oppositional behavior, and somatic complaints (Rimsza, Berg, & Locke, 1988). In addition, 10% of the participants had run away at least once, and three victims attempted suicide (Rimsza, Berg, & Locke, 1988). This is similar to results found by the Tufts study (1984) in which almost 50% of abused children aged 7-13 had elevated scores for aggression and antisocial behavior as measured by the Louisville Behavior Checklist (Miller, 1981).

In a study by Einbender and Friedrich (1989), 45 sexually abused females (aged

6-14) were compared with nonabused matched controls. The abused children were clearly a clinical sample in that 95% received prior therapy compared to only 4% of the nonabused children (Einbender & Friedrich, 1989). Overall, the researchers found that the abused children reported more stressful past histories, demonstrated more behavioral problems, and had elevated scores for each of the nine subscales on the Achenbach Child Behavior Checklist (CBCL) (Achenbach, 1991 a; Einbender & Friedrich, 1989).









In another study, researchers utilized the CBCL to assess children who were

abused within the past 2 years (N = 85) (Friedrich, Urquiza, & Beilke, 1986). The results indicated that 39% of the children had elevated scores on the Internalizing Scales (i.e., anxious, inhibited, and depressed behaviors) and 46% had elevated scores on the Externalizing Scales (i.e., aggression and acting-out behaviors) (Friedrich, Urquiza, & Beilke, 1986). In comparison, only 2% of normative samples have elevated scores in these areas (Achenbach, 1991b). In this study, aggression, depression, and social withdrawal were elevated most consistently (Friedrich, Urquiza, & Beilke, 1986).

In the above study, the authors also found that the internalizing behaviors were correlated significantly with the duration, frequency, and severity of the abuse, yet inversely correlated with the time elapsed since the abuse and the relationship with the offender (Friedrich, Urquiza, & Beilke, 1986). Therefore, child victims who were abused more frequently and more severely by an emotionally close offender exhibited more internalizing behaviors. Similarly, the externalizing behaviors were correlated positively with the duration, frequency, and the number of perpetrators, and inversely with time elapsed and the relationship with the offender (Friedrich, Urquiza, & Beilke, 1986). Externalizing behaviors were more pronounced with abuse by (an) emotionally close perpetrator(s) over longer durations. Yet, both the internalizing and externalizing behaviors decreased with the time elapsed since the last abusive incident (Friedrich, Urquiza, & Beilke, 1986). However, it is important to note that the authors did not use a teacher rating form to compare with the parent report forms, thus limiting the accuracy of these findings.









Sexualized Reactions

Several studies have documented the presence of sexualized behaviors and sexual preoccupations in abused children (Cohen & Mannarino, 1988; Deblinger, McLeer, Atkins, Ralphe, & Foa, 1989; Einbender & Friedrich, 1989; Friedrich, Beilke, & Urquiza, 1987; 1988; Goldston, Tumquist, Knutson, 1989; Kolko, Moser, & Weldy, 1988). The sexualized acts and preoccupations commonly observed and reported in child victims include sexualized language, self-stimulating behaviors, and imitative behaviors (i.e., inserting objects into genital area or initiating intercourse with dolls, peers, or other adults) (Friedrich, Grambsch, Damon, Hewitt, Koverola, Lang, Wolfe, & Broughton, 1992). Sexually abused children were found to draw genitalia in their pictures more frequently than nonabused children (Hibbard, Roghmann, & Hoeckelman, 1987), and their interactions with anatomically correct dolls involved more sexualized play (Jampole & Weber, 1987). Like the emotional and behavioral reactions, these behaviors are associated with the duration, frequency, and severity of the abuse. In fact, Friedrich, Urquiza, and Beilke (1986) found that young children who were abused frequently and over a long-term period by a parent or by multiple perpetrators were more likely to demonstrate sexual behavior problems.

Four studies in particular demonstrate the tendency for abused children to exhibit sexual ideation and sexualized behaviors (Friedrich, 1990; Friedrich & Leucke, 1988; Gale et al., 1988; Tufts New England Medical Center, 1984). Friedrich (1990) found that nearly 75% of the male victims and 40% of the females in his sample exhibited sexual behaviors, including preoccupations with masturbation, sexual acting out, and sexual talk.







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In the Tufts study (1984), 33% of the child sexual abuse victims, aged 7-13, had elevated scores on sexual behavior scales. In another small study of 14 boys referred to therapy for sexual aggression, II had histories of sexual abuse (Friedrich & Leucke, 1988). In a fourth study, sexually inappropriate behavior seemed to distinguish the abused children from nonabused control groups (Gale et al., 1988). More specifically, 41% of the sexually abused children exhibited sexually inappropriate behaviors compared to less than 5% of the comparison groups (Gale et al., 1988).

The predominance of the sexualized behavior problems and preoccupations is an obvious outgrowth of abuse. When a child is abused, sexualized behavior is modeled which impacts the child's subsequent thoughts and behavior. In this sense, the child who acts out sexually is repeating what she learned. It is important to recognize that following an extremely traumatic event, children are faced with a need to master the excess of new stimuli (Furman, 1986). The child's attempt to gain mastery may take the form of repetitive and compulsive behaviors. Therefore, for these children, sexualized behaviors become a means for them to feel mastery over the trauma (Friedrich & Luecke, 1988).

According to Maltz and Holman (1987), sexually abused children either withdraw socially and avoid overt sexual behavior or they engage in unusually frequent sexual activity and promiscuity. With ongoing abuse, victims become confused about their sexual identity, sexual behavior norms, and the differences between sex and caregiving. As a result of the conditioning of sexual activity with negative emotions, some child victims develop aversions to sex or intimacy (Downs, 1993; Finkelhor & Browne, 1986; Peterson & Urquiza, 1993). These problems may follow the child into adulthood as evidenced by









the fact that many adult survivors report difficulties with interpersonal relations and sexual adjustment (Courtois, 1988; Meiselman, 1978; Mrazek & Mrazek, 1981). Victims abused during adolescence are particularly at risk for difficulties with adult intimacy (Downs, 1993; Erickson, 1968; Peterson & Urquiza, 1993). The inability to secure healthy adult intimate relationships and the feelings of low self-worth may account for why some survivors select abusive mates in adulthood (Gelinas, 1983).

According to the child sexual abuse research, sexualized behaviors provide

important discriminating information (Gale et al., 1988). When abuse is suspected but the child is reluctant to disclose, reports of sexualized behaviors should alert professionals to suggest further evaluations (Deblinger et al., 1989; Finkelhor, 1979; Kercher & McShane, 1984). Once in therapy, clinicians are advised to address these sexual issues and behaviors with victims/clients (Deblinger et al., 1989). This is an essential part of therapy because many adult survivors report on-going difficulties with their sexuality (Becker, Skinner, Abel, & Chichon, 1986; Steele & Alexander, 1981). In fact, if left untreated, Steele (1986) postulated that abused children will continue to be exploited or exploit others sexually as adults due to a lack of a positive sexual identity. Psychopathological Reactions

For victims of sexual abuse, there are various observed and reported psychological effects ranging from the absence of symptoms considered psychopathological to the presence of "extreme and pervasive emotional problems" (Gomes-Schwartz, Horowitz, & Sauzier, 1985, p.507). The emotional difficulties found in sexual abuse victims are more severe than those found in nonabused children, and yet there is less psychological









disturbance when compared to clinical samples of nonabused children (Gomes-Schwartz, Horowitz, & Sauzier, 1985). It can be concluded, therefore, that any psychopathological reactions are causally related to the abuse and not an inherent condition as found in a clinical, nonabused sample.

While there is limited information regarding the predominance of characteristics in abused children that lead to DSM diagnoses, several researchers have focused exclusively on diagnosis and sexual abuse victims. Depending on the methodology of the study and the nature of the sample, it appears that anywhere from 40%-100% of abused children are diagnosed with DSM disorders. In one study of 70 child victims, 70% were found to meet the criteria for at least one psychiatric disorder (Maisch, 1973). However, standardized instruments for classifying diagnoses were not utilized, thus limiting the accuracy of these results (Sirles, Smith, & Kusama, 1989). In another small study of 13 sexually abused children on a child psychiatry inpatient unit, standardized interviews were employed (Livingston, 1987). Using the Diagnostic Interview for Children and Adolescents (1977), the researchers found that over 50% of the children met the criteria for at least one DSM diagnosis, including major depressive episode, psychosis, attention deficit disorder, overanxious disorder, and separation anxiety (Herjanic, 1977; Livingston, 1987). In a third study of incest victims (N = 22), 68% received a DSM-III diagnosis (Krener, 1985). The most common diagnosis was adjustment disorder with mixed emotional features (Krener, 1985). In a fourth study, all of the sexually abused children (N = 27) received DSM-III diagnoses after 3-hour psychiatric evaluations (Adams-Tucker, 1982).









In a study by Sirles, Smith, and Kusama (1989), approximately 40% of a sample of 207 abused children from an outpatient population were diagnosed with DSM clinical disorders. In fact, 38% of the children met the criteria for an Axis I diagnosis, including adjustment disorder (23%), conduct disorder (5%), disorders with physical manifestations (3%), attention deficit disorder (3%), mental retardation (3%), oppositional disorder (0.5%), and anxiety disorder (0.5%). In regard to the adjustment disorders, most often this was accompanied by depressed mood (49%) (Sirles, Smith, & Kusama 1989). Other variations of this diagnosis were found to include adjustment disorder with mixed disturbance of emotions and conduct (17%), with atypical features (15%), with mixed emotional features (11%), with disturbance of conduct (6%), and with anxious mood (5%) (Sirles, Smith, & Kusama 1989). In addition to adjustment disorders, 62% of the children were given V-code diagnoses, most often including Phase of Life or Other Life Circumstance Problem codes (Sirles, Smith, & Kusama 1989).

Along with a predominance of adjustment disorders, researchers have validated the presence of PTSD symptomology in child sexual abuse victims (Kiser, Ackerman, Brown, Edwards, McColgan, Pugh, & Pruitt, 1988; McLeer et al., 1988). The diagnostic characteristics for PTSD include trauma-related fears, intrusive thoughts, avoidance of trauma-related stimuli, numbing, and hyper-arousal as seen in sleep disturbances, irritability, and difficulties with concentration (Wolfe, Gentile, & Wolfe, 1989). Associated with these criteria are feelings of fear, anxiety, depression, and guilt (Wolfe, Gentile, & Wolfe, 1989). In a review of the literature, it appears that 40%-80% of the commonly reported symptoms following sexual abuse include anxiety and other









manifestations of it such as hyper-arousal, hyper-vigilance, avoidant behaviors, phobias, difficulties sleeping, intrusive thoughts, and reexperiencing phenomenon (i.e., nightmares or sexual play imitating the abuse) (Adams-Tucker, 1981; Burgess & Holstrom, 1975; DeFrancis, 1969; Friedrich, Urquiza, & Beilke, 1986; Mannarino & Cohen, 1986; McLeer et al., 1988; Peters, 1976; Tufts New England Medical Center, 1984; Wolfe, Gentile, & Wolfe, 1989). In addition to anxiety, some abused children have been found to demonstrate affective numbing and dissociative behaviors (Wilber, 1984).

A number of researchers have examined sexually abused children for the presence of PTSD. In a review of 155 inpatient records, 29 sexual abuse victims and 20 physical abuse victims were identified (Deblinger et al., 1989). In this study, the sexually abused children were matched on the basis of age, sex, and socioeconomic status with nonabused patients and those who experienced physical abuse but not sexual abuse (Deblinger et al., 1989). The authors found that 21% of the sexually abused children met the criteria for PTSD compared to only 7% of the physically abused children and 10% of the nonabused group (Deblinger et al., 1989).

In another study of 31 sexually abused children (aged 3-16 years), 48% met the DSM-III-R PTSD criteria (McLeer et al., 1988). Other subjects demonstrated some PTSD symptomology but did not meet the full criteria for the diagnosis (McLeer et al., 1988). In this study, the presence of PTSD in child sexual abuse victims corresponded with more overt behavior problems. More specifically, the authors found that the children who exhibited the criteria for PTSD scored higher on the internalizing and externalizing scales of the CBCL (McLeer et al., 1988).









In another study of physically and/or sexually abused children (N = 163) from a clinical setting, 55% were diagnosed with PTSD (Kiser et al., 1988). The authors found that the children who did not show signs of PTSD exhibited more depressed and externalized behaviors, including delinquency and aggression (Kiser et al., 1988). Because the children who did not develop PTSD showed greater overall problems, the authors proposed that PTSD promotes healing by providing the child with a means for coping with the trauma (Kiser et al., 1988). However, this conclusion conflicts with the findings of the McLeer et al. (1988) study. Therefore, it is apparent that more research is required in this area before a definitive stance on the merits of a PTSD diagnosis can be proffered.

Along with DSM clinical diagnoses, some abuse victims are hospitalized as

psychiatric patients. In fact, in a study of several psychiatric inpatient units (N = 188 adolescent and adult male and female patients), nearly 50% of the patients had histories of physical abuse, sexual abuse, or both, and 90% of the abuse occurred within the family (Carmen, Reiker, & Mills, 1984). In another study of 51 adolescent inpatients, 55% reported some type of abuse, with 27% experiencing both physical and sexual abuse (Hart et al., 1988). In this study, 6% experienced just sexual abuse (Hart et al., 1988).

It appears that children who have less parental support have more severe

diagnoses and more pronounced psychological disturbances when compared to those children who have obvious parental support (Adams-Tucker, 1982). Other researchers found that the offender's relationship with the child was associated with the level of diagnosable disturbance (Sirles, Smith, & Kusama, 1989). In particular, children abused by fathers or father-figures were found to be at risk for more damaging effects









(Adams-Tucker, 1982; Burgess & Holstrom, 1978; Herman, Russell, & Trocki, 1986). For example, 45% of the victims abused by a natural father and 44% abused by a step-father received an Axis I diagnosis (Sirles, Smith, & Kusama, 1989). This compares to only 26% of the victims abused by other relatives (Sines, Smith, & Kusama, 1989). In another study, the relationship with the offender was associated with the presence of PTSD (McLeer et al., 1988). More specifically, 75% of the children abused by their natural fathers and 25% of those abused by another trusted adult met the criteria for PTSD (McLeer et al., 1988). On the other hand, none of the children who were abused by an older peer met the PTSD criteria (McLeer et al., 1988). Accordingly, a diagnosis of PTSD was found to be associated with more severe abuse over longer durations (Kiser et al., 1988). This is consistent with the results of a study of Vietnam veterans in which the intensity of the combat experiences was positively associated with the severity of PTSD (Goldberg, True, Eisen, & Henderson, 1990).

In addition to parental support, the type of abuse, the relationship with the

offender, and the frequency and duration are related to the severity of the child's diagnosis (Sines, Smith, & Kusama, 1989). In fact, the more frequently the abuse occured, the more likely that the child will receive an Axis I diagnosis. For example, in one study, 50% of the victims abused on a weekly basis were assigned a psychiatric disorder compared to 38% of those children who were abused monthly and 27% of those who reported only "occasional" abuse (Sirles, Smith, & Kusama, 1989). In addition to frequency, the longer the abuse occurred, the more likely that the child would have subsequent psychological difficulties (Sirles, Smith, & Kusama, 1989). In the above study, the children who had









received diagnoses had experienced an average length of abuse of 36 months while the nondiagnosed children experienced an average of 21 months of abuse (Sirles, Smith, & Kusama, 1989).

In terms of the duration of psychological disturbance, some researchers have

found that traumatized children exhibited PTSD symptoms for years after the traumatic event (e.g., the Chowchilla school bus kidnapping), despite their participation in crisis intervention therapy (Terr, 1981 a; 1981 b; 1983). However, little is known about the nature of this crisis intervention and the length of time these children spent in therapy. Yet, this finding suggests that the symptoms for PTSD are long term and continue despite therapy. According to Terr (1991), PTSD symptoms in children may endure over time such that they develop into adult personality styles. Again, because little is known about the course of PTSD in childhood, more research is needed in this area (McLeer et al., 1988).

In the studies described above, anywhere from 0%-60% of the child sexual abuse victims did not meet the criteria for a major mental disorder (Deblinger et al., 1989; Kiser et al., 1988; Krener, 1985; Livingston, 1987; Maisch, 1973; McLeer et al., 1988; Sirles, Smith, & Kusama, 1989). Therefore, it may be concluded that either abused children are not disturbed enough to meet the DSM criteria or the DSM does not contain a disorder with criteria specific to child sexual abuse and the resulting difficulties. Eventually, the American Psychiatric Association may adopt a "Sexually Abused Child's Syndrome" as part of the DSM to include the symptoms and clusters of symptoms specific to this population (Sirles, Smith, & Kusama, 1989). This is important because accurate









assessment and problem definition will guide treatment planning and effective service delivery.

Long-Term Effects

Unfortunately, some of the emotional, behavioral, sexual, and psychopathological symptoms described above continue as long-term effects for child sexual abuse victims. In fact, some victims experience the effects of abuse throughout their lifetimes (Gold, 1986; Silver, Boon, & Stones, 1983). In a study of 152 female adult survivors, almost 50% reported that they had experienced long-term effects and 27% reported that they were affected "greatly" by the abuse (Herman, Russell, & Trocki, 1986). Similarly, Russell (1988) found that 53% of adult survivors reported experiencing "some" or "great" long-term psychological difficulties as a result of sexual abuse.

Like the immediate victim reactions, there are no significant long-term difficulties common to all victims of sexual abuse (Fritz, Stoll, & Wagner, 1981; Tsai, Feldman-Summers, & Edgar, 1979). The extent of long-term distress is associated with the victim's relationship with the offender, the duration of the abuse, the degree of violence, and whether penetration was involved (Herman, Russell, & Trocki, 1986). Survivors of incest, especially if the offender was a father figure, are more at risk for long-term effects (Finkelhor, 1986; Herman, Russell, & Trocki, 1986).

As to long-term effects, some victims experience fear, isolation, stigma, poor selfconcept, distrust, social dysfunction, difficulties with intimate relationships, anxiety, and revictimization (Browne & Finkelhor, 1986; DePanfilis & Salus, 1992; Herman, Russell, & Trocki, 1986; McLeer et al., 1988). In addition, sexual difficulties, depression









(Browning & Boatman, 1977; Summit & Kryso, 1978), and guilt (Finkelhor, 1979) are observed and reported frequently as long-term consequences of abuse. Other researchers have found that adult survivors of sexual abuse exhibit sleep disorders, dissociation, and low self-esteem leading to substance abuse, self-mutilation, and suicide attempts (Gelinas, 1983; Goodwin, 1979; Herman, 1981; Herman, Russell, & Trocki, 1986; James & Meyerding, 1977; Russell, 1986).

Some areas of dysfunction surface in adolescence and continue into adulthood for victims of sexual abuse. In order to avoid feelings of victimization, some victims withdraw from intimate relationships (Herman, Russell, & Trocki, 1986). Other survivors have difficulties with sexuality expressed through sexual deviance, sexual dysfunction, promiscuity, and/or prostitution (Herman, 1981; James & Meyerding, 1977; Meiselman, 1978; Russell, 1986). In fact, in one study, 10% of the sample of sexually abused female adolescents exchanged sex for money; 9% exchanged sex for shelter; and 7% exchanged sex for drugs or alcohol (Boyer & Fine, 1992). Silbert (1984) found that 61% of all prostitutes reported having experienced childhood sexual abuse, with a majority (66%) reporting that they were abused by a father, stepfather, or foster-father. Only 10% of the sample of abused prostitutes were sexually abused by strangers (Silbert, 1984). Furthermore, in 91% of these cases, the victim felt that there was no one she could tell, and only 3% of these victims reported the abuse to the police (Silbert, 1984).

Along with sexual indiscretions, the rates of pregnancy for abuse victims are

higher than nonabused comparison groups (Boyer & Fine, 1992). For example, 66% of pregnant teenagers reported that they were abused at some time in their lives, and 62%









reported that the sexual abuse occurred before their pregnancy (Boyer & Fine, 1992). In two separate studies of pregnant teenagers surveyed through social service agencies, 11% disclosed that they became pregnant as a result of sexual abuse (Boyer & Fine, 1992; DeFrancis, 1969).

The results of two studies suggest that adult survivors of abuse have more

long-term symptomology when compared with both clinical and nonclinical samples of nonabused adults. In one study, 47 adult survivors of incest who were participating in outpatient treatment were compared with 50 nonabused matched controls who were also in therapy (Meiselman, 1978). The author found that 64% of the incest victims reported marital conflicts in comparison to 40% of the controls (Meiselman, 1978). In addition, these survivors reported more sexual difficulties (24% vs. 8%) and more physical problems (52% vs. 30%), and they were hospitalized more often than control groups (24% vs. 14%) (Meiselman, 1978). In another study, 40 female incest survivors in an outpatient setting were compared to 20 nonabused controls (Herman & Hirschman, 1981). The incest survivors exhibited more symptoms of negative self-concept, distrustfulness, depression, anger, and feelings of isolation (Herman & Hirschman, 1981). In addition, they reported fantasies of power over men and fears of being inadequate mothers (Herman & Hirschman, 1981). While these symptoms appeared to continue as long-term effects of childhood abuse, the impact of therapeutic efforts is unknown.

In addition to the effects described previously, researchers have found that some adult survivors exhibit long-term PTSD symptomology (Burgess & Holstrom, 1974; 1979; McLeer et al., 1988). For these victims, PTSD symptomology began in childhood









and followed them into adulthood, thus suggesting an unremitting course of the disorder (McLeer et al., 1988). For survivors of childhood abuse, the fears, hypervigilence, and reexperiencing phenomenon endure as long-term effects through nightmares, flashbacks, and/or dissociative states (Herman, Russell, & Trocki, 1986). Similarly, in research with adult rape victims, 33-63% report ongoing PTSD symptoms that persisted for years after the assault (Burgess & Holstrom, 1979; Ellis, Atkeson, & Calhoun, 1981; Kilpatrick, Veronen, & Resick, 1979; McCahill, Meyer, & Fishman, 1979). In addition to PTSD, some researchers have found an association between long-term childhood sexual abuse and the development of borderline personality disorder (Briere & Runtz, 1988a; 1988b; MacVicor, 1979; Wilber, 1984).

In summary, despite methodological limitations, researchers investigating the short- and long-term effects of child sexual abuse have confirmed the presence of distressing symptomology. These symptoms may persist as long-term distressing effects, especially when the abuse involved penetrating acts by a father-figure over a long duration (Hartman, Finn, & Leon, 1987). It is unknown, however, which treatment methods are recommended and utilized most often with child sexual abuse victims and whether early treatment interventions ameliorate the short-term symptoms and/or prevent the long-term damaging effects. In the following sections, the state of the art in treatment is described.

Intervening in Child Sexual Abuse Cases

In many sexual abuse cases, teachers, school counselors, family friends, and other relatives hear initial disclosures from child victims (Leahy, 1991). In 1965, American







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legislators passed the first child abuse reporting law which required physicians to report suspected physical abuse (Peterson & Urquiza, 1993). Since that time, the laws have expanded to include other forms of child maltreatment including sexual abuse, neglect, and emotional abuse. Today, every state in the United States has enacted laws requiring professionals to report alleged abuse as soon as possible (usually within 24 hours) to the local child protective services division of the State Department of Social Services (DePanfilis & Salus, 1992). The list of professionals required to make these reports includes not only physicians but also teachers, nurses, mental health professionals, social workers, day care providers, school officials, and other professionals who have regular contact with children (Peterson & Urquiza, 1993). These professionals are required to make reports "when one acquires knowledge of or observes a child under conditions that give rise to a reasonable suspicion of child abuse and/or neglect or when one has knowledge of or observes a child whom he or she knows has been the victim of child abuse and neglect" (Peterson & Urquiza, 1993, p. 11). The goals of these mandated reporting laws are to protect current and future victims from these forms of maltreatment.

Following a report of sexual abuse, a child protective services worker will initiate an investigation. Eventually, this worker will classify the allegations of abuse as "confirmed," "indicated," or "unsubstantiated." In some cases, the investigator will refer the child for a medical/forensic examination. With the medical examination, forensic evidence is collected, and the physician assesses for evidence of genital trauma, sexually transmitted diseases, and/or pregnancy. If necessary, medical treatment may be provided.









Cases identified as "indicated" or "confirmed" are referred to the therapeutic community for assessment and counseling.

During the social service investigation, a multidisciplinary child protection team may become involved in the case. These teams include individuals from varied disciplines including child protective services workers, teachers, therapists, doctors, advocators, and legal professionals. "The need for multidisciplinary teams emerged over 30 years ago from the realization that no one discipline can successfully intervene in cases of child abuse and neglect" (Peterson & Urquiza, 1993, p. 14). The first multidisciplinary teams were established in 1958 within hospital settings (i.e., the Pittsburgh Children's Hospital, the Children's Hospital in Los Angeles, and the University Hospital in Denver) (Peterson & Urquiza, 1993). These child protection teams focus on child abuse assessment, training, and research initiatives in the field (Peterson & Urquiza, 1993). Some child protection teams provide short-term therapy as well.

Many communities continue to utilize child protection teams for multidisciplinary intervention in abuse cases. In order for this team approach to be successful, it is necessary for all professionals involved to coordinate their interventions and communicate on a regular basis (Baglow, 1990; Faller, 1993). When case conferences or team meetings are called to discuss a case, the team addresses the following questions: (a) Has child sexual abuse occurred?; (b) Who is the perpetrator?; (c) Is the child protected from future abuse?; (d) Does the child require an immediate medical examination?; (e) Is there a risk sufficient to warrant removing the child from the home?; (f) Will the case proceed to juvenile or criminal court?; (g) What is known about the individual and family







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functioning?; (h) What treatment methods are most appropriate in this case?; and (i) What treatment options are available to the family? (Baglow, 1990).

Following an investigation of a substantiated report of sexual abuse, the social service agencies have four options. They may choose to (a) allow the family to remain intact, (b) remove or detain the offender, (c) remove the child from the home, or (d) remove both the child and the offender (Sgroi, 1982). "Assessment and counseling are not effective if the child continues to be abused or if the family environment is not supportive" (Conte & Berliner, 1981b, p. 603). Therefore, when a report of incestuous abuse is substantiated and the offender is in the home, rarely is the family left intact (Finkelhor, 1984). Juvenile Court hearings are initiated if there is a question about the child's safety and protection from further abuse. Usually, this occurs when the social service workers find that the nonoffending parent does not believe the child or cannot protect her (Martin, 1976).

Following a Juvenile Court hearing, the child may be placed in the temporary care of a relative or a foster family. When this occurs, often the child feels alienated and unsupported by family members and punished for disclosing (Finkelhor, 1979). On the other hand, when the offender is removed, he is held responsible for the abuse and forced to demonstrate sufficient change before interacting with the victim and/or returning home (Trepper & Barrett, 1989). Depending on local laws, removing the offender means that he will be incarcerated or forced to find another place of residence.

A case proceeds to Criminal Court if the State's Attorney accepts the case and intends to prosecute the alleged offender (Faller, 1993). The penalties for first degree









child sexual abuse in the United States range from a $500 fine and up to a year in prison (Virginia Law) to I to 50 years in prison (California Law) (Giaretto, 1976). A convicted offender may be imprisoned and/or mandated to attend therapy, depending on his motivation for treatment and other factors such as previous offenses, local attitudes about rehabilitation, and the available resources (Dixon & Jenkins, 1981). If he is not detained legally in prison, usually a convicted offender must find another place of residence and may be placed on house arrest after a certain time in the evening (Russell, 1986). In some cases, however, where resources are limited, a convicted offender remains in the home but is restricted to certain areas of the house (Parker & Parker, 1986). Probation and/or parole officers monitor the offender's compliance with these legal orders.

Treatment for Child Sexual Abuse

According to Herman, Russell, and Trocki (1986), "only a small percentage of abused children are ever seen by mental health or social agencies" (p. 1293). Finkelhor (1984) suggested that one out of every five cases comes to the attention of these professional agencies. However, the number of clinical treatment programs has increased rapidly in the last decade (Gomes-Schwartz, Horowitz, & Sauzier, 1985). In fact, the number of treatment programs for offenders and their families rose from 20 in 1976 to over 300 in 1981 (Bulkey, 1985). These specialized treatment centers are essential because many doctors, social workers, psychologists, and other clinicians are not trained or do not feel comfortable dealing with sexual abuse and/or incest (Hall & Gloyer, 1985).

Treatment for child sexual abuse victims and their families often involves a

complex and long-term process. Traditionally, there were three approaches in treating







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abused children identified by Cohn (1979): (a) lay therapy including peer counseling and support groups, (b) professionally led group therapy, and (c) individual psychotherapy. As a fourth approach, systemic therapy is common (Madanes, 1990; Star, 1983). While there are varied therapeutic approaches for treating child sexual abuse, often they are polarized into two opposing "camps," victim advocacy and systemic therapy (Barrett, Sykes, & Byrnes, 1986).

In the victim advocate approach, the rights of the child victim are emphasized and there is extreme pessimism about offenders in terms of rehabilitation (Larson & Maddock, 1986). Victim advocates (who may be employed in child protective service agencies or correctional institutions) typically advocate for the separation of the victim and offender, and they recommend individual treatment interventions (Larson & Maddock, 1986). Victim advocates assist the child and family by providing referrals, emotional support, and court accompaniment (Peterson & Urquiza, 1993). If the abuse occurred within the family, victim advocates do not support reunification and usually recommend long-term incarceration for the offender (Larson & Maddock, 1986). For the abused child, victim advocates emphasize individual and play therapy interventions. Other family members (i.e., nonoffending parents) may participate in group or individual therapy, but, in general, all therapeutic efforts are directed towards the child victim. To address the prevention of abuse, victim advocates target the socio-cultural contributors to violence against women and children (Friedrich, 1990).

Therapists with a systemic orientation argue that sexual abuse is best understood and treated in the family context. For incestuous abuse, systemic therapists treat the









incest as a symptom of other distorted elements in family functioning (Larson & Maddock, 1986). The causality is conceptualized as circular, and the incest is a result of dysfunctional family interactions over one or more generations (Trepper & Barrett, 1989). In this view, each family member is an integral part of the system, and the actions of each member influence every other member (Friedrich, 1990). Therefore, family systems theorists encourage the participation of several or all family members in the assessment and treatment processes (Friedrich, 1990). To prevent future abuse, the systemic therapist employs interventions to restructure dysfunctional interactional patterns and promote family change.

While both the victim advocate and family systems approaches contain merit, the current trend in the field combines the efforts of both to promote a comprehensive, integrated, coordinated multisystems approach utilizing eclectic techniques (Forseth & Brown, 1981; Trepper & Barrett, 1989). The multisystemic model is derived from the humanistic family treatment model for sexual abuse developed by Henry Giarretto (1982a, 1982b). In addition, this approach draws from the work of the structural (Minuchin, 1974) and strategic (Haley, 1976; Madanes, 1990) schools of family therapy. As a multidisciplinary approach, it combines the theories and strategies of offender treatment, individual psychology, social learning theory, victim advocacy, group methodology, art and play therapy, behavior therapy, feminist family therapy, and skills training (Friedrich, 1990; Madanes, 1990; Martin, 1976; Trepper & Barrett, 1989).

To provide comprehensive services for the child victim and the family, the multisystemic therapist implements group, individual, collateral, and family









methodologies during various treatment phases. The course of treatment and the introduction of alternate methodologies are dependent upon the needs of the victim, offender, and the family (Keller, Cicchinelli, & Gardner, 1989). When deciding on the direction of treatment, the multisystemic therapist determines how the abuse was maintained by the individual family members, culture, and society. In addition, the therapist considers the nature and degree of trauma, community resources, financial resources, limitations set by the court, and the family's motivation for treatment (Kempe & Kempe, 1984). For the child victim, the multisystemic therapist tailors interventions based on the child's age, developmental level, gender, and diagnosis (Furniss, 1983).

The multisystemic model supports the interest and well-being of the child, yet views family involvement as essential for change (Trepper, 1990). Within the multisystemic approach, incest is viewed as a symptom of dysfunctional interactional patterns within the family and the contexts in which the family operates (Friedrich, 1990). Therefore, systemic factors beyond the nuclear family, including culture, society, extended family, and social support networks, are recognized and included in the treatment process. This approach is utilized with both intrafamilial and extrafamilial sexual abuse cases. In addition, practitioners and researchers report that physical abuse recovery is enhanced with the multisystemic treatment approach (Madanes, 1990; Trepper & Barrett, 1989).

Giaretto (1982a, 1982b) identified treatment guidelines for a "Comprehensive

Sexual Abuse Treatment Program" and created a self-help group facilitated by therapists called "Parent United." This program encourages a comprehensive continuum of







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therapeutic services including (a) individual counseling for the child, nonoffending parent, and offender, (b) dyad sessions with the nonoffending parent and the child, (c) marital counseling for the nonoffending parent and the offender, (d) dyad sessions with the offender and the victim, (e) family counseling, (f) group counseling for parents, offenders, victims, and siblings, and (g) self-help groups for parents and children (e.g., Parents United, Daughters and Sons United) (Giaretto, 1982b). While variations of this program have evolved over the last 15 years, "the organizing theme of every program is the development of a comprehensive and coordinated approach designed to meet the needs of all the family members" (Peterson & Urquiza, 1993, p. 30). The family members benefit by obtaining integrated services at one location so that they are not referred from one agency or clinician to another (Hall & Gloyer, 1985).

Following disclosures of abuse, legal mandates, pressures by social service

workers, and/or desperation and fear compel family members to seek therapeutic services. As a prerequisite to successful treatment, the therapist must develop a thorough diagnostic evaluation of all involved parties and define clear treatment goals (Leahy, 1991; Pittman, 1977). The offender's motivation is a key indicator of success, and the offender's rehabilitation is essential to the prevention of further abuse because unlike other criminal behaviors, pedophilic disorders do not decrease with age (Leahy, 1991). The treatment prognosis is poor for offenders who do not choose to attend therapy or request help but feel that they are being forced to seek treatment due to court orders (Leahy, 1991). The same is true for family members who feel that they are forced to attend therapy sessions when they would rather "handle it on their own" (Finkelhor,







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1979). To diffuse this sentiment, the therapist must inform the family that he/she is not "out to get them," but rather available to assist them in any way possible.

The overall objectives for child sexual abuse treatment are healing and the

prevention of future abuse (Faller, 1993). However, "therapy may be used to work on longstanding problems, to provide support during the crisis that surrounds the reporting of incest, and hopefully to prevent some of the sequellae that have been associated with incest" (Furniss, 1983, p. 44). In particular, the therapeutic goals include (a) limiting the physical and emotional dysfunction experienced by the child, (b) improving the child's overall functioning and encouraging appropriate development, (c) ensuring that the child is protected from future abuse, and (d) restructuring dysfunctional family interactional patterns (Bentovim, Boston, & Van Elburg, 1987). These therapeutic goals may be accomplished through individual, group, and/or family therapy interventions. In some cases, treatment is provided by a team of therapists such that different therapists within an agency intervene at different stages in the recovery process (Faller, 1993). Individual Interventions

According to Madanes (1990), during the early stages of treatment, individual

interventions benefit all family members and introduce the recovery process. Each family member, especially the child, needs support for the initial disclosures and the chaos that follows (Mayer, 1985). Individual therapy sessions provide a forum for members to express their feelings about the abuse and the events following disclosure (Sgroi, 1982). In this sense, alliances are established to foster trust and a belief that change is both possible and desirable (Faller, 1993). Furthermore, in individual sessions, the therapist









can provide insight into the general causes of abuse and help each member understand why the abuse occurred in their family.

For the nonoffending parent, an exploration of the causes of sexual abuse is especially important. It may be difficult for the mother to accept and understand the abuse if the offender was her spouse or another close relative (Faller, 1993).

The disclosure of incest differs from other family crises in that the mother is asked to believe something that she may not want to believe, to interpret something that is at best difficult for her to comprehend, and to resolve the
conflict between her roles as central support figure to both her child and her male partner at a time when her own social, emotional, and economic
supports may be at risk. (Everson et al., 1989, p. 198)

According to Faller (1993), mothers are more supportive to the victim when they are no longer married to the offender. In some cases of incestuous abuse, social service workers find fault with mothers as well as perpetrators (Dietz & Craft, 1980). Even if it is not stated, the nonoffending mothers may sense this blame. As a result, some mothers ally with the offender, and both unite in feeling that they were falsely accused.

Despite the fact that in one study 78% of the mothers reported that they were physically abused by the offender in the past, many do not believe the child victim, and they respond to disclosures of abuse with rejection, blame, and denial (Dietz & Craft, 1980; Everson et al., 1989; Herman, 1981; Summit, 1983). From the available data, anywhere from 44% to 73% of mothers are not supportive to their children who disclose abuse (Adams-Tucker, 1982; Meyer, 1985; Everson et al., 1989). More specifically, in a study of 88 families with child victims aged 6-17, less than 50% of the mothers were identified as "consistently supportive" to their children (Everson et al., 1989). In this









study, almost 25% of the mothers supported the offender over the child victim (Everson et al., 1989).

As discussed, several researchers have found that children who were not

supported by their primary caretakers were more likely to experience severe emotional and behavioral disturbances (Adams-Tucker, 1982; Everson et al., 1989; Fromuth, 1986; Tufts New England Medical Center, 1984). In fact, the degree of emotional support from the nonoffending parent was found to be a key factor in the child's adjustment following abuse (Conte & Schuerman, 1988; Friedrich, 1990). Two separate studies reported finding that affective support from parents served to protect child victims from long-term dysfunction and distress (Rutter, 1987; Runyan, Everson, Edelsohn, Desmond, Hunter, & Coulter, 1989). Bowlby (1973) found that self-esteem and coping were enhanced by positive and secure relationships with primary attachment figures, especially during times of crisis. Therefore, in early individual sessions, it is necessary for the therapist to assess the degree of maternal support for the victim. Next, the therapist must help the nonoffending parent understand the plight of the victim so as to avoid creating stress, shame, and guilt in the child (Peterson & Urquiza, 1993).

In addition to the degree of maternal support, other issues deserve exploration in these individual sessions with the nonoffending parent. In particular, the therapist will assess for dependency on the offender, substance abuse, past physical or sexual abuse, and depression (Faller, 1993). To cope with the aftermath of disclosure, nonoffending parents need information about what to expect emotionally, A mother's response to allegations of incest can range from anger, rage, guilt, and confusion to anguish, disbelief,


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Full Text

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A COMPARISON OF RECOMMENDED COUNSELING INTERVENTIONS FOR SEXUALLY ABUSED CHILDREN By CHERALYN PAYTON LEEBY A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 1998

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ACKNOWLEDGMENTS The completion of this research project has been a true challenge to my perseverance, commitment, and tolerance for change. Since the conception of this project, I moved three different times, and I became a mother for the first time. I also had to abandon an original study due to low response rates and initiate the current study as a second attempt. Despite these life changes and research challenges, my goals remained constant; it just took a little longer to actualize them. I am thrilled to be at a point where this acknowledgment section can be written. My gratitude extends to many individuals for all the unending support and encouragement I received as I worked towards my goals of completion. I am particularly indebted to my committee chairperson. Dr. Larry Loesch. Dr. Loesch accepted each new phone call about my next move or my difficulties obtaining subjects with a supportive ear and wise counsel. My love of writing blossomed under the expert tutelage of Dr. Loesch. His editorial skills are unmatched in my opinion. This dissertation would not have been completed were it not for Dr. Loesch's support, guidance, and direction; I am deeply grateful. I am also thankful to my other committee members. Dr. Peter Sherrard, Dr. Sandra Seymour, and Dr. Elizabeth Bondi. My committee members graciously accepted the long-distance correspondence and provided valuable insight and support. ii

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I greatly appreciate the continued support and guidance provided by my friend and colleague, Dr. Marsha Wiggins Frame. Dr. Frame was always willing to give me that extra little push to say "you can do it . . . keep going." Her practical insight and time spent deciphering the raw data were invaluable. Dr. Frame has mastered SPSS, and 1 am thankful for her willingness to share her knowledge with me. I am truly grateful to Dr. Frame for her time, encouragement, and genuine interest in my educational and career endeavors. I am thankflil to the 470 participants who responded to this study. I am attuned to the myriad of requests that counselors in practice receive on a daily basis from clients, colleagues, and coworkers. I am grateful for those participants who chose to take the time to complete the surveys. Without their cooperation, this project would not have been possible. I also thank the many child sexual abuse victims and families with whom I worked. These survivors inspired my interest in the field of child sexual abuse treatment, and they provided the impetus for this research. I dedicate this research to all victims of abuse and neglect. I hope that the results of this study can be utilized to develop further and research effective treatment methods for child abuse victims so that they can truly become symptom-free survivors. To my family members, who continue to support me in my educational pursuits, I am grateful. Their faith in my abilities and the belief that one day I would successfully complete this project kept me focused. My love of formal education began at an early iii

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age, and I thank my father, Marty Payton, for his ongoing support, encouragement, and reassurance as I pursue my educational goals. Finally, I am grateful to my husband, Doug, and our son, Chase. My husband continually placed my research as a top priority in our lives, and when I needed to work on it, all else came second. My son allowed me to work on the computer when he would much rather that I play outside with him. My family lived through the ups and downs of this research on a daily basis yet never allowed me to "throw in the towel." My family provides me with the love, confidence, and support to succeed. I am truly blessed. iv

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TABLE OF CONTENTS Page ACKNOWLEDGMENTS ii ABSTRACT ix CHAPTERS I INTRODUCTION 1 Overview 2 Scope of the Problem 2 Individual Effects of Child Abuse 5 Treatment for Child Sexual Abuse 9 Statement of the Problem 10 Need for the Study 1 1 Purpose of the Study 16 Rationale for the Approach 16 Null Hypotheses 18 Definition of Terms 20 Overview of the Remainder of the Study 22 II REVIEW OF THE RELATED LITERATURE 23 Theoretical Constructs Underlying the Study 24 Etiology of Abuse 24 Offender Characteristics 27 Family Vulnerability Factors 32 The Child Sexual Abuse Victim 35 Individual Effects of Child Sexual Abuse 38 Is Sexual Abuse Detrimental? 38 Moderating Variables 40 The Victim-Offender Relationship 41 Behavioral Aspects of the Abuse 43 Victim Characteristics 46 v

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Family and Environmental Response 49 Participation in Legal Hearings 51 The Psychological Effects of Child Sexual Abuse 56 Emotional Reactions 56 Betrayal 58 Stigmatization 59 Powerlessness 61 Traumatic Sexualization 62 Behavioral Reactions 63 Sexualized Reactions 67 Psychopathological Reactions 69 Long-Term Effects 76 Intervening In Child Sexual Abuse Cases 79 Treatment for Child Sexual Abuse 83 Individual Interventions 88 Group Interventions 99 Family Treatment for Incestuous Abuse 102 The Structure of Incestuous Families 105 Boundaries 1 06 Hierarchy 106 Role Imbalance 107 Power 108 Cohesion 109 Adaptability 1 1 1 Clarity of Expression 112 Negotiation 113 Family Affect 114 Other Therapeutic Interventions 1 15 Treatment Studies 1 1 5 Offender Treatment 1 1 8 Victim Treatment 124 Family Treatment 128 Conclusion 130 m METHODOLOGY 132 Research Design 133 Sample I34 Instruments 136 Research Procedures 141 vi

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Data Analyses 142 Limitations of the Study 142 IV RESULTS 145 Participants 145 Results of Testing the Hypotheses 1 50 Hypothesis 1 151 Hypothesis 2 153 Hypothesis 3 153 Hypothesis 4 153 Hypothesis 5 153 Hypothesis 5a 156 Hypothesis 5b 157 Hypothesis 5c 158 Hypothesis 5 d 160 Hypothesis 5e 162 Hypothesis 6 163 Hypothesis 6a 165 Hypothesis 6b 1 66 Hypothesis 6c 1 68 Hypothesis 6d 1 69 Hypothesis 6e 1 69 Hypothesis 7 1 69 Hypothesis 7a 1 69 Hypothesis 7b 170 Hypothesis 7c 1 70 Hypothesis 7d 1 70 Hypothesis 7e 1 72 V DISCUSSION 176 Evaluation and Discussion of the Results 1 77 Hypothesis 1 177 Hypothesis 2 183 Hypothesis 3 183 Hypothesis 4 184 Hypothesis 5 185 Hypothesis 5a 186 Hypothesis 5b 1 87 Hypothesis 5c 187 vii

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Hypothesis 5d 188 Hypothesis 5e 1 89 Hypothesise 190 Hypothesis 6a 191 Hypothesis 6b 191 Hypothesis 6c 192 Hypothesised 193 Hypothesis 6e 1 93 Hypothesis 7 193 Hypothesis 7a 195 Hypothesis 7b 195 Hypothesis 7c 195 Hypothesis 7d 195 Hypothesis 7e 196 Limitations 197 Implications and Recommendations for Further Research 1 97 Conclusions 201 APPENDICES A PROFESSIONAL PROFILE QUESTIONNAIRE 204 B TREATMENT RECOMMENDATIONS QUESTIONNAIRE, FORM A 205 C TREATMENT RECOMMENDATIONS QUESTIONNAIRE, FORMB 207 D LETTER OF TRANSMITTAL FOR PARTICIPATING COUNSELORS 209 REFERENCES 210 BIOGRAPHICAL SKETCH 236 viii

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Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy A COMPARISON OF RECOMMENDED COUNSELING INTERVENTIONS FOR SEXUALLY ABUSED CHILDREN By Cheralyn Payton Leeby May 1998 Chairperson: Larry C. Loesch Major Department: Counselor Education As many as one in three female children experience child sexual abuse. These child victims may seek the services of varied professionals including school, mental health, and/or marriage and family counselors. It is unknown, however, what types of treatment these particular counseling professionals recommend for female child sexual abuse victims. The primary purpose of this study was to determine whether therapist-chosen field of practice (school, mental health, or marriage and family) was associated with the type of treatment recommended (individual, group, or family) for female child sexual abuse victims. The child's relationship with the offender (father vs. nonrelated swim teacher) was introduced as the chief moderating variable. The Professional Profile Questionnaire and the Treatment Recommendations Questionnaires were used to gather ix

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the data. The sample included 470 professional members of the American Counseling Association (ACA) . The results of the study revealed no significant differences based on the child's relationship with the offender. In addition, there were few significant differences found among the counselor groups. Most of the counselors, regardless of their professional affiliation in ACA, chose individual counseling as the primary mode of treatment. Family therapy was considered secondary and group was rated as least essential to the resolution process. A large percentage of the population chose to refer the hypothetical clients. This may indicate that child sexual abuse treatment is becoming or should be a distinct field of counselor specialization. While there were few differences found among the counselor groups, there were significant differences associated with particular counselor demographics. For example. White American, bachelor-level school counselors recommended group treatment most often. Therapists with more formal education were found to rate family therapy higher. School counselors rated individual counseling higher than the other two groups, and marriage and family counselors saw the most value in family therapy. It can be concluded, therefore, that child sexual abuse treatment recommendations are more counselor driven than client driven. The results of this study imply that it is essential for clients and referral agencies to know what types of counseling they request and choose a therapist accordingly. X

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CHAPTER I INTRODUCTION "/ talk to you, you make me feel much better on the inside and I cry on the outside " --An 8 year old incest survivor (1993) This statement, from a child in treatment for sexual abuse, reflects her internal sense of "feeling better" and the external manifestations of her perceived progress as evidenced by her ability to cry. What is unknown, however, is whether this sexually abused child is in fact recovering as a result of therapy and, if so, which type of therapy made the difference. Within the last decade, authors have developed and described numerous therapeutic methods for the treatment of sexual abuse (e.g., Friedrich, 1990; Giarretto, 1982a, 1982b; Madanes, 1990; Mayer, 1983; Trepper &. Barrett, 1989). Professional school counselors, mental health counselors, and family therapists provide varied services to victims and their families in an effort to ameliorate and resolve the effects of abuse. These treatment providers may recommend that a particular child victim participate in individual, group, and/or family therapy. However, which treatments are most often recommended by which fields of practice is unknown. Furthermore, it is unknown whether the recommended treatment varies when the offender is related or not related to the child. Therefore, there is a need for data on which treatment methods are 1

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2 most often recommended by which professionals in each of three professional categories (i.e., school counselors, mental health counselors, or family therapists) based on the child's relationship with the offender (i.e., family member vs. nonfamily member). Overview Experts define child sexual abuse as any "sexual contact with a child by an adult, by a person who is more than five years older than the child, or by anyone with the use of force" (Berliner & Barbieri, 1984, p. 128). "Sexual contact" with children is a crime. It may be labeled as incest, rape, indecent assault, sexual battery, criminal sexual conduct, and/or indecent liberties (Finkelhor, 1979). Incest, in particular, is defined as any sexual activity between family members who are not marital partners (Mayer, 1983). By custom and law, all modem societies prohibit parent-child sexual activity (Kempe & Kempe, 1 984), regardless of the degree or type of coercion by the adult or accommodation by the victim (Berliner & Barbieri, 1984). Unfortunately, however, it appears to transcend all races and socioeconomic classes in America (Finkelhor, 1986). Scope of the Problem Current researchers who report on the extent of child sexual abuse typically investigate both incidence (i.e., the number of cases that have occurred over a period of time ) and prevalence data (i.e., the number of victimized individuals) (Finkelhor, 1979). There are difficulties in accurately estimating the numbers of child victims due to limitations in definition, access to personal (usually "shamefial") data, methodological research biases, and reported verses nonreported cases (Mayer, 1985). Thus, it is

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3 estimated that only 2% of intrafamilial and only 6% of extrafamilial child sexual abuse cases ever get reported to authorities (Russell, 1983). While exact incidence and prevalence data are not available, it is known that reports of child sexual assault are increasing. Unfortunately, it is unclear whether the numbers reflect an increase in the actual occurrence of abuse or in "mandatory" reporting due to widespread media attention to the subject. Within the last 10 years, the American media have taken great strides to direct public attention to this "secret" trauma. The common thread for child sexual abuse is secrecy and silence. However, more and more stories about child sexual abuse are being reported in American newspapers, magazines, and on television. This increased recognition of the problem, along with mandated reporting laws in every state, has likely had a significant impact on the numbers of reported child sexual abuse cases and the numbers of individuals seeking treatment. Regardless of the reason for this increase, however, the scope of the problem is alarming. It has been suggested that incidence of child sexual abuse has quadrupled since the early 1900s (Russell, 1986). Estimates of cases of child sexual abuse have increased from one child in a million in 1955 (Weinburg, 1955) to one child in three in 1980 (Herman & Hirshman, 1981). National estimates of all forms of child maltreatment (including physical abuse, sexual abuse, and neglect), which have more than tripled since 1980, range from 100,000 to 500,000 cases per year (National Center on Child Abuse and Neglect, 1988). Mayer (1985) indicated that a child rape occurs every 15 minutes in the United States. According to other published data, anywhere from 19% to 45% of adult women report having experienced child sexual abuse (Bagley & Ramsay, 1986; Conte, 1984;

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4 Finkelhor, 1979; Fromuth, 1986; Lewis, 1985; Miller, Johnson, & Johnson, 1991; Russell, 1983; Timnick, 1985; Wolfe, Gentile & Wolfe, 1989; Wyatt, 1985). In addition, it is estimated that one of every three girls and one of every six to ten boys is sexually victimized at least once during childhood (Finkelhor, 1979, 1986; Russell. 1984b; 1988). There also are at least 2 million known (i.e., adjudicated) pedophiles in the United States, and it is projected that each can victimize an average of 50 children over a lifetime (Mayer, 1985). Furthermore, Russell (1986) found that, in 32% of the known cases of intrafamilial child sexual abuse, the offender abused one or more other relatives but that abuse was never reported. It is apparent that a large number of child sexual abuse cases are incestuous. Approximately one in six children and one in ten families are affected by incest, although this is considered a conservative estimate (Finkelhor, 1984; Russell, 1986). It also is estimated that 60% to 70% of all child molestations occur within the family, and the offender is known to the child in 80% of all reported cases (Dixon & Jenkins, 1981 ; Finkelhor, 1984; Peters, 1976). Father-daughter and stepfather-stepdaughter incest accounts for three-fourths of all the reported cases (Kempe & Kempe, 1984). It also has been estimated that 17% of adult women raised by a stepfather were sexually abused by him by age 14 (Russell, 1984b). Father-son, mother-son, and mother-daughter incest also are being reported more often than in previous years (Miller, Johnson, «fe Johnson, 1991 ; Trepper & Barrett, 1989). Along with the increased numbers of reported cases, inevitably there are more and more victims entering therapy to relieve the resultant psychological effects.

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5 Individual Effects of Child Abuse Several researchers have focused on the psychological effects of sexual abuse for child and adult survivors (e.g., Alter-Reid, Gibbs, Lachenmeyer, Sigal, & Massouth, 1986). The individual effects vary in terms of the symptomology, intensity, and dtiration. However, there are "typical" specific, short-term effects (Friedrich, Urquiza, & Beilke, 1986; Gomes-Schwartz, Horowitz, & Sauzier, 1985; Mannarino & Cohen, 1986) and long-term traumatic symptoms found in abused children (Bagley & Ramsay, 1 986; Briere & Runtz, 1988a; 1988b; Conte, 1987; De Young, 1982; Finkelhor, 1984; Finkelhor & Browne, 1985; Mrazek & Mrazek, 1981; Tufts New England Medical Center, 1984; White, Halpin, Strom, & Santilli, 1988). In a study conducted at the Tufts New England Medical Center (1984), between 20% to 40% of child victims displayed clinical problems immediately after the abuse. Between 46% and 95% of child victims eventually exhibit problematic symptomology related to the trauma (Browne & Finkelhor, 1986; Friedrich, Urquiza, &. Beilke, 1986; Gale, Thompson, Moran, & Sack, 1988; Mannarino & Cohen, 1986; Mian, Wehrspann, Klajner-Diamond, LeBaron, & Winder, 1986). Two commonly reported psychological symptoms following child sexual abuse are anxiety and depression (Murrey, Bolen, Miller, Simensted, Robbins. & Truskowski, 1993). With child victims, anxiety may be evidenced by fear, somatic complaints, intrusive thoughts, impaired impulse control, enuresis, sleep disturbances, hyperactivity, and socially inappropriate behaviors (Gomes-Schwartz, Horowitz, & Cardarelli, 1 990; Kiser, Heston, Millsap, & Pruitt, 1991). Symptoms of depression may include low selfesteem, impaired self-concept, depressed affect, suicidal ideation, social withdrawal.

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6 difficulties with interpersonal relations, and feelings of helplessness (Adams-Tucker, 1984; Browne «fe Finkelhor, 1986; Conte, 1987; Conte & Schuerman, 1987; Kendall-Tackett, Williams, & Finkelhor, 1992; Kiser et al., 1991; Mrazek & Mrazek. 1981; Wolfe, Gentile, & Wolfe, 1989; Wolfe & Wolfe, 1988). Victims also may experience disorganized thought, avoidance of certain places/people, aggressiveness, selfdestructive behaviors, eating disorders, substance abuse, and intense feelings of guilt, shame, and/or anger (Finkelhor, 1986; Greenberg, 1979; Trepper & Barrett, 1989). In addition to these commonly reported symptoms, "two-thirds of all (victims) suffer identifiable emotional disturbance and 14% become severely emotionally disturbed" following sexual abuse (Weiss & Berg, 1982, p. 515). The most common diagnosis for abuse victims is Post-Traumatic Stress Disorder (PTSD) as described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 1994; Mayer, 1985). In fact, in one clinical sample of sexually abused children, as many as 55% met the criteria for PTSD (Kiser et al., 1991; McLeer, Deblinger, Atkins, Foa, & Ralphe, 1988). For these children, the symptoms included (a) flashbacks or recurrent and intrusive recollections of the abuse, (b) distressing dreams related to the abuse, (c) reenactments of the abuse through play or overt behavior, (d) psychological distress and physiological reactivity when exposed to aspects of the abuse, (e) persistent avoidance of stimuli associated with abuse, and (f) symptoms of increased arousal which were not present before the abuse (American Psychiatric Association, 1994).

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Researchers also have identified the presence of PTSD symptomology in child sexual abuse victims to include phobic/avoidant behaviors (Fromuth, 1986; Wilbur, 1984), affective numbing (Wilbur, 1984), nightmares (Burgess & Holstrom, 1975; Goodwin, 1982), and repetitive or inappropriate sexual behaviors (Friedrich, Urquiza, & Beilke, 1986; Tufts New England Medical Center, 1984). These symptoms are considered temporar}' but causally related to the abuse. In addition, the PTSD response may be acute, chronic, or delayed. Several researchers have documented a relationship between childhood sexual abuse and chronic adult PTSD (Briere & Runtz, 1993; Craine, Hensen. Cliver, & MacLean, 1988; Donaldson & Gardner, 1985; Goodwin, 1984; Lindberg & Distad, 1985). Therefore, it is evident that for some child survivors, the psychological effects continue for many years, even into adulthood (Gold, 1986; Herman, Russell, & Trocki, 1986). In addition to PTSD, there are more serious dysfunctions that may surface or become pronounced following childhood sexual abuse. Sixty-six percent of adult survivors reported that at the time of the abuse the experience was severely emotionally distressing, and 50% continued to report at least some on-going difficulties related to the trauma (Finkelhor, 1979, 1986). As many as 40% of women seeking outpatient mental health therapy for other related difficulties eventually reveal child sexual abuse (Gordon & Alexander, 1993; Leahy, 1991). Consequently, adult survivors of abuse demonstrate more symptoms of psychological distress and dysfunction when compared with nonabused control groups (Browne & Finkelhor, 1986).

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8 The resultant symptomology for adult survivors has been clustered into three areas: (a) symptoms of anxiety, (b) symptoms of depression and lowered self-esteem, and (c) symptoms of social and sexual dysfunction (Browne & Finkelhor, 1 986; McLeer et al., 1988; Murrey et al., 1993). For some adult survivors, these symptoms contribute to the development of other maladaptive personality styles and self-destructive behaviors. Adult survivors also represent a significant proportion of individuals with dissociative disorders, multiple personality disorder, and borderline personality disorder when compared to community controls (Gordon & Alexander, 1993). Giarretto (1978) estimated that nearly 90% of all women who were treated for sexual dysfunction were raped during their childhood. In a study of 1 1 8 female substance abusers, 44% were victims of incest, and 75% reported having been sexually abused before the age of 9 (Densen-Gerber, 1977). Elias (1983) reported that 75% of his sample of 200 "street prostitutes" had been raped as children. Sexual abuse also is one of the three main reasons why children run away from home (Mayer, 1985; McCormack, 1986). However, for the most part, individual psychotic or psychopathological disorders are rarely experienced by victims, offenders, and/or nonoffending parents (Finkelhor, 1979). Researchers indicate that the long-term, negative effects of child sexual abuse are associated with (a) type of relationship the child had with the offender, (b) length of time the abuse occurred, (c) type of assault and whether violence was involved, (d) extent to which the child was involved in legal proceedings, (d) reactions of others, and (e) whether the child was believed and supported following disclosure (Fromuth, 1986; Katz & Mazur, 1979; Kelly, 1990; Russell, 1986). More specifically, if the child had a close

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9 relationship with the offender and if the sexual abuse occurred over several developmental stages, then the resulting symptomology is both more severe and more lasting (Russell, 1986). Similarly, if the offender was initially a "positive" person in the child's life, then the resolution of the abuse is more difficult. With more violent and violating abusive acts (i.e., forced penetration), there also is an increased likelihood for long-term emotional scarring (Russell, 1986; Trepper & Barrett; 1989). Finally, if a child victim testifies in court and feels victimized by the process, then the child's recovery may be temporarily disrupted or permanently compromised (Brownmiller, 1975; Kelly, 1990; Symonds, 1980). However, family support, especially maternal validation, can lessen the effects of these significant factors for the child victim (Fromuth, 1986). Treatment for Child Sexual Abuse An alarming number of families in the United States have suffered the shame, secrecy, and destruction caused by child sexual abuse (Finkelhor, 1986; Mayer, 1985; Russell, 1986). Due to the widespread nature of this problem, mental health counselors, medical practitioners, legal professionals, educators, researchers, and the general public are recognizing the need for effective interventions to prevent, treat, and heal child sexual abuse. "When incest was considered a one-in-a-million occurrence, the few people working in the field had little disagreement as to the causes, effects, and treatments" (Trepper & Barrett, 1989, p. xiii). However, since the establishment in 1974 of the National Center on Child Abuse and Neglect, varied theoretical and clinical developments have emerged in the field (Elmer, 1977). Mental health practitioners have created numerous and diverse specialized programs to provide comprehensive services to victims.

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"Whereas 20 years ago, there were none, today experts estimate the number of programs (for child and aduU victims of abuse, assauh, and other crimes) to be in excess of 5,000" (Davis & Henley, 1990, p. 157). To treat sexually abused children today, counselors utilize varied techniques, including those found in individual, group, and family therapy (Friedrich, 1 990; Mayer, 1983; Trepper & Barrett, 1989). The recommended course of intervention may depend upon several factors, including the relationship with the offender and the child's age, developmental level, gender, diagnosis, and family situation (Boatman, Borkman, & Schetky, 1981; Trepper & Barrett, 1989). The type of treatment provided also varies according to the availability of services, treatment center philosophy, and therapist training and style (Trepper & Barrett, 1 989). In most cases, therapy with child sexual abuse victims addresses the following issues: (a) immediate effects of disclosure, (b) physical and emotional damage to the child, and (c) prevention of long-term dysfunction and future abuse (Bentovim, Boston, & Van Elberg, 1987). Consequently, treatment is considered to be effective if further abuse is prevented and dysfunctional and distressing symptomology are alleviated. Statement of the Problem As noted, researchers have presented significant data on the extent of child sexual abuse (Finkelhor, 1979, 1986; Finkelhor & Hotaling, 1984; Herman & Hirshman, 1981; Lewis, 1985; Russell, 1988; Sarafino, 1979) and the resultant psychological effects (Bagley & Ramsay, 1986; Briere & Runtz, 1988a, 1988b; Conte, 1987; De Young, 1982; Finkelhor, 1980; Finkelhor & Browne, 1985; Friedrich, Urquiza, & Beilke. 1986;

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11 Gomes-Schwartz, Horowitz, «& Sauzier, 1985; Herman, Russell, & Trocki, 1986; Mannarino & Cohen, 1986). Theorists and practitioners have, in response, created specialized treatment methods and programs for recovery from childhood sexual abuse (Friedrich, 1990; Giarretto, 1982b; Madanes, 1990; Mayer, 1983; Rencken, 1993; Trepper & Barrett, 1989). However, a particular child victim may begin counseling with a school counselor, mental health counselor, or family therapist without knowing which type of treatment will be recommended. That is, there is a relative dearth of empirical data on which types of treatment are currently being recommended and utilized with this population. Furthermore, it is unknown whether the type of treatment recommended varies according to the practitioner's chosen field of practice (i.e., school counseling, mental health counseling, or family therapy). Therefore, the problem addressed in this study is that the differences in professional treatment recommendations for child sexual abuse victims are unknown. For purposes of this study, individual, group, and family therapy modalities were examined for victims abused by either a family member (e.g., father) or a nonrelative offender (e.g., swim teacher). Need for the Study The intent of this study is to collect data from a large, random sample of counseling professionals in order to determine which methods of intervention are most often recommended for female child sexual abuse victims. The most significant influences on treatment recommendation are delineated. The results of this study have implications for the mental health professions and for social policy.

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12 In the mental health arena, this research provides clinicians with information on the most common therapeutic practices for this population. If specific treatments are recommended more often because they are believed to produce more positive changes in child victims, other clinicians will be more apt to utilize these interventions. In addition, clinicians may determine when alternate treatment modalities can be most successfully implemented. For example, if a majority of professionals recommend that a child begin in individual treatment and later enter group or family therapy, this may be helpful to other clinicians encountering similar clients. Furthermore, it may be found that different treatment methods are recommended based on the child's relationship with the offender. Clearly, this information will aid counselors in effective treatment planning, program development, and service delivery. In this study, data were collected on the types of interventions most commonly utilized today by representative treatment providers from the three professional counselor groups. While a large number of mental health professionals treat sexual abuse victims, most report feeling undertrained in this area (Dietz & Craft, 1980). The need for specialized training in child sexual abuse treatment may be ftirther realized in light of this research. If it is determined that specific modalities are chosen more often, then it may be recommended that clinicians be trained to provide these services. For example, if family therapy sessions are shown to be utilized most often, then counselors may need further education in systemic therapy. Similarly, clinicians may have more information about when to refer a client to a counselor with a particular expertise (e.g., group counseling).

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13 Finally, the content for professional seminars and training manuals on the subject of abuse may be expanded to include data on these recommended therapies. In regard to specialized training, most credentialing boards have instituted mandates for mental health professionals, with the exception of psychiatrists, to complete continuing education in child sexual abuse (Powell, 1988). Future credentialing boards may expand this requirement to include psychiatric and other health practitioners including professionals in pediatrics, family practice, education, and emergency health. Accordingly, professionals who are hired and reimbursed by third-party payers will most likely be those individuals who are recognized as competent and knowledgeable in this specialized field. Surveying professionals in each of the three fields of practice, therefore, will provide information that may assist credentialing boards, educators, trainers, and insurance providers in developing standards of care and practice for this specific client group. Several theoretical implications could evolve from the findings of this study. If it is found that one method of intervention is clearly utilized more often than other modalities, then theorists can utilize these data to study and develop further these methodologies. Consequently, specific recommendations about how clinicians might implement these modalities can be proposed. In addition, theories related to the course of recovery and symptom relief may be expanded. Theorists may proffer that different interventions are necessary at different stages in the recovery process. Theorists also may further define how mediating variables, such as the child's relationship with the offender, alter the recommended course of treatment. On the other hand, if it is shown

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14 that neither individual, group, nor family therapies are recommended as the primary form of treatment, then alternate theoretical formulations will need to be explored. There will be implications for research as well. Future inquiry may focus on which particular aspects of each treatment methodology and which techniques (e.g., art or play therapy) are most often recommended with these clients. Then, better research on the efficacy of these treatment methods can be initiated. The results of this study also can be compared with studies that include male victims as well as other age groupings. Furthermore, test developers may create measures specific to child abuse which identify trauma symptomology and treatment variables. Data from such measures can be compared to measures of therapist knowledge, training, style, and theoretical orientation. The implications of this study are not limited to counselors and the counseling professions. Child sexual abuse is not only a crime but also a mental health, medical, and social problem in America (Conte, 1984). Therefore, professionals in the legal, educational, medical, and social service arenas are faced with the tasks of treating and preventing child sexual abuse. In order to advocate successfully for child sexual abuse victims, these professionals must know what treatment alternatives are available and most often recommended. In addition, these professionals must know who provides these services for victims. For example, do only "family therapists" provide only family counseling services for victims? Professionals in these related disciplines can utilize these data to make the appropriate and necessary treatment referrals. With a clearer understanding of therapeutic processes and expected outcomes, professionals across disciplines also can cooperate better to provide comprehensive victim services.

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15 There also are important implications for the American society as a whole in regards to the prevention of sexual victimization. If there is a consensus regarding the most appropriate form of treatment for child victims of abuse, then it may be presumed that this treatment is in fact working to lessen the effects and prevent future abuse. It is estimated that only 13% of sexually abused children and their families participate in treatment for sexual abuse (Alter-Reid et al., 1986). Yet, as aduUs, 40% of child sexual abuse survivors seek mental health treatment (Browne & Finkelhor, 1 986). Therefore, the problems most likely do not diminish over time, and the cycle of victimization continues. As child sexual abuse becomes "a way of life," some child victims learn to become adult offenders. Current studies indicate that anywhere from 32% to 57% of incarcerated adult sex offenders and 1 8% of adolescent offenders report a history of childhood sexual victimization (Fehrenbach, Smith, Monastersky, & Deisher, 1986; Groth, 1979; Owen & Steele, 1991; Rosenfeld, Nadelson, Krieger, & Backman, 1979). In addition to a proclivity to offend, adult survivors are prone to fiirther victimization. In fact, 63% of female adult survivors of childhood sexual abuse report being assaulted as adults compared to 36% of women who were not victims (Russell, 1986). It is unclear, however, whether these adult offenders and/or victims were treated as children and which types of therapy were introduced. In summary, there is great need for accurate data on the recommended course of treatment with child sexual abuse victims. The results of this study broaden the existing research in the field of child sexual abuse treatment. Ultimately, with improved service

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16 delivery of effective treatment interventions, child sexual abuse victims may become symptom-free survivors. Purpose of the Study In this study the recommended course of treatment for female child sexual abuse victims was investigated. The purpose of this study was to determine whether therapistchosen field of practice (school, mental health, or family counseling) had an effect on the type of treatment (individual, group, or family therapy) these providers typically recommend for a female child sexual abuse victim. In addition, the child's relationship with the offender (i.e., family member vs. nonfamily member) was examined as a variable. Data were gathered about which types of treatment are recommended by which of the three professional counselor groups. In particular, the following questions were addressed: "Is there a difference in the type of treatment recommended (i.e., individual, group, or family therapy) for a female child sexual abuse victim based on the professional counselor's chosen field of practice (school, mental health, or family therapy)?" Secondly, "Is there a difference in the type of treatment recommended based on the child victim's relationship with the offender (i.e., family member vs. nonfamily member)?" Rationale for the Approach Data were collected to compare the outcome results for school, mental health, and family counselors and therapists who are current members of the American Counseling Association. A random sample of 1,000 professional AC A members in each of these three groups was generated. A total of 470 ACA members chose to participate by returning the completed surveys (N = 470). Data from the participating counselors were

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17 used to examine whether individual, group, and/or family therapy modalities are recommended for a typical female child sexual abuse victim as described in a hypothetical client profile (Appendices B and C). The counselor groups were chosen because they are the professionals who most often come in contact with child sexual abuse victims through their chosen fields of practice. The treatment modalities were chosen because they are the ones most often cited in the child sexual abuse treatment literature (Friedrich, 1 990; Madanes, 1990; Mayer, 1985; Rencken, 1993). A detailed explanation of the theoretical constructs underlying the chosen treatment methods is described in Chapter II. The random sample of 1 ,000 ACA members was sent a research packet of materials including the Professional Profile Questionnaire (PPQ) and the Treatment Recommendations Questionnaire (TRQ) (Form A or B). The PPQ contained questions related to the participating therapist's ACA affiliation, age, gender, ethnicity, and education (Appendix A). The TRQ contained a description of a 10-year-old female child sexual abuse victim entering treatment (Appendices B and C). Also contained in the TRQ child victim scenario were demographic data and information on the child's current level of fiinctioning. The offending individual was depicted as either the child's father (Form A) or a nonrelative male swim teacher (Form B). The participating therapists were asked to read the scenarios on the TRQ and respond as if this were an actual client coming to them for treatment. Counselors were then asked to answer questions about their recommended course of treatment. Specifically, they were asked whether they would recommend individual, group, or family therapy for each particular child victim. The information from the completed TRQs was compared with data collected from the PPQ.

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18 Null Hypotheses The following null hypotheses were evaluated in this study: 1 . There is no association between counselor type, the form for the Treatment Recommendations Questionnaire, and the primary counseling intervention type recommended. 2. There is no difference in the rating for individual counseling based on form. 3. There is no difference in the rating for group counseling based on form. 4. There is no difference in the rating for family counseling based on form. 5. There is no difference in the rating for individual counseling based on counselor type. 5a. There is no difference in the rating for individual counseling based on gender. 5b. There is no difference in the rating for individual counseling based on ethnicity. 5c. There is no difference in the rating for individual counseling based on highest degree held. 5d. There are no significant interactions among counselor type, gender, ethnicity, and degree for the ratings for individual counseling. 5e. There is no relationship between age and the rating for individual counseling. 6. There is no difference in the rating for group counseling based on counselor type.

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6a. There is no difference in the rating for group counseling based on gender. 6b. There is no difference in the rating for group counseling based on ethnicity. 6c. There is no difference in the rating for group counseling based on highest degree held. 6d. There are no significant interactions among counselor type, gender, ethnicity, and degree for the rating for group counseling. 6e. There is no relationship between age and the rating for group counseling. 7. There is no difference in the rating for family counseling based on counselor type. 7a. There is no difference in the rating for family counseling based on gender. 7b. There is no difference in the rating for family counseling based on ethnicity. 7c. There is no difference in the rating for family counseling based on highest degree held. 7d. There are no significant interactions among counselor type, gender, ethnicity, and degree for the rating for family counseling. 7e. There is no relationship between age and the rating for family counseling.

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20 Definition of Terms For purposes of this study, child sexual abuse is defined as any sexual contact between someone who is at least 5 years older than the child and who has permanent or temporary care and custody of the child. Sexual contact includes a range of abusive acts with or without the use of force (i.e., fondling, oral copulation, or vaginal or anal intercourse) (Downs, 1993; Friedrich, Urquiza, & Beilke, 1986). Incest means sexual activity by anyone who is 5 or more years older and has a preexisting familial relationship with the child (Gelinas, 1983). In this study, only abuse by male offenders to female children was investigated because this is the most common situation (Finkelhor, 1979; Rencken, 1996). For ease in reading, the child victim is referred to as "she" and the perpetrator as "he" throughout the study. This does not in any way imply that abuse is perpetrated only by males or that victims are always female. Finally, the terms incest and child sexual abuse are used interchangeably when the material applies to both. There are several terms frequently used in the literature to identify and describe the family members affected by abuse and incest. In particular, the nonoffending parent is the parent or guardian who did not abuse the child. Conversely, an offender or perpetrator is the person who has committed the crime of child sexual abuse. A pedophile is an individual who is sexually attracted to children (Groth, 1979); an offender may or may not be considered a pedophile. There are two types of pedophilia: (a) fixated (a persistent pattern) or (b) regressed (a new activity that is situationally induced) (Groth, 1979). The fixated pedophile has a chronic compulsion to abuse children through which his needs for affirmation and affection are met (Groth, 1979; Mayer, 1983). The

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21 regressed pedophile has a primary sexual orientation toward adults, yet, due to precipitating stressors, displaces his sexual impulses onto children (Mayer, 1983). In this study, no differentiation is made between types of offenders and the specific motivations for abuse. The term adult survivor is utilized in this study to identify a male or female adult who has experienced abuse as a child. This term captures and encourages the individual's ability to move beyond the sexual victimization as a survivor. To describe children who are sexually assaulted, the terms child "survivor" and "victim" are used (interchangeably). Identifying a child as a victim is not intended to discount the child's ability to survive. Instead, this term is used to acknowledge who was victimized and that the responsibility for the offense lies with another person (Russell, 1986). The American Counseling Association (ACA) is the primary representative professional organization of counselors in the United States (Vacc & Loesch, 1987). American Counseling Association members can choose affiliate membership from a list of 17 divisions including school, mental health, or family therapy affiliate groups. The sample for this study included members from three specific ACA divisions. The American School Counselors As sociation (ASCA) enlists members who promote professional school counseling activities that affect personal, educational, and career development decisions of students (ACA, 1995). Members of the American Mental Health Counselors Association (AMHCA) administer and advocate for quality mental health services within the health care industry (ACA, 1995). The International Association of Marriage and Famil v Counselors (lAMFC) represents members who

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22 promote the health of family systems through prevention, education, and therapy (ACA, 1995). In this study, individual therapy is used to describe sessions with an individual client alone using individual techniques and theories of counseling. Group therapy usually involves three or more clients and a counselor. Group members work towards growth through their interactions with the counselor and each other (Belkin, 1980). The term family therapy is used to describe a variety of counseling approaches in which family members are brought together to address issues collectively (Belkin, 1980). Family therapy in a broad sense extends beyond family members to include other significant persons who have an impact on family functioning and areas of difficulty. Overview of the Remainder of the Study Presented m Chapter II is a review of the related literature, including an overview of child sexual abuse and the known psychological effects. Also, individual, group, and family therapy treatment modalities are discussed as they apply to the population. Presented in Chapter III is a description of the methodology for the study, including the research design, sample, instruments, and data analysis. In Chapter IV the results of the study are presented. Finally, Chapter V contains a summary of the results, discussion, implications, and recommendations for further research.

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CHAPTER II REVIEW OF THE RELATED LITERATURE Following sexual abuse, most child victims face a potential traumatic aftermath plagued by distressing and dysftinctional symptomology (Browne & Finkelhor, 1986; Friedrich, Urquiza & Beilke, 1986; Gale et al., 1988; Mannarino & Cohen, 1986; Mian et al., 1986). In fact, according to Finkelhor and Browne (1986), between 46% and 66% of sexually abused children exhibit these distressing symptoms following abuse. As a result, child victims are encouraged to enter mental health treatment in order to heal from the trauma, alleviate long-term dysftinctional symptomology, and prevent future abuse (Finkelhor, 1979, 1986; Giarretto, 1978; Madanes, 1990; Trepper & Barrett, 1989). When a child victim enters treatment, the child may participate in individual, group, and/or family therapy lasting anywhere from 12 sessions to over two years (Friedrich, 1990; Jones, 1986; Madanes, 1990; Mayer, 1983; Trepper & Barrett, 1989). While these children may be involved in therapy for a year or more, it is unclear which type of therapy is most often recommended to alleviate symptomology. Furthermore, there are limited data available on how treament recommendation varies according to the counselor's chosen profession and the child's relationship with the offender. The numbers of victims, along with the required length of treatment and the rising costs of mental health care, require that these areas be examined. 23

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24 This chapter contains a literature review highlighting the theoretical constructs underlying the study and current research in the field. Included is information on the nature and causes of child sexual abuse as well as the particular characteristics found in offenders, families, and child victims. Next, research on the mediating factors and the psychological victim effects following sexual abuse are described. Both the child sexual abuse "Accommodation Syndrome" (Summit, 1983) and Post-Traumatic Stress Disorder (DSM-IV, 1994) in relation to abuse victims are addressed. Also included is a discussion of the social service intervention processes and the prevailing methods for child sexual abuse treatment. In this section, individual, group, and family therapy modalities are illuminated. Finally, an examination of the research on treatment outcome is presented. Theoretical Constructs Underlving the Study Etiology of Abuse American theorists and researchers have attempted to understand the nature and causes of child abuse since the 19th Century (DePanfilis & Salus, 1992). Following this quest for understanding, it was concluded that there is no one cause for sexual abuse and no one victim typology (Rencken, 1996). According to the literature on all forms of abuse and neglect in America, there are four major theories about the etiology of abusive parenting practices (Burgess 8c Conger, 1978; Parke «fe CoUmer, 1975). While these are not specific to sexual abuse, they can be applied to h readily. The first model, the psychiatric approach, focuses exclusively on the personality characteristics of the offender and examines how these contribute to abusive acts (Kempe, 1973; Spinetta & Rigler, 1972). This model has its roots in traditional psychoanalytic

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25 theory. However, when traditional psychoanalysts examined incest, they placed greater emphasis on the child victim and nonoffending parent (i.e., the mother). In fact, it was thought that incestuous abuse was the result of oral deprivation experienced by the child during the preoedipal stage so that the abuse satisfied the child's oral needs while revenging the nonattentive mother (Gordon, 1955; Tompkins, 1940). Furthermore, according to this view, "the daughter incorporates the father's penis as a substitute for the mother's breast, which she has been denied" (Raphling, Carpenter, & Davis, 1967, p. 506). This conceptualization is not accepted widely today. Instead, followers of the modem psychiatric view focus more on the psychopathology and sexual deviance of the offender. In a second approach, the sociological model, the social and environmental contexts which foster abusive patterns, are examined (Burgess & Conger, 1978). According to this view, abuse is the resuh of environmental stressors, especially for parents who lack efficient coping skills (Gelles, 1973; Gil, 1970). This is similar to a behavioral perspective in which specific environmental factors, such as early sexual modeling and spousal nonresponsiveness, are thought to contribute to incestuous abuse (Harbert, Barlow, Hersen, & Austin, 1974). Other behaviorists have postulated that sexual abuse is not a result of individual sexual deviation but rather a product of cultures in which the behavior is accepted (Lukianowicz, 1972). A third model, the social-psychological approach, examines the patterns of interactions among family members in the context of external environmental events or stressors (Burgess & Conger, 1978). In this view, everyday family interactions and

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26 dysfunctional patterns of relating are carefully examined as precursors of abuse (Brant & Tisza, 1978; Meiselman, 1978; Weinberg, 1955). According to Meiselman (1978), a crisis in the family that disrupts the equilibrium provides the impetus for sexual abuse. This crisis may take the form of injury, disease, relational strain, or financial loss (Meiselman, 1978). This theory is supported by Weinberg's (1955) finding that in the year or two before incestuous acts began, a family disruption was noted which left the offender in a state of tension and restlessness. In the fourth approach, feminist family therapists argue that the power structure for the family, set up by society, leads to incestuous abuse (Butler, 1 978). The patriarchal family structure is thought to perpetuate men's dominance over women and children and create the conditions for incest to occur (Rush, 1980). In this sense, fathers abuse their children because they are socialized to use sex as a way to express emotion, obtain power, and feel a sense of adequacy (Butler, 1978; Ward, 1984). The child victim is rendered powerless by society who expects her to love and trust her father (James & MacKinnon, 1990). Similarly, mothers feel that they are supposed to "honor and obey" their husbands at all costs (Butler, 1978). Therefore, feminist family therapists contend that incest becomes representative of an extreme version of the normal sexual arrangements in American society (Rush, 1980). As described above, a variety of factors may predispose or cause abuse. Most likely, a combination of these factors motivates an offender to abuse a child. Therefore, children are at risk for abuse as a result of the patterns of interaction between themselves, the offender, their families, and the environment (DePanfilis & Salus, 1992; Holder &

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27 Corey, 1987). While there is no one etiological explanation for abuse, researchers have validated the presence of common characteristics for offenders, families, and child victims (Finkelhor, 1984, 1986; Friedrich, 1990; Groth, 1979; Mayer, 1983; Mrazek, Lynch, & Bentovim, 1983; Summit, 1983). These characteristics, or vulnerability factors, are addressed following. Offender Characteristics Finkelhor (1984) described four preconditions which are specific to the offender and must be overcome in order for sexual abuse to occur. These include (a) the motivation to abuse, (b) overcoming internal inhibitors, (c) overcoming external inhibitors, and (d) overcoming resistance by the child (Finkelhor, 1984). As delineated above, initially the offender must have the motivation to abuse a child. This may be manifest in an arousal to children, stress, and/or the need for mastery and control (Groth, 1979). Sexual offenders are identified as either "fixated" or "reactive" based on their individual motivations. Groth (1979) described the "fixated offender" as having deviant sexual patterns manifest in sexual arousal to children rather than aduhs. On the other hand, the "reactive offender" responds to nonsexual problems and stress by sexually abusing a child which provides the offender with a sense of power and mastery (Groth, 1979). While both types of offenders have a predisposed arousal to children, most sexual offenders abuse children to serve emotional needs, especially the need for power and control, rather than for sexual gratification (Sgroi, 1982). Often these motivational patterns are learned behaviors supported by the offender's family history and early modeling.

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With the second precondition to abuse, the offender must overcome internal inhibitors. Internal inhibitors activate both conscious and subconscious processes that attempt to convince the offender not to proceed (Finkelhor, 1984). If the offender is unable to empathize with the child and suppresses any internal inhibitors, then he finds ways to rationalize the behavior of engaging the child's trust and eventually abuse occurs (Groth, 1979). To rationalize this behavior, the offender may adhere to stereotyped beliefs about sex roles and power over children. According to Finkelhor (1986), if the first two preconditions are not present (i.e., the offender is not motivated or inhibits desires to abuse), then the two remaining factors are not sufficient for sexual abuse to occur. Once the first two preconditions are met, then the offender must overcome external inhibitors. Usually, these include the child's mother and other caretakers as well as social and legal agencies who are commissioned to protect children (Larson & Maddock, 1986). Friedrich (1990) contended that the degree to which the family members are able to protect and care for a child is the degree to which a child is safe from abuse. Likewise, a physically or emotionally absent and overwhelmed parent allows an offender greater access to a child. In fact, Rhinehart (1961) found that a high-risk time for incest is when a mother has gone to the hospital to give birth to another child. Therefore, if a motivated offender has unsupervised access to a child and that child has a limited support network, the opportunity for sexual abuse is increased greatly (Finkelhor, 1984). Finally, the offender must overcome the resistance of the child. If the primary caretakers discuss sexual abuse and prevention openly while monitoring the child's safety

PAGE 39

at all times, there is a decreased likelihood for abuse (Horton, Johnson, Roundy, & Williams, 1990). Similarly, a child who is aware of the warning signs and feels supported by caretakers is more likely to seek help before abuse occurs or to disclose immediately (Finkelhor, 1984). Often times, victims do not disclose because of threats, fear, intense feelings of guilt, trust in the offender, dependence on the offender, and/or feeling powerless (Russell, 1986). Therefore, if the offender has the motivation and opportunity to abuse and the child maintains the "secret," then the sexual abuse will continue over a period of time (Fmkelhor, 1984). While these four preconditions are necessary for abuse to occur, other psychosocial elements contribute to abusive patterns including cultural, familial, environmental, and personality factors (Faller, 1993). These contributing factors alone do not cause abuse, but if they are present, they increase the risk for abuse to occur (Faller, 1993). According to Finkelhor (1984), there are four basic ingredients to the making of a child molester that correspond with the preconditions for abuse. These are found in (a) the offender's need to relate to someone on his emotional level identified as a need for emotional congruence, (b) a predisposed sexual arousal to children, (c) the inability to satisfy sexual or emotional needs in an appropriate manner, and (d) the ability to overcome social nonns that would prohibit sexual activity with children (Finkelhor, 1984). These ingredients are influenced by male cultural socialization factors including (a) a tendency for males to be raised to sexualize their emotions such that sex becomes a means to meet their emotional needs, (b) a tendency for men to be attracted to younger, smaller, and less powerful partners as portrayed in the media, and (c) a tendency for men

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30 to be exempt from primary child care concerns so that victim empathy is reduced and the abusive behavior is rationalized (e.g., "she needed to learn about sex anyway, why not from me?") (Finkelhor, 1984). While the above factors contribute to abusive patterns, the most common characteristics for offenders are (a) poor impulse control, (b) low frustration tolerance, (c) sexual and/or emotional immaturity, (d) an absence or a questionable degree of guilt or remorse, (e) substance abuse, (f) frustrated dependency needs, (g) passive-aggressive expression of affect, (h) low ego strength and low self-esteem, (i) powerlessness and passivity outside the home, (j) rationalization and denial of acts (i.e., projection of blame), and (k) manipulative behavior patterns (Mayer, 1983, p. 29). Offenders commonly report feelings of hostility, isolation, loneliness, anxiety, depression, apathy, rigidity, fear of rejection, narcissism, distrustfulness, and/or neuroticism (DePanfilis & Salus, 1992; Holder & Mohr, 1 980). While many offenders report having experienced emotional and behavioral difficulties, severe mental illness is not apparent in most cases (DePanfilis & Salus, 1992; Garbarino, 1985). However, the most common diagnosis for sexual offenders is narcissistic personality disorder (Leahy, 1991). According to Gentry (1978), the offender's poor self-concept and limited sexual identification are important predictors of abuse. "If the individual's negative self-concept sustains even one ego-deflating crisis, he or she may seek approval through sexual means from someone who cares, even a child" (Gentry, 1978, p. 362). This "ego-deflating" crisis may surface from a variety of stressors. In fact, 48% of the offenders in one study reported marital problems; 47% reported sexual problems; and reported 22%

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31 unemployment problems (Bentovim, Boston, & Van Elburg, 1987). The high incidence of reported marital problems is significant because some experts (e.g., Browning & Boatman, 1977; Gentry, 1978) contend that marital dysfunction is at the root of incestuous abuse. In addition, the risks for abuse are increased if the offender experiences any conditions that reduce his impulse control, including substance use/abuse or any psychopathological disorders (Brant & Tisza, 1978; Browning & Boatman, 1977; Dixon & Jenkins, 1981; Meiselman, 1978). In many cases, alcohol is used to suppress the offender's internal inhibitors. In fact, Crewdson (1988) found that nearly 70% of incest victims reported that their father was drinking at the time of their first abusive experience. In addition to crises in the offender's current family, there are significant aspects of his family of origin that contribute to this proclivity for sexual abuse. Often times, parents who (sexually, physically, and/or emotionally) abuse their children report experiencing similar abuse or neglect in their own childhood (DePanfilis & Salus, 1992; Garbarino, 1985). Previously, experts believed that 80% of all pedophiles were themselves molested as children (Groth, 1979). However, other research has surfaced discounting the idea that sexual abuse encourages child victims to become adult offenders. Researchers have since documented the fact that false claims about bemg victimized as a child are common and enable offenders to relieve themselves from the responsibility for the abuse (Goldstein, Keller & Erne, 1985). With the use of polygraph testing, data indicate that there is actually only a 30% rate of intergenerational abuse (Groth, 1 979; Goldstein, Keller, & Erne, 1985). If this finding is accurate, then over two-thirds of all victims will not re-offend in adulthood.

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32 While some data indicate that sexual abuse does not always lead victims to offend fiiture generations of children, researchers have found that particular "family styles" can lead to vulnerability for abuse (Trepper & Barrett, 1989). A "family style" contains generational patterns for relating to and parenting children. As such, a man who was exposed to rigid sexual guidelines and stereotypes, the use of power and control for selfworth, and the use of sex for affection is more prone to become sexually abusive (Trepper & Barrett, 1989). In addition, an adult who did not have his own developmental needs met as a child may find it difficult to understand and meet the needs of children (DePanfilis & Salus, 1992; Maslow, 1970). Family Vulnerability Factors Along with the characteristics of the offender and the preconditions for abuse, there are family vulnerability factors. These vulnerability factors are cumulative, and with each additional factor, the risk for child sexual abuse increases between 1 0% and 20% (Friedrich, 1990). The specific risk factors for incestuous abuse include (a) the presence of a stepfather, (b) a mother or primary caretaker who is passive and emofionally or physically absent due to work or illness, (c) an acceptance of male supremacy and power, (d) a dominant male figure in the family who feels a sense of entitlement over the children, (e) a sexually repressed family environment, (f) an unsatisfactory or dysfunctional marital relationship, (g) a past history of incestuous abuse in either parent's family of origin, (h) social isolation for the family and the child, (i) chronic stress in the family, (j) a father or father-figure who performed little nurturing to the child during the growth process, (k) strict role stereotypes and a rigid adherence to

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33 traditional sexual attitudes, (1) living in a community that tacitly accepts incest or other forms of child abuse, (m) secrecy in family communication that is modeled, tolerated, and encouraged, and (n) a child who is particularly needy of affection, has strained relations with the mother, or is estranged from siblings (Brant & Tisza, 1978; Dixon & Jenkins, 1981; Finkelhor, 1984, 1986; Finkelhor, Hotaling, Lewis, & Smith, 1990; Friedrich, 1990; Gentry, 1978; Justice & Justice, 1979; Meiselman, 1978; Parker & Parker, 1986; Trepper & Barrett, 1989). With incestuous abuse, the family as a whole presents a dysfunctional closed system which perpetuates member dependence and possibly cyclical abuse patterns (Sgroi, 1982). Characteristics of the incestuous family have been found to include (a) the blurring of generational boundaries, (b) family isolation or rigid boundaries with those outside the family, (c) role imbalances and rigidly assigned or inappropriate family roles, (d) an imbalance of power contributing to a dysfunctional marital dyad and/or a fragmented or nonexistent parental dyad, (e) a deteriorated marital sexual relationship, (f) strained or disturbed sibling relationships, (g) difficulties with cohesion marked by excessive separateness or connectedness within the family, (h) muffled, distorted, or ignored affect, (i) the predominance of secrets and denial, 0) difficulties with trust and intimacy, (k) problems with dependency, and (1) difficulties with effective negotiation and conflict resolution (Friedrich, 1990; Larson & Maddock, 1986). The presence of these family vulnerability factors is supported by research with both child victims and adult survivors of sexual abuse. For example, when adult survivors of incest (N = 20) were asked to describe their family history, most often they reported

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34 family secrecy and the blurring of generational boundaries (Justice & Justice, 1979). In addition, these survivors reported that their fathers were overpossessive, jealous of any peer relationships and dating, and showed favoritism to the victim over other siblings (Justice & Justice, 1979). In a larger study of sexually abused children in London (N = 41), 63% of the nonoffending mothers reported marital problems; 32% reported sexual problems; and 34% reported that the offender was violent towards them in the past (Bentovim, Boston, & Van Elburg, 1987). Furthermore, 14% of these mothers had a recent or long-term physical illness, and another 14% had a previously diagnosed psychiatric disorder (Bentovim, Boston, & Van Elburg, 1987). Similarly, other researchers found that 56% of abusive families in London were severely disturbed, with 34% reporting marital dysfunction, 14% reporting parental mental illness, \3% unemployment, and 10% alcoholism (Mrazek, Lynch, & Bentovim, 1983). According to the literature, the overall family atmosphere and the level of systemic distress are related to child sexual abuse. In fact, in a study comparing young, sexually abused children (N = 37) with nonabused controls (N = 130), the abusive families displayed higher levels and greater rates of stress than the nonabusive families (Gale et al., 1988). In another study with adult survivors (N = 2,626), it was found that "growing up in an unhappy family appeared to be the most powerful risk factor for abuse" (Finkelhor et al., 1990, p. 24). In fact, individuals who described their families as "unhappy" had a 50% higher risk for abuse (Finkelhor et al., 1990). Most likely, this is related to the fact that an offender is more apt to overcome the resistance of the child if her home life is not supportive (Finkelhor, 1984).

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35 If the sexual abuse is perpetrated by a father or a father-figure, there are commonly found characteristics for the nonoffending parent as well. These characteristics include (a) poor self-image, (b) feelings of inadequacy as a wife and mother; (c) strong dependency needs, (d) the inability to take responsibility and cope with everyday problems, (e) passivity, (f) emotional immaturity, (g) sexual dysfunction, (h) denial as a defense mechanism, and (i) guilt (Mayer, 1983, p. 30). The combination of these factors, along with the offender's motivation to abuse and the child's natural vulnerability, engender incestuous abuse. In contrast to the family and individual vulnerability factors, there are protective factors which prevent sexual abuse. These protective factors are found in the child's disposition and self-esteem, healthy external support systems, and family cohesion and warmth (Ratnor, 1990). Other findings indicate that adequate social and cognitive skills, an internal locus of control, and at least one positive adult identification figure decreases the likelihood of child sexual abuse (Garmezy, 1983). The Child Sexual Abuse Victim It is difficult to describe a portrait of the typical child sexual abuse victim due to variations in age, personality, family experience, coping skills, and preabuse knowledge and ftinctioning (Mayer, 1983). While a typical victim portrait is not defined clearly in the literature. Summit (1983) identified the presence of an "Accommodation Syndrome" in many female victims of sexual abuse. According to Summit (1983), a child victim adopts and acquiesces to the characteristics of this syndrome for protection and immediate survival. The five conditions of the Accommodation Syndrome are (a) secrecy,

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36 (b) helplessness, (c) entrapment and accommodation, (d) delayed, conflicted and unconvincing disclosure, and (e) retraction (Summit, 1983). The first two variables of this syndrome, secrecy and helplessness, are necessary components of child sexual abuse. According to Summit (1983), when an adult sexually abuses a child, "the child has no choice but to submit quietly and keep the secret" (p. 193). The offender uses promises, bribes, and threats of harm to coerce the child and prevent disclosures (Mayer, 1985). In fact, in one study of sexually abuse adolescents, 100% of the victims reported that threats were made by their offenders (Hart, Mader, Griffith, & deMendonca, 1988). Feelings of helplessness are fostered by these threats and the realization that the child cannot match the offender's power. If the abuse continues, eventually the child learns to accommodate in order to survive. Accommodation techniques include denial, martyrdom, splitting of reality, altered consciousness, dissociation, delinquency, sociopathy, projection of rage, and selfmutilation (Summit, 1983). In time, some child victims tentatively reveal aspects of the abuse to a trusted person. Usually, this is not the child's mother, but it may be a friend, teacher, or other relative (Mayer, 1983; Russell, 1983). "Disclosure is an outgrowth either of overwhelming family conflict, incidental discovery by a third party, or sensitive outreach and community education by child protective agencies" (Summit, 1983. p. 186). However, due to the child's fear and guilt, usually she does not intend to disclose the abuse fully. In fact, most child victims never disclose sexual abuse or disclose only later in adulthood to members outside the immediate family (Herman, 1981; Russell, 1983;

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37 Summit, 1983). In one study of female adult survivors (N = 1,481), 33% reported that they had never disclosed the abuse to anyone prior to the study (Finkelhor et al., 1990). Similarly, in another study, 42% of the respondents told someone about the abuse within a year; 21% told someone at some point after a year; and 36% never told anyone (Crewdson, 1988). On the other hand, even when abuse is disclosed or discovered, it is not always reported to the local child protection agencies. Russell (1983) found that of the mothers who were told or discovered the abuse of their child (which constituted a minority of mothers in these cases), few of them reported it to outside agencies. Following a delayed, conflicted, or tentative disclosure, often there is a retraction of allegations (Summh, 1983). According to Summit (1983), whatever a child victim discloses, she is likely to retract if she feels a strong sense of guilt or responsibility for maintaining the family stability. Similarly, many children retract their statements because the consequences of disclosure seem worse than enduring further abuse (Gentry, 1978). This final aspect of the Accommodation Syndrome renders the child at risk for further maltreatment and consequently more severe psychological disturbance. As described, the offender's predisposition to abuse, based on his personality and family history, along with specific victim and family characteristics, lead to a greater probability for abuse. When sexual abuse occurs, these individual, interactional, and environmental factors impact the victim's experience and the resultant psychological effects. The extent of psychological harm and the research on the mediating factors are discussed following.

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38 Individual Effects of Child Sexual Abuse Is Sexual Abuse Detrimental ? Professionals in the field differ in their views about the effects of sexual abuse. Some believe that sexual abuse has only minimal (Gagnon, 1965; Henderson, 1983) or no effects for the child victim (Lempp, 1978). Yet, other experts believe that sexual abuse is extremely detrimental to child development, evoking adverse emotional and behavioral symptomology (Finch, 1982; Finkelhor, 1979; Haugaard & Reppucci, 1988; Koch, 1980). In a study of 200 child psychiatrists, a majority believed that sexually abused children experienced psychiatric difficulties (LaBarbera, Martin, & Dozier, 1980). However, it is important to note that the psychiatrists who had the most experience in the field were the least likely to support this finding (LaBarbera, Martin, & Dozier, 1980). This seems reminiscent of Sgroi's (1975) statement regarding sexual abuse as the "last frontier" in child abuse: Recognition of sexual molestation in a child is entirely dependent on the individual's inherent willingness to entertain the possibility that the condition may exist. Unfortunately, willingness to consider the diagnosis of suspected child sexual molestation frequently seems to vary in inverse proportion to the individual's level of training. That is, the more advanced the training of some, the less willing they are to suspect molestation, (p. 21) Despite this debate, there is evidence of a range of distress and dysfunction for child sexual abuse victims. In Russell's (1984b) study of aduh survivors, 53% of the subjects reported being affected by the abuse at least moderately. With child victims, the results from two studies indicate that between 33%-50% of abused children exhibit significant behavioral problems following disclosures of sexual abuse (Friedrich, Urquiza,

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39 & Beilke, 1986; Tufts New England Medical Center, 1984). In another study comparing young sexually abused children (under age 7, N = 37) with nonabused controls (N =130), only two of the sexually abused children (5%) were thought to have no demonstrated emotional or behavioral difficulties (Gale et al., 1988). Consequently, 95% of the sexually abused children displayed at least one symptom, and 61% demonstrated at least three symptomatic effects (Gale et al., 1988). Another study by Einbender and Friedrich (1989) compared 45 sexually abused females (aged 6-14) with nonabused controls matched for age, race, family income, and family constellation. In this study, 95% of the abused children received prior therapy compared to only 4% of the nonabused controls (Einbender & Friedrich, 1989). The researchers foimd that the abused sample of children reported more stressful past histories and demonstrated more behavioral problems, lower cognitive abilities, and lower school achievement (Einbender & Friedrich, 1989). Other researchers found that sexually abused children demonstrated more behavioral problems than nonabused children and yet less severe psychopathology than nonabused psychiatric outpatient samples (Cohen & Mannarino, 1988; Friedrich, Urquiza, & Beilke, 1986; Tufts New England Medical Center, 1984). However, it is important to note that, overall, the abused children exhibited more sexual problems than the clinical comparison groups (Friedrich, Urquiza, & Beilke, 1986). From the research described, it is clear that there are significant differences found between sexually abused and nonabused controls. While numerous studies document the presence of psychological distress following sexual abuse, the nature of this distress and

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40 any resultant dysfunction is distinct and variable (Burgess, Hartman, McCausland, & Powers, 1978; Finkelhor & Browne, 1986). This finding may be the result of individual differences before the abuse or the result of research studies which utilize varied instruments and differing methodologies. Because none of the studies described above utilized random sampling techniques, the results should be interpreted with caution. In addition to sampling problems, the child sexual abuse research is limited by other methodological and empirical deficiencies. Moderating Variables Following a traumatic event, the psychological effects are influenced by a variety of factors including the victim's pretrauma history, the nature of the trauma, the broad socio-cultural and political contexts, and the interpersonal and institutional response the victim receives (Figley, 1985; Lebowitz, Harvey, & Herman, 1993). According to an ecological theory of trauma, the particular aspects of the person, event, and the environment must be examined; these variables interact and influence how individual victims respond to traumatic situations (Lebowitz, Harvey, & Herman, 1993). Similarly, for child sexual abuse, a victim's response is dependent upon the interactions among several variables. Of particular importance are (a) the offender's relationship with the child and the child's feelings toward the offender, (b) the behavioral aspects of the abuse (i.e., the type of sexual contact, degree of force, and the duration of the abuse), (c) the victim's age and psychosocial development, (d) the reactions of significant others following disclosure and whether the child is believed and supported, and (e) the extent to which the child is involved in legal proceedings following disclosure

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41 (Basta & Peterson, 1990; Benedek & Schetky, 1986; Downs, 1993; Goodman, 1984; Groth, 1978; Katz & Mazur, 1979; MacFarlane, 1978; Mrazek 8c Mrazek, 1981). "Taken together, the strength and interaction of these variables must be considered in order to evaluate the degree of harm to the child and the subsequent behavioral, emotional, and sexual problems which may resuU" (Basta & Peterson, 1990, p. 556). The Victim-Offender Relationship Several researchers have found that the child's relationship with the offender has a significant impact on the resulting symptomology (Adams-Tucker, 1982; Finkelhor, 1986; Russell, 1984b). In most sexual abuse cases, the perpetrator is a known and trusted male adult who may be a family member (Conte & Berliner, 1981b; Finkelhor, 1984). In fact, 98% of the offenders of female child sexual abuse are male (Gelinas, 1983; Finkelhor et al., 1990; National Center on Child Abuse and Neglect, 1978), and in 80% of the cases, the offender has some preexisting relationship with the child (Peters, 1976). Because 60%-70% of all child sexual abuse occurs within the family, parents and parent surrogates constitute a substantial portion of offenders (Burgess et al., 1978; Peters. 1976). According to Russell (1984), a female child who is raised by a stepfather is 6 times more likely to be sexually abused by him than a child who is raised by her biological father. In one study of young sexually abused children under age 7 (N = 37), 50% of the perpetrators were related to the child and 28% were biological fathers (Gale et al., 1988). Similarly, Adams-Tucker (1982) found that 50% of the sexually abused children in an outpatient clinic (aged 2-15, N = 28) were abused by fathers or father-figures.

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42 In most cases, sexual abuse is not a violent, one-time attack but rather progresses through a persuasive seduction process over time (Brownmiller, 1975; Horowitz, 1983; Morrow & Sorell, 1989; Vander Mey & Neff, 1982). If the offender was a once loved and trusted adult in the child's life, the child may have difficulty defining who is to blame, and she may experience more self-blame. Similarly, adult rape victims were found to be less symptomatic when the rape was less forceful and the responsibility more ambiguous (e.g., date rape) (Becker, Skinner, Abel, & Treacy, 1982). The effects of abuse appear to increase when the offender is an adult who is close to the child. For example, Finkelhor (1986) found that victims who were abused by adult offenders suffered more long-term traumatic effects than victims who were abused by adolescents. Children abused by their fathers or father-figures are especially at risk for traumatic effects due to family loyalty issues and feelings of betrayal following disclosures (Adam-Tucker, 1982; Burgess, Holstrom, & McCausland, 1978; Everson, Hunter, Runyan, Edelsohn, & Coulter, 1989; Herman, Russell, & Trocki, 1986; Summit, 1983). Adams-Tucker (1982) found that children who were abused by father figures had more severe diagnoses, including symptoms of depression and withdrawal. In fact, 50% of the children abused by their natural fathers were placed in an inpatient facility for severe maladjustment problems (Adams-Tucker, 1982). In this study, the emotional disturbances were more pronounced when (a) the offender was a father-figure, (b) the child was abused by more than one person, and (c) the abuse began at an early age and continued over a long period of time (Adams-Tucker, 1982).

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43 From a review of the research, it appears that the child's relationship with the offender correlates with the severity and duration of the abuse which in turn affects victim symptomology (Phelan, 1986). Father-daughter cases tend to involve more intrusive and violating acts over longer durations, rendering the abuse more traumatic for the child (Finkelhor, 1979; Phelan, 1986). In a study of 102 families referred to an outpatient clinic for treatment, 54% of the cases of abuse by a natural father involved full intercourse in comparison to 27% of the stepfather abuse cases (Phelan, 1986). Furthermore, in 80% of the biological father cases, the abuse continued for over a year, while 64% of the stepfather cases lasted over a year (Phelan, 1986). On the other hand, the frequency of the abuse did not appear to be affected significantly by these relational distinctions (father vs. stepfather). For example, in 66% of the father cases and 71% of the stepfather cases, the abuse occurred from once a week to more than once a month (Phelan, 1986). Behavioral Aspects of the Abuse In addition to the relational factors, victim outcome is affected by particular behavioral aspects of the abuse. More specifically, the type of abuse, the degree of force, and the duration are shown to impact the victim's experience. According to Morrow and Sorell's study (1989) of 101 female adolescent incest victims, the severity of the abusive acts (ranging from exposure to intercourse) was the "single most powerful predictor of distress levels" (p. 677). In fact, "greater severity of abuse was associated with lower self-esteem, greater depression, and a higher frequency of negative behaviors," including antisocial and self-injurious behaviors (Morrow & Sorell, 1989, p. 681). Similarly, others

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44 have found that actual vaginal penetration was associated with more distressing and dysfunctional traumatic symptomology than with other forms of abuse (Friedrich, Urquiza, & Beilke, 1986; Russell, 1984a; 1984b; 1986). When the abuse involved intercourse and the child's mother was nonsupportive, the effects on self-esteem were found to be even greater (Morrow & Sorell, 1989). From the available data, anywhere between 32% and 77% of child victims experience penetrating forms of abuse (Gale et al., 1988; Shapiro, Leifer, Martone, & Kassem, 1990). According to Crewdson (1988), 55% of abuse cases involve intercourse; 36% fondling; 7% exhibitionism; and 1% sodomy. In another study (N = 1 12, mean age=10 years), 28% of the abused children experienced vaginal or anal intercourse, and 38% experienced other forms of penetrating abuse, including oral-genital contact or object penetration (Gomes-Schwartz, Horowitz, & Sauzier, 1985). In a third study of sexually abused children (N = 37, aged 0-7 years), 68% of the cases involved molestation (fondling or exposure), and 32% penetration (26% vaginal penetration, 3% sodomy, 3% oral-genital contact) (Gale et al., 1988). In a large study of female adult survivors of childhood sexual abuse (N = 1,481), 49% of the respondents said that their abuse involved either attempted or actual intercourse (Finkelhor et al, 1990). The highest rate of penetrating abuse was found in a study of 53 AfricanAmerican sexually abused girls (aged 5-16) in which 77% experienced some form of penile penetration (Shapiro et al., 1990). Most likely, these results vary due to differences in each participant's willingness to report on these severe sexual acts. Most child victims disclose sexual abuse in stages, saving the "worst" for last, and full disclosure occurs only in the context of a trusting relationship

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45 (Mayer, 1983). The development of a trusting relationship that endures over time is not possible in most research methodologies. Along with the type of abuse, the degree of force has been shown to have an impact on the victim's psychological distress. Nearly half of all victims report that the abuse was accompanied by force or coercion (Finkelhor, 1979; Russell, 1986). Finkelhor (1979) found that abused children exhibited greater traumatic reactions with increased force. Others have found that trauma was increased when penetrating acts, aggressiveness, and physical injury were combined (Elwell & Ephross, 1987; Friedrich & Luecke, 1988). In a study by Cohen and Mannarino (1988) (N = 24), abused children who experienced physical force or vaginal penetration demonstrated higher scores for aggressive behavior when compared to other victim control groups. The effects of the sexual abuse duration and frequency are inconclusive. Some research data suggest that these variables affect victim outcome greatly while other suggest that these variables are irrelevant (Finkelhor «fe Browne, 1986; Morrow & Sorell, 1989; Tufts New England Medical Center, 1984). In a study of AfricanAmerican female victims (N = 53) aged 5-16, the median duration for the abuse was 5 months, and 53% were abused at least once every 2 weeks or more (Shapiro et al., 1990). Russell (1988) found that 73% of adult survivors labeled their abuse as "extremely traumatic" when it lasted more than 5 years in comparison to 62% when the abuse lasted 1 week to 5 years, and 46% when the abuse occurred one time. Others have found greater traumatic reactions with longer durations when the offender was closely related to the child (Burgess et al., 1978).

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46 In another study, however, the duration and frequency of abuse were not related to victim distress (Morrow & Sorell, 1989). Yet, the duration and the frequency of the abuse were positively related to the severity of the abuse which has been found to affect victim distress significantly (Cohen & Mannarino, 1988; Morrow & Sorell, 1989). In many cases, sexual abuse progresses along a continuum of acts beginning with fondling and leading to actual intercourse (Groth, 1979). Therefore, there is an increased risk for the abuse to proceed to intercourse if the offender has regular contact with the victim and the abuse continues over a period of time (Finkelhor, 1979). In one study, 72% of the offenders were living in the child's home at the time of the abuse (Shapiro et al., 1990). This may account for why 77% of the victims in this study experienced penetrating abuse (Shapiro et al., 1990). In summary, it may be concluded that the frequency and duration are significant to an extent because they are related to the severity of the abuse (Morrow & Sorell, 1989). Victim Characteristics The most significant moderating variable for the child victim is the age at which the abuse began (Jackson, Calhoun, Amick, Maddever, & Habif, 1990). According to a Los Angeles Times poll (1985), 14% of victims were first abused between 0-6 years old; 61% between 7-12; and 25% between 13-18 (Timnick, 1985). Accordingly, the average age during which a child is first abused is 10 (Crewdson, 1988; Finkelhor, 1986; Finkelhor et al., 1990). While the impact of child sexual abuse is thought to vary with the stage of development during which the abuse occurs (Jackson et al., 1990), there is disagreement about which stage has the most deleterious effects (Downs, 1993; Gomes-Schwartz,

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7 47 Horowitz, 8c Cardarelli, 1990). In fact, some studies have found that younger children show greater symptomatic effects (Meiselman, 1978; Wolfe, Gentile, & Wolfe, 1989) while others demonstrate that older children are affected more deeply (Conte & Schuerman, 1987; Gomes-Schwartz, Horowitz, & Sauzier, 1985). Young children may experience more adverse effects because early abuse disrupts a greater number of developmental stages (Downs, 1993). Some researchers have found that a young age at the time of the abuse was predictive of serious long-term psychological disturbance (Meiselman, 1978; Wolfe, Gentile, & Wolfe, 1989). Younger victims were more prone to have difficulties with self-esteem, intimacy, and adult heterosexual relationships (Courtois, 1979). Coping with the traumatic effects may be more difficult for these young victims because they have fewer cognitive and language skills with which to understand the abuse and communicate their feelings. Likewise, younger victims may have difficulties negotiating sex-role expectations as adults because they were introduced to adult sexual behavior at such an early stage in their development (Morrow & Sorell, 1989; Simmons, Rosenberg, & Rosenberg, 1973). On the other hand, some adults who were abused as young children may be less symptomatic because they have had more time to recover and heal (Friedrich, 1 988). Gomes-Schwartz, Horowitz, and Sauzier (1985) found that sexually abused school-aged children exhibited more clinically significant symptomology when compared to preschool victims. In this study, 40% of the school-aged victims had disturbances in one or more areas of functioning (Gomes-Schwartz, Horowitz, & Sauzier, 1985). School-aged victims may have more pronounced traumatic reactions following sexual

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48 abuse because they are more likely to understand the interpersonal and psychological ramifications (Gomes-Schwartz, Horowitz, & Cardarelli, 1990). In addition, school-aged children may experience more severe abuse for longer durations because they are not monitored as closely as preschool children or infants. A third age grouping encompasses adolescents. According to Conte and Schuerman (1987), the older the child is when first abused, the greater the risks for depression and other negative effects. Some experts contend that adolescents are affected severely by sexual abuse due to their crucial stage of development (Conte & Schuerman, 1987). During adolescence, individuals attempt to form their self-concepts into a coherent psychosocial identity (Erickson, 1968). When sexual abuse occurs, this developmental process is tarnished by feelings of stigmatization, guilt, shame, and negative self-concept (Downs, 1993). Adolescents may have more difficulties openly discussing and resolving the abuse due to this intense shame and guilt. As a result, these victims may withdraw socially and may never develop healthy self-concepts (Conte & Schuerman, 1987). In fact, 36% of sexually abused alcoholic women and 33% of nonalcoholic survivors reported negative feelings about self as a long-term consequence of the abuse (Downs, 1993). In addition to difficulties with self-concept, other researchers have found a positive relationship between age and acting out or self-injurious behaviors (Morrow & Sorell, 1989). However, this does not mean that the most harmful effects occur during adolescence. Instead, this finding may be attributed to the fact that older adolescents have more opportunities and more free time to engage in self-destructive, acting-out behaviors (Morrow & Sorell, 1989).

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49 In light of these findings, it appears that with each developmental stage there are deleterious effects. There are no data to support the notion that children at one particular stage are better equipped to cope with sexual abuse than others. According to some experts, regardless of the age at which the abuse first occurs, the behavioral effects change over time, suggesting that development alters the experience and symptomology (Friedrich & Reams, 1987). In addition, "developmental triggers" usually occurring during adolescence or early adulthood may exacerbate distressing symptomology (Downs, 1993). With each new developmental stage and the stressors of emotional growth, previously denied intense emotions may surface (Downs, 1993; Gelinas, 1983). Therefore, treatment efforts should be developmentally focused and victims may need to reenter treatment with each new developmental stage. Family and Environmental Response Most often, disclosures of sexual abuse cause family distress accompanied by chaos, fear, and denial by family members (Everstine & Everstine, 1989; Friedrich & Reams, 1987; Mayer, 1983). Disclosures of incestuous abuse are shown to precipitate family and individual crises, leaving the child victim feeling unprotected, emotionally deprived, and personally weak (Everstine & Everstine, 1989; Simrel, Berh, & Thomas, 1979; Sgroi, 1982; Summit, 1983). The family distress following disclosures may become so overwhelming for the child that it is indistinguishable from distress that is specific to the abuse (Friedrich & Reams, 1987). Researchers investigating the effects of physical abuse found that nonabused children from distressed families had similar levels of behavioral difficulties when compared to children from physically abusive families (Wolfe

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50 & Mosk, 1983). The authors concluded that "disturbances in the child's social and behavioral development may be more a function of family events and interaction patterns than isolated abusive episodes" (Wolfe & Mosk, 1983, p. 707). Similarly, many researchers have found that a sexual abuse victim's view of herself was highly correlated with the responses of others following disclosure (Ageton, 1983; Atkeson, Calhoun, Resick, & Ellis, 1982; Burgess & Holstrom, 1978; Burgess, Holstrom, & McCausland, 1978; Finkelhor, 1984). In particular, the reactions of the offender and the nonoffending parent have been shown to mediate the resultant psychological effects of sexual abuse. For example, Finkelhor and Browne (1986) found that when the offender openly assumed responsibility for the abuse instead of reacting with denial and blame towards the victim, the victim distress was less. Fromuth (1986) found that the symptomology for abused children was lessened when parental supportiveness was controlled. In another study, when mothers reacted to disclosures in a punitive, angry manner, the victims demonstrated more frequent behavioral disturbances in comparison to those children whose mothers provided obvious support (Tufts New England Medical Center, 1984). Other authors found that the degree of maternal support was more predictive of psychological health than the type and length of abuse or the child's relationship with the offender (Everson et al, 1989). This may be due to the fact that children who are rejected or blamed by caretakers are removed from the home more often, thus removing them from school, friends, and family (Everson et al., 1989). Furthermore, when the child is removed from the home, there is an increased likelihood that social services will be

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51 involved and the child may be asked to testify in court (Everson et al., 1989). According to Elwell and Ephross (1987), children are more at risk for traumatic effects when the disclosure process involves (a) reports or involvements of friends and neighbors outside the immediate family, (b) insensitive comments made by these individuals, (c) insensitive and repeated questioning by police and other officials, and (d) the anticipation of court appearances (Elwell & Ephross, 1987). Participation in Legal Hearings Experts estimate that as many as 25,000 families, or 40,000 children, may be exposed to the legal system annually because of sexual abuse (DePanfilis, 1986). In one study, 40% of sexually abusive families were referred for prosecution in court, compared to only 13% of families involved with other forms of child abuse and neglect (Russell & Trainor, 1984). The prosecution of these cases is extremely difficult due to the nature of the crime and the fact that there are seldom other witnesses involved or corroborating physical evidence (Einbender & Friedrich, 1989). Even if the case is referred for prosecution and tried successfully, it does not always mean that the offender will be detained legally. In fact, only 10% to 12% of those offenders convicted of felony child molestation in America are actually imprisoned (DePanfilis, 1986). For those who are sentenced to incarceration, the average length of time spent in prison is 3.5 years (Mayer, 1985). Furthermore, Conte and Berliner (1981a) reported that 14% of the convicted offenders in their study were sentenced to attend sexual rehabilitation programs as opposed to prison. If these findings are generalizable, then almost 75% of sexual

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52 offenders remain in the community. The devastating result is that not only do offenders escape penalty, but they also have the opportunity to continue abusing children. In sexual abuse cases, usually child victims are the only witnesses to the abuse, and it is incumbent upon them to testify if the case proceeds to trial. The American legal system, as it stands today, however, is not attuned to the specific emotional, developmental, and physical needs of the child victim witness (Finkelhor, 1983; Whitcomb, Sharior, & Stellwagon, 1985). In fact, "when a child is called to assist the prosecution of his/her accused assailant, he/she is treated basically the same way as an aduh witness" (Libai, 1969, p. 978). In a criminal case against a sexual offender, the offender has rights guaranteed by the U.S. Constitution, including the right to confront and cross examine all witnesses, the right to a jury trial, strict adherence to the rules of evidence, and the rights to a public and speedy trial (DePanfilis & Salus, 1992). The defendant is presumed innocent until proven guilty, and in these cases, the burden of proof lies with the child victim (Dixon & Jenkins, 1981; Weiss & Berg, 1982). As a resuk, the child's testimony is open to direct challenge and confrontation on the grounds of incompetence or fabrication (Goodman, 1984). The child victim is placed in the middle of conflicting groups, including the offender and his supporters, the family, child protective services, and the courts (Dixon & Jenkins, 1981). Therefore, according to some experts, child victims who testify in court are at risk for increased traumatic effects and psychological distress (Benedek & Schetky, 1986; Dixon & Jenkins, 1981; Gibbens & Prince, 1963; Runyan, Everson, Edelsohn, Hunter, & Coulter, 1988).

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53 There are several systemic factors associated with a child's involvement in the legal system which increase the possibilities for further trauma. First, the legal assembly routinely grants continuances which prolong the process. Typically, 6 months or more elapse between the initial event and the child's court appearance (Goodman, 1984). This means that the child will be preoccupied with the anticipation of legal outcomes which will in turn delay the abuse recovery process. Second, the child is forced to remember the detailed events surrounding her sexual assault and report on this repeatedly to groups of unfamiliar adults. The child may be asked to recount the details of the abuse as many as 12 times to varied professionals at different times during the legal processes (Weiss & Berg, 1982; Whitcomb, Shapiro, & Stellwagon, 1985). Before a trial, the child victim may be interviewed repeatedly by legal, medical, social service, and law enforcement personnel. These interviews interrupt the child's daily functioning and may mean absences from school and other activities. In addition to the abuse factors, when the child eventually takes the stand, she is generally unprepared for what is going to occur (Berstein & Claman, 1986). The responsibilities of the court personnel and the formality of the process may be confusing and overwhelming for the child. For example, judges may seem to loom large, powerful, and threatening. In addition, the child may be confused by the legal language and fearful of attorneys who appear to argue over everything said in court. Common feelings experienced by child witnesses are (a) fears of retaliation by the offender, (b) fears that she will not be believed, (c) feelings as if she is on trial, (d) confusion about the roles of legal personnel, (e) humiliation and embarrassment about the

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54 nature of the questions being asked, and (f) confusion about legal decisions and rulings following a hearing (Benedek & Schetky, 1986). Feelings of guilt and shame may be exacerbated by challenges to her testimony through cross examination, regardless of the verdict (Weiss & Berg, 1982; Whitcomb, Shapiro, & Stellwagon, 1985). Furthermore, the child's anxiety may be amplified by the nonoffending parent's stress and anxiety. While the child wants the abuse to stop, she may feel that testifying means that the fate of the offender is in her hands, and she may begin to empathize with the offender (Dixon & Jenkins, 1981). If the offender is incarcerated, guilt may surface from feelings that the child "sent him to jail." Finally, family members may react with anger and resentment towards the child who they feel "ruined" the family (Dixon & Jenkins, 1981). Under these conditions, it is not surprising that, while on the stand, "some children freeze and are unable to remember events that they previously recalled in great detail; some children cry or are visibly shaken; and under the stress of cross examination, some children recant their previous testimony" (Benedek 8c Schetky, 1986, p. 1227). Gibbens and Prince (1963) found that child sexual abuse victims who were involved in legal proceedings experienced greater trauma than child victims who did not participate in court. In this study, however, it is likely that the sample of cases was severe enough to warrant prosecution and the children were most likely unprepared emotionally and intellectually for their court appearances (Gibbens & Prince, 1963). In another study comparing sexually abused children who were involved in court proceedings with controls, it also was found that children who participated in court demonstrated more adverse effects (Runyan et al., 1988). In particular, the researchers

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55 found that the children who were not involved in court proceedings (N = 33) improved 30% over a 5-month period, and, in comparison, only 17% of the children waiting for court proceedings demonstrated improvement in symptomology (Runyan et al., 1988). Of the children who had actually testified in court (N = 12), 42% showed an improvement on anxiety subscales, and 1 7% demonstrated overall improvement (Runyan et al., 1988). In this study, the court delays which hindered the resolution of the legal proceedings seemed to affect victim outcome greatly (Runyan et al., 1988). While some researchers have found that court involvement was traumatic, others have found that testifying in court was therapeutic for child victims (Berstein, Claman, Harris, & Samson, 1982; Whitcomb, Shapiro, 8c Stellwagon, 1985). For some victims, participating in court can validate the child's credibility, encourage self-mastery, and confirm her sense of justice. The child may feel supported in understanding who was wronged and who was to blame for the wrongdoing (Mayer, 1985). In addition, the child can benefit from the experience of testifying in court as she learns self-assertion and finds a constructive means for expressing her anger about the abuse. In this sense, the child is empowered by her testimony which serves to protect other potential victims and may provide the impetus for the defendant to seek help (Benedek & Schetky, 1986). According to Berstein et al. (1982), children who experience court preparation and appropriate legal support are able to testify without experiencing undue stress or negative psychological effects. In summary, researchers have found that specific moderating variables affect victim outcome significantly. Of particular importance are the offender's relationship

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56 with the child, the behavioral aspects of the abuse, the child's age, the family reactions to disclosure, and the child's involvement in legal proceedings. More deleterious effects were found when a young child experienced penetrating abuse by a father-figure over a long duration (Haugaard & Reppucci, 1988). In addition, if family members were nonsupportive and the child anticipated legal testimony without preparation, further damaging effects were observed (Benedek & Schetky, 1986; Berstein et al., 1982; Everson et al., 1989; Fromuth, 1986; Runyan et al., 1988; Tufts New England Medical Center, 1984). The Psychological Effects of Child Sexual Abuse It appears that a large percentage of victims experience distressing and dysftmctional symptoms following sexual abuse. However, the percentages of children with any particular symptom vary from study to study, and there is no symptom found to be universal to all victims (Faller, 1993). In 60% to 80% of the child sexual abuse cases, the child victim is not injured physically (DeJong, 1985). Usually, child molestation does not produce physical trauma, but other emotional, behavioral, and sexual indicators are evident. Some child and adult victims even develop severe psychopathological responses that continue as long-term consequences of abuse (Browne & Finkelhor, 1986; Gold, 1986; Livingston, 1987). In the following section, research on the emotional, behavioral, sexual, and psychopathological victim reactions is addressed. Emotional Reactions Experts in the field have identified numerous emotional consequences of child sexual abuse, including shame, guilt, fear, depression, low self-esteem, poor social skills.

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57 repressed anger and hostility, impaired ability to trust, anxiety, role confusion and blurred boundaries, pseudomaturity coupled with a failure to accomplish developmental tasks, and difficulties with self-mastery and control (Browne & Finkelhor, 1986; Porter, Blick, & Sgroi, 1982). The first five of these symptoms are common to sexually abused children, and the latter symptoms are considered more specific to incest victims (Alter-Reid, Gibbs, Lachenmeyer, Sigal, & Massoth, 1986; Porter, Blick, & Sgroi, 1982). While there are various symptoms considered to be "common" among child sexual abuse victims, there is no one typical emotional response. According to the Tufts New England Medical Center study (1984), the most prominent symptom for sexually abused children was fear, especially for those children over 6 years old. Other researchers found that feelings of self-blame and guilt are common, especially to victims of incest (Finkelhor, 1984; Selby, Calhoun, Jones, & Matthews, 1980). In addition, a loss of normal developmental capabilities or developmental regression (e.g., enuresis/encopresis) and somatic complaints (e.g., stomachaches, headaches, or loss of appetite) are well documented with this population (Adams-Tucker, 1982; Dixon, Arnold, & Calestro, 1978; Goodwin, Simms, & Bergman, 1979; Peters, 1976). Finally, depression, witiidrawal, and poor self-concept are found consistently in the child sexual abuse literattire as well (Blumberg, 1981; Justice & Justice, 1979; Sgroi, 1982; Yates, 1982). In a recent study, sexually abused children were compared with nonabused controls (total N = 48, aged 6-10 years) using the Children's Personality Questionnaire (1972) (Basta & Peterson, 1990). The authors found that the abused children demonstrated significantly lower scores for ego strength, enthusiasm, social boldness, and

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58 extroversion and elevated scores for anxiety, guilt, and social withdrawal (Basta & Peterson, 1990). In addition, the overall adjustment of the abused children was lower as illustrated by a predominance of somatic concerns, depression, delinquency, deficient social skills, low self-confidence, and unusual thought processes (i.e., elevated psychosis scales) (Basta & Peterson, 1990). It is evident that abused children experience varied emotional effects following sexual abuse. In light of the existing research, Finkelhor (1986) has conceptualized four traumatogenic emotional effects identified as (a) betrayal, (b) stigmatization, (c) powerlessness, and (d) traumatic sexualization. Betraval. "Perhaps the most fundamental damage from sexual abuse is its undermining of trust in those people who are supposed to be protectors and nurturers" (Faller, 1993, p. 19). If the perpetrator was considered close to the victim, a sense of betrayal surfaces (Friedrich & Luecke, 1988). Often, the child is victimized by the adults upon whom she is dependent for physical and emotional survival (Finkelhor, 1984). If the nonoffending parent rejects the child or denies the abuse, the child's sense of betrayal is heightened. These adult caretakers are supposed to nurture, encourage, protect, and care for the child in order to foster healthy development (Gelinas, 1983). As such, "incest is a profound abandonment and betrayal, a travesty of the parental love and care that is a young child's inherent right" (Gelinas, 1983, p. 319). Furthermore, with incest, "there is a profound failure of parental empathy--the centerpiece of a child's emotional well being" (Leahy, 1991, p. 392). As a resuk of this betrayal, victims have difficulty with trust, affective expression, and normal developmental tasks (Finkelhor, 1986; Mayer, 1983).

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59 The child who is reared by an incestuous system has "no perspective, no language and no experience base with which to stand outside these relational and sexual forces and form a healthy personality and set of relational templates uncontaminated by incest" (Gelinas, 1983, p. 319). Therefore, the foundation of a healthy sense of self has been damaged and replaced by various psychopathological defensive structures" (Leahy, 1991, p. 392). The betrayal by the offender and family may be compounded by a perceived betrayal by social service, medical, or legal professionals, especially if traumatic court experiences follow disclosure (Runyan et al, 1988). Some victims respond to these feelings of abandonment and betrayal with intense anger, aggression, and mistrust (Finkelhor, 1986). These feelings may continue into adulthood as evidenced by an avoidance of intimate relationships, manipulation of others, and/or reenacting the trauma through exploitive and damaging adult relationships (Browne & Fmkelhor, 1986; DePanfilis & Salus, 1992; Herman, Russell, & Trocki, 1986). Stismatization. For sexually abused children, a sense of stigmatization has been identified as the "Damaged Goods Syndrome" (Sgroi, 1982). The "Damaged Goods Syndrome" affects the child's sense of self both physically and psychologically (Sgroi, 1982). The child may feel that she is different from her peers or that she is damaged, dirty, or inferior as a result of the abuse. In fact, in one study of female adult survivors, 70% reported that after the abuse they felt "different" from other girls their age (Downs, 1993). Often times, the child victim experiences anger or resentment in feeling that she was robbed of her virginity and defiled by the offender (Gagliano, 1987). For sexual abuse victims, self-destructive behaviors are observed as behavioral manifestations of this

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60 anger (i.e., substance abuse, risk-taking behaviors, self-mutilation, suicidal gestures, and provocative behaviors designed to elicit punishment) (Dixon, Arnold, & Calestro, 1978; Faller, 1993). Moreover, if there is a public report of the abuse or the child expects to testify in court, these feelings of stigmatization may be more pronounced (Runyan et al., 1988). For many sexually abused children, feelings of stigmatization lead to guilt and low self-esteem (Mannarino & Cohen, 1986; Peters, 1974; Tong, Gates, & McDowell, 1987). Following disclosures of abuse, often the child feels guilty for having "caused trouble" for the family and the offender (Finkelhor, 1979). Many victims experience guilt for participating in the acts and/or concealing them, yet they also feel responsible for punishment to the offender (Gagliano, 1987). Guilt may surface as a resuh of direct statements made by the offender, convincing the child that she "wanted" or "brought on" the abuse. In addition, some child victims are told by nonoffending parents that they "should have told sooner," and they may feel guilt about not having done so. This is compounded if there was any aspect of the abuse that was pleasurable in terms of physical arousal or if the child enjoyed the offender's "special" attention (Faller, 1993). The victim's guilt and sense of responsibility are accompanied by feelings of shame and low self-esteem (Finkelhor, 1979). Several research studies have validated the fact that child sexual abuse victims have lower levels of self-esteem when compared to nonabused controls (Steele, 1986; Tong, Gates, & McDowell, 1987). According to Steele (1986), low self-esteem, arises when the child realizes that the abuse will occur regardless of her thoughts and feelings which appear to be of no import to the offender. In one

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61 study, 45 sexually abused children (aged 3-16) were examined over 2 years after the abuse occurred and compared with matched controls (Tong, Gates, & McDowell, 1987). The sexually abused children had significantly lower scores on measures of self-concept when compared to the control groups. In fact, the abused children demonstrated lower scores for all six dimensions on the Piers-Harris Self-Concept Scale (1984) (i.e., behavior, intellectual and school performance, physical appearance and attributes, anxiety, popularity, happiness and satisfaction) (Tong, Gates, & McDowell, 1987). Gverall, the abused group exhibited more aggressive behavior, poor school performance, difficulties with friendships, and lowered self-confidence and self-esteem (Tong, Gates, & McDowell, 1987). As a resuh, "formally maltreated children tend to have in greater or lesser degree an impairment of a cohesive integrated sense of identity" (Steele, 1986, p. 286). Incest survivors appear to be affected greatly by low self-esteem. In fact, in a study of 101 adult survivors of sexual abuse from clinical populations, the authors found that incest victims experienced more negative feelings about themselves when compared to nonincestuous abuse survivors (Hartman, Finn, & Leon, 1987). In addition, adult incest survivors exhibit higher current levels of depression and anxiety (Hartman, Finn, & Leon, 1987) and reduced coping abilities (Steele, 1986). Powerlessness . In addition to a sense of betrayal and stigmatization, sexual abuse victims experience a sense of vuhierability and powerlessness (Finkelhor, 1986). Gften times, these feelings of powerlessness are amplified by social service investigations, legal proceedings, and placement decisions over which the child has no control (Runyan et al..

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62 1988). In addition, researchers have found that when the abuse involved physical force, the child's experience of powerlessness was more pronounced (Friedrich & Luecke, 1988). As a result, victims may experience intense anxiety, manifest in phobias, sleep problems, elimination problems, and/or eating problems (Jones & Emerson, 1994). In some cases, these feelings of powerlessness may be manifest in avoidant behaviors such as dissociation or running away. These anxiety problems and phobias can become debilitating and continue into aduhhood (Faller, 1993). In some cases, this sense of vulnerability leads to revictimization. On the other hand, abused children who are rendered powerless may identify with the offender over time and develop a desire to control or prevail over others (Freund & Kuban, 1994). Often, this desire to control others is manifest in aggressive or exploitive behaviors. As described by Miller, Johnson, and Johnson (1991), To have one's helplessness preyed upon by a person one loves leads to the interlinking of feelings of love and hate. This later becomes a central dynamic in one's aduh object relationships, (p. 160) Traumatic Sexualization. Following child sexual abuse, victims may develop aversive feelings about sex and sexuality; they may overvalue sex; or they may have difficulties with their sexual identities (Finkelhor, 1986). Therefore, the behavioral manifestations of traumatic sexualization range from hypersexual behaviors (i.e., sexual acting out or exaggerated interests in sexuality) to avoidant behaviors or negative sexual identification (Finkelhor, 1986). For many victims, the effects of this traumatic sexualization become more pronounced with insensitive and forcefiil medical examinations or repeated questioning about the abuse (Runyan et al., 1988). The behavioral

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63 manifestations of this phenomenon are described in detail in an upcoming section deUneating the sexuaHzed reactions to abuse. Behavioral Reactions In addition to the emotional reactions following abuse described above, anywhere from 33% to 95% of all victims will exhibit significant behavioral problems (Friedrich, Urquiza, & Beilke, 1986; Gale et al., 1988; Tufts New England Medical Center, 1984). Mannarino and Cohen (1986) found that 69% of the children in their sample (N = 45, aged 3-16) exhibited psychological and behavioral symptoms over an 18-month period as reported by the parent/caretakers. Most often, these symptoms included nightmares, bedwetting, clinging behavior, inappropriate sexual behaviors, anxiety, and sadness (Mannarino & Cohen, 1986). Others have observed dysftinctional behaviors manifest in aggression, irritability, truancy, and/or running away (Adams-Tucker, 1981; Bess & Janssen, 1982; Browne & Finkelhor, 1986; DeFrancis, 1969; DePanfilis & Salus, 1992; Friedrich & Einbender, 1983; Meisehnan, 1978; Orr & Downes, 1985; Tufts New England Medical Center, 1984; Vander Mey & Neff, 1982). In addition, researchers have found that abused children exhibited lower cognitive abilities, lowered school achievement, and poor academic performance when compared with controls (Browning & Boatman, 1977; Einbender & Friedrich, 1989; Elwell & Ephross, 1987; Peters, 1976). More specifically, in a small study of sexually abused children referred within 1 month after disclosure (N = 20, aged 5-12), 90% had some physical symptoms (i.e., sleeping or eating difficulties) and 85% experienced school problems (Elwell & Ephross, 1987).

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64 In a study of 152 female adult survivors of childhood sexual abuse, nearly 100% of the respondents reported feeling "upset" by the abuse at the time it was occurring and 35% described themselves as "extremely upset" (Herman, Russell, & Trocki, 1986). Researchers have found that many sexually abused children demonstrate heightened anxiety or "upsetness" as evidenced by hypervigilence, impaired impulse control, enuresis, eating disorders, sleep disturbances, and socially inappropriate behaviors (Browne & Finkelhor, 1986; DePanfilis & Salus, 1992; Jones & Emerson, 1994; Kiser et al., 1991). In one study (N = 130), 68% of the abused children exhibited anxiety, and 62% had difficulties with compliance (Gale et al., 1988). In addition, over one-third of the abused group demonstrated symptoms of depression, social withdrawal, and inappropriate sexual behavior (Gale et al., 1988). To cope with the anxiety and trauma, some children engage in reenactive behaviors including fantasy or aggressive play, selfdestructive behaviors, and/or delinquency (Kiser et al., 1991). According to Faller (1993), some of these behavioral problems, such as difficulties with sleeping, eating, toileting, and being alone, "may be acute after disclosure but diminish over time and eventually disappear" ( p. 70). On the other hand, some symptoms continue as long-term effects of sexual abuse (i.e., anxiety, social dysfimction, poor self-concept, fear, distrust, sexual difficulties, depression, and/or guih (Browne & Finkelhor, 1986; DePanfilis & Salus, 1992; Finkelhor, 1979; Herman, 1981; Russell, 1986; Summit & Kryso, 1978). In a study of 103 children in an inpatient setting (mean age=10 years old), parents of the sexually abused children reported more symptoms of hypersexuality, fear, mistrust, and withdrawal compared to nonabused patient control groups (Kolko, Moser,

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65 & Weldy, 1988). From an examination of medical records, it was confirmed that the abused children exhibited more sexual behaviors, fears, anxieties, and sadness while in the hospital (Kolko, Moser, & Weldy, 1988). The behaviors associated with fears and anxiety were found to include fears of being alone, discomfort in the bathroom, and hypersensitivity to touch (Kolko, Moser, & Weldy, 1988). The sexualized behaviors included seductive behaviors, discussions of sexual matters, sexualized gestures with objects, sex play, and inappropriate physical touching (Kolko, Moser, & Weldy, 1988). In another study of 72 abused children, 67% demonstrated dysfunctional symptomology including depression, fearfulness, oppositional behavior, and somatic complaints (Rimsza, Berg, & Locke, 1988). In addition, 10% of the participants had run away at least once, and three victims attempted suicide (Rimsza, Berg, & Locke, 1988). This is similar to results found by the Tufts study (1984) in which almost 50% of abused children aged 7-13 had elevated scores for aggression and antisocial behavior as measured by the Louisville Behavior Checklist (Miller, 1981). In a study by Einbender and Friedrich (1989), 45 sexually abused females (aged 6-14) were compared with nonabused matched controls. The abused children were clearly a clinical sample in that 95% received prior therapy compared to only 4% of the nonabused children (Einbender & Friedrich, 1989). Overall, the researchers found that the abused children reported more stressful past histories, demonstrated more behavioral problems, and had elevated scores for each of the nine subscales on the Achenbach Child Behavior Checklist (CBCL) (Achenbach, 1991a; Einbender & Friedrich, 1989).

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66 In another study, researchers utiUzed the CBCL to assess children who were abused within the past 2 years (N = 85) (Friedrich, Urquiza, & Beilke, 1986). The resuhs indicated that 39% of the children had elevated scores on the Internalizing Scales (i.e., anxious, inhibited, and depressed behaviors) and 46% had elevated scores on the Externalizing Scales (i.e., aggression and acting-out behaviors) (Friedrich, Urquiza, & Beilke, 1986). In comparison, only 2% of normative samples have elevated scores in these areas (Achenbach, 1991b). In this study, aggression, depression, and social withdrawal were elevated most consistently (Friedrich, Urquiza, & Beilke, 1986). In the above study, the authors also found that the internalizing behaviors were correlated significantly with the duration, frequency, and severity of the abuse, yet inversely correlated with the time elapsed since the abuse and the relationship with the offender (Friedrich, Urquiza, & Beilke, 1986). Therefore, child victims who were abused more frequently and more severely by an emotionally close offender exhibited more internalizing behaviors. Similarly, the externalizing behaviors were correlated positively with the duration, frequency, and the number of perpetrators, and inversely with time elapsed and the relationship with the offender (Friedrich, Urquiza, & Beilke, 1986). Externalizing behaviors were more pronounced with abuse by (an) emotionally close perpetrator(s) over longer durations. Yet, both the internalizing and externalizing behaviors decreased with the time elapsed since the last abusive incident (Friedrich, Urquiza, & Beilke, 1986). However, it is important to note that the authors did not use a teacher rating form to compare with the parent report forms, thus limiting the accuracy of these findings.

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67 Sexualized Reactions Several studies have docimiented the presence of sexuaUzed behaviors and sexual preoccupations in abused children (Cohen & Marmarino, 1988; Deblinger, McLeer, Atkins, Ralphe, & Foa, 1989; Einbender & Friedrich, 1989; Friedrich, Beilke, & Urquiza, 1987; 1988; Goldston, Tumquist, Knutson, 1989; Kolko, Moser, & Weldy, 1988). The sexualized acts and preoccupations commonly observed and reported in child victims include sexualized language, self-stimulating behaviors, and imitative behaviors (i.e., inserting objects into genital area or initiating intercourse with dolls, peers, or other adults) (Friedrich, Grambsch, Damon, Hewitt, Koverola, Lang, Wolfe, & Broughton, 1992). Sexually abused children were found to draw genitalia in their pictures more frequently than nonabused children (Hibbard, Roghmann, & Hoeckelman, 1987), and their interactions with anatomically correct dolls involved more sexualized play (Jampole & Weber, 1987). Like the emotional and behavioral reactions, these behaviors are associated with the duration, frequency, and severity of the abuse. In fact, Friedrich, Urquiza, and Beilke (1986) found that young children who were abused frequently and over a long-term period by a parent or by multiple perpetrators were more likely to demonstrate sexual behavior problems. Four studies in particular demonstrate the tendency for abused children to exhibit sexual ideation and sexualized behaviors (Friedrich, 1990; Friedrich & Leucke, 1988; Gale et al., 1988; Tufts New England Medical Center, 1984). Friedrich (1990) found that nearly 75% of the male victims and 40% of the females in his sample exhibited sexual behaviors, including preoccupations with masturbation, sexual acting out, and sexual talk.

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68 In the Tufts study (1984), 33% of the child sexual abuse victims, aged 7-13, had elevated scores on sexual behavior scales. In another small study of 14 boys referred to therapy for sexual aggression, 1 1 had histories of sexual abuse (Friedrich & Leucke, 1988). In a fourth study, sexually inappropriate behavior seemed to distinguish the abused children from nonabused control groups (Gale et al., 1988). More specifically, 41% of the sexually abused children exhibited sexually inappropriate behaviors compared to less than 5% of the comparison groups (Gale et al., 1988). The predominance of the sexualized behavior problems and preoccupations is an obvious outgrowth of abuse. When a child is abused, sexualized behavior is modeled which impacts the child's subsequent thoughts and behavior. In this sense, the child who acts out sexually is repeating what she learned. It is important to recognize that following an extremely traumatic event, children are faced with a need to master the excess of new stimuli (Furman, 1986). The child's attempt to gain mastery may take the form of repetitive and compulsive behaviors. Therefore, for these children, sexualized behaviors become a means for them to feel mastery over the trauma (Friedrich & Luecke, 1988). According to Maltz and Holman (1987), sexually abused children either withdraw socially and avoid overt sexual behavior or they engage in unusually frequent sexual activity and promiscuity. With ongoing abuse, victims become confused about their sexual identity, sexual behavior norms, and the differences between sex and caregiving. As a result of the conditioning of sexual activity with negative emotions, some child victims develop aversions to sex or intimacy (Downs, 1993; Finkelhor & Browne, 1986; Peterson & Urquiza, 1993). These problems may follow the child into adulthood as evidenced by

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69 the fact that many adult survivors report difficukies with interpersonal relations and sexual adjustment (Courtois, 1988; Meiselman, 1978; Mrazek & Mrazek, 1981). Victims abused during adolescence are particularly at risk for difficulties with adult intimacy (Downs, 1993; Erickson, 1968; Peterson & Urquiza, 1993). The inability to secure healthy adult intimate relationships and the feelings of low self-worth may account for why some survivors select abusive mates in adulthood (Gelinas, 1983). According to the child sexual abuse research, sexualized behaviors provide important discriminating information (Gale et al., 1988). When abuse is suspected but the child is reluctant to disclose, reports of sexualized behaviors should alert professionals to suggest flirther evaluations (Deblinger et al., 1989; Finkelhor, 1979; Kercher & McShane, 1984). Once in therapy, clinicians are advised to address these sexual issues and behaviors with victims/clients (Deblinger et al., 1989). This is an essential part of therapy because many adult survivors report on-going difficulties with their sexuality (Becker, Skinner, Abel, & Chichon, 1986; Steele & Alexander, 1981). In fact, if left untreated, Steele (1986) postulated that abused children will continue to be exploited or exploit others sexually as adults due to a lack of a positive sexual identity. Psvchopathological Reactions For victims of sexual abuse, there are various observed and reported psychological effects ranging from the absence of symptoms considered psychopathological to the presence of "extreme and pervasive emotional problems" (Gomes-Schwartz, Horowitz, & Sauzier, 1985, p.507). The emotional difficulties found in sexual abuse victims are more severe than those found in nonabused children, and yet there is less psychological

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70 disturbance when compared to clinical samples of nonabused children (Gomes-Schwartz, Horowitz, &, Sauzier, 1985). It can be concluded, therefore, that any psychopathological reactions are causally related to the abuse and not an inherent condition as found in a clinical, nonabused sample. While there is limited information regarding the predominance of characteristics in abused children that lead to DSM diagnoses, several researchers have focused exclusively on diagnosis and sexual abuse victims. Depending on the methodology of the study and the nature of the sample, it appears that anywhere from 40%100% of abused children are diagnosed with DSM disorders. In one study of 70 child victims, 70% were found to meet the criteria for at least one psychiatric disorder (Maisch, 1973). However, standardized instruments for classifying diagnoses were not utilized, thus limiting the accuracy of these results (Sirles, Smith, & Kusama, 1989). In another small smdy of 13 sexually abused children on a child psychiatry inpatient unit, standardized interviews were employed (Livingston, 1987). Using the Diagnostic Interview for Children and Adolescents (1977), the researchers found that over 50% of the children met the criteria for at least one DSM diagnosis, including major depressive episode, psychosis, attention deficit disorder, overanxious disorder, and separation anxiety (Herjanic, 1977; Livingston, 1987). In a third study of incest victims (N = 22), 68% received a DSM-III diagnosis (Krener, 1985). The most common diagnosis was adjustment disorder with mixed emotional features (Krener, 1985). In a fourth study, all of the sexually abused children (N = 27) received DSM-III diagnoses after 3 -hour psychiatric evaluations (Adams-Tucker, 1982).

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71 In a study by Sirles, Smith, and Kusama (1989), approximately 40% of a sample of 207 abused children from an outpatient population were diagnosed with DSM clinical disorders. In fact, 38% of the children met the criteria for an Axis I diagnosis, including adjustment disorder (23%), conduct disorder (5%), disorders with physical manifestations (3%), attention deficit disorder (3%), mental retardation (3%), oppositional disorder (0.5%), and anxiety disorder (0.5%). In regard to the adjustment disorders, most often this was accompanied by depressed mood (49%) (Sirles, Smith, & Kusama 1989). Other variations of this diagnosis were found to include adjustment disorder with mixed disturbance of emotions and conduct (17%), with atypical features (15%), with mixed emotional features (11%), with disturbance of conduct (6%), and with anxious mood (5%) (Sirles, Smith, & Kusama 1989). In addition to adjustment disorders, 62% of the children were given V-code diagnoses, most often including Phase of Life or Other Life Circumstance Problem codes (Sirles, Smith, & Kusama 1989). Along with a predominance of adjustment disorders, researchers have validated the presence of PTSD symptomology in child sexual abuse victims (Kiser, Ackerman, Brown, Edwards, McColgan, Pugh, & Pruitt, 1988; McLeer et al., 1988). The diagnostic characteristics for PTSD include trauma-related fears, intrusive thoughts, avoidance of trauma-related stimuli, numbing, and hyper-arousal as seen in sleep disturbances, irritability, and difficulties with concentration (Wolfe, Gentile, & Wolfe, 1989). Associated with these criteria are feelings of fear, anxiety, depression, and guilt (Wolfe, Gentile, & Wolfe, 1989). In a review of the literature, it appears that 40%-80% of the commonly reported symptoms following sexual abuse include anxiety and other

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72 manifestations of it such as hyper-arousal, hypervigilance, avoidant behaviors, phobias, difficulties sleeping, intrusive thoughts, and reexperiencing phenomenon (i.e., nightmares or sexual play imitating the abuse) (Adams-Tucker, 1981; Burgess & Holstrom, 1975; DeFrancis, 1969; Friedrich, Urquiza, & Beilke, 1986; Mannarino & Cohen, 1986; McLeer et al., 1988; Peters, 1976; Tufts New England Medical Center, 1984; Wolfe, Gentile, & Wolfe, 1989). In addition to anxiety, some abused children have been found to demonstrate affective numbing and dissociative behaviors (Wilber, 1984). A number of researchers have examined sexually abused children for the presence of PTSD. In a re\iew of 155 inpatient records, 29 sexual abuse victims and 20 physical abuse victims were identified (Deblinger et al, 1989). In this study, the sexually abused children were matched on the basis of age, sex, and socioeconomic status with nonabused patients and those who experienced physical abuse but not sexual abuse (Deblinger et al., 1989). The authors found that 21% of the sexually abused children met the criteria for PTSD compared to only 7% of the physically abused children and 10% of the nonabused group (Deblinger et al., 1989). In another study of 31 sexually abused children (aged 3-16 years), 48% met the DSM-III-R PTSD criteria (McLeer et al., 1988). Other subjects demonstrated some PTSD symptomology but did not meet the full criteria for the diagnosis (McLeer et al., 1988). In this study, the presence of PTSD in child sexual abuse victims corresponded with more overt behavior problems. More specifically, the authors found that the children who exhibited the criteria for PTSD scored higher on the internalizing and externalizing scales of the CBCL (McLeer et al., 1988).

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73 In another study of physically and/or sexually abused children (N = 163) from a clinical setting, 55% were diagnosed with PTSD (Kiser et al., 1988). The authors found that the children who did not show signs of PTSD exhibited more depressed and externalized behaviors, including delinquency and aggression (Kiser et al., 1988). Because the children who did not develop PTSD showed greater overall problems, the authors proposed that PTSD promotes healing by providing the child with a means for coping with the trauma (Kiser et al., 1988). However, this conclusion conflicts with the findings of the McLeer et al. (1988) study. Therefore, it is apparent that more research is required in this area before a definitive stance on the merits of a PTSD diagnosis can be proffered. Along with DSM clinical diagnoses, some abuse victims are hospitalized as psychiatric patients. In fact, in a study of several psychiatric inpatient units (N = 188 adolescent and adult male and female patients), nearly 50% of the patients had histories of physical abuse, sexual abuse, or both, and 90% of the abuse occurred within the family (Carmen, Reiker, & Mills, 1984). In another study of 51 adolescent inpatients, 55% reported some type of abuse, with 27% experiencing both physical and sexual abuse (Hart et al., 1988). In this study, 6% experienced just sexual abuse (Hart et al., 1988). It appears that children who have less parental support have more severe diagnoses and more pronounced psychological disturbances when compared to those children who have obvious parental support (Adams-Tucker, 1982). Other researchers found that the offender's relationship with the child was associated with the level of diagnosable disturbance (Sirles, Smith, & Kusama, 1989). In particular, children abused by fathers or father-figures were found to be at risk for more damaging effects

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74 (Adams-Tucker, 1982; Burgess & Holstrom, 1978; Herman, Russell, & Trocki, 1986). For example, 45% of the victims abused by a natural father and 44% abused by a step-father received an Axis I diagnosis (Sirles, Smith, & Kusama, 1989). This compares to only 26% of the victims abused by other relatives (Sirles, Smith, & Kusama, 1989). In another study, the relationship with the offender was associated with the presence of PTSD (McLeer et al., 1988). More specifically, 75% of the children abused by their natural fathers and 25% of those abused by another trusted adult met the criteria for PTSD (McLeer et al., 1988). On the other hand, none of the children who were abused by an older peer met the PTSD criteria (McLeer et al., 1988). Accordingly, a diagnosis of PTSD was found to be associated with more severe abuse over longer durations (Kiser et al., 1988). This is consistent with the results of a study of Vietnam veterans in which the intensity of the combat experiences was positively associated with the severity of PTSD (Goldberg, True, Eisen, & Henderson, 1990). In addition to parental support, the type of abuse, the relationship with the offender, and the frequency and duration are related to the severity of the child's diagnosis (Sirles, Smith, & Kusama, 1989). In fact, the more frequently the abuse occured, the more likely that the child will receive an Axis I diagnosis. For example, in one sftady, 50% of the victims abused on a weekly basis were assigned a psychiatric disorder compared to 38% of those children who were abused monthly and 27% of those who reported only "occasional" abuse (Sirles, Smith, & Kusama, 1989). In addition to frequency, the longer the abuse occurred, the more likely that the child would have subsequent psychological difficulties (Sirles, Smith, & Kusama, 1989). In the above study, the children who had

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75 received diagnoses had experienced an average length of abuse of 36 months while the nondiagnosed children experienced an average of 21 months of abuse (Sirles, Smith, & Kusama, 1989). In terms of the duration of psychological disturbance, some researchers have found that traumatized children exhibited PTSD symptoms for years after the traumatic event (e.g., the Chowchilla school bus kidnapping), despite their participation in crisis intervention therapy (Terr, 1981a; 1981b; 1983). However, little is known about the nature of this crisis intervention and the length of time these children spent in therapy. Yet, this finding suggests that the symptoms for PTSD are long term and continue despite therapy. According to Terr (1991), PTSD symptoms in children may endure over time such that they develop into adult personality styles. Again, because little is known about the course of PTSD in childhood, more research is needed in this area (McLeer et al., 1988). In the studies described above, anywhere from 0%-60% of the child sexual abuse victims did not meet the criteria for a major mental disorder (Deblinger et al., 1989; Kiser et al., 1988; Krener, 1985; Livingston, 1987; Maisch, 1973; McLeer et al., 1988; Sirles. Smith, & Kusama, 1989). Therefore, it may be concluded that either abused children are not disturbed enough to meet the DSM criteria or the DSM does not contain a disorder with criteria specific to child sexual abuse and the resulting difficulties. Eventually, the American Psychiatric Association may adopt a "Sexually Abused Child's Syndrome" as part of the DSM to include the symptoms and clusters of symptoms specific to this population (Sides, Smith, & Kusama, 1989). This is important because accurate

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76 assessment and problem definition will guide treatment planning and effective service delivery. Long-Term Effects Unfortunately, some of the emotional, behavioral, sexual, and psychopathological symptoms described above continue as long-term effects for child sexual abuse victims. In fact, some victims experience the effects of abuse throughout their lifetimes (Gold, 1986; Silver, Boon, & Stones, 1983). In a study of 152 female adult survivors, almost 50% reported that they had experienced long-term effects and 27% reported that they were affected "greatly" by the abuse (Herman, Russell, & Trocki, 1986). Similarly, Russell (1988) found that 53% of aduh survivors reported experiencing "some" or "great" long-term psychological difficulties as a resuh of sexual abuse. Like the immediate victim reactions, there are no significant long-term difficulties common to all victims of sexual abuse (Fritz, Stoll, & Wagner, 1981 ; Tsai, Feldman-Summers, & Edgar, 1979). The extent of long-term distress is associated with the victim's relationship with the offender, the duration of the abuse, the degree of violence, and whether penetration was involved (Herman, Russell, & Trocki, 1986). Survivors of incest, especially if the offender was a father figure, are more at risk for long-term effects (Finkelhor, 1986; Herman, Russell, & Trocki, 1986). As to long-term effects, some victims experience fear, isolation, stigma, poor selfconcept, distrust, social dysfunction, difficulties with intimate relationships, anxiety, and revictimization (Browne & Finkelhor, 1986; DePanfilis & Salus, 1992; Herman, Russell, «fe Trocki, 1986; McLeer et al., 1988). In addition, sexual difficulties, depression

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77 (Browning & Boatman, 1977; Summit & Kryso, 1978), and guilt (Finkelhor, 1979) are observed and reported frequently as long-term consequences of abuse. Other researchers have found that adult survivors of sexual abuse exhibit sleep disorders, dissociation, and low self-esteem leading to substance abuse, self-mutilation, and suicide attempts (Gelinas, 1983; Goodwin, 1979; Herman, 1981; Herman, Russell, & Trocki, 1986; James & Meyerding, 1977; Russell, 1986). Some areas of dysfunction surface in adolescence and continue into adulthood for victims of sexual abuse. In order to avoid feelings of victimization, some victims withdraw from intimate relationships (Herman, Russell, & Trocki, 1986). Other survivors have difficulties with sexuality expressed through sexual deviance, sexual dysfunction, promiscuity, and/or prostitution (Herman, 1981; James & Meyerding, 1977; Meiselman, 1978; Russell, 1986). In fact, in one study, 10% of the sample of sexually abused female adolescents exchanged sex for money; 9% exchanged sex for shelter; and 7% exchanged sex for drugs or alcohol (Boyer & Fine, 1992). Silbert (1984) found that 61% of all prostitutes reported having experienced childhood sexual abuse, with a majority (66%) reporting that they were abused by a father, stepfather, or foster-father. Only 10% of the sample of abused prostitutes were sexually abused by strangers (Silbert, 1984). Furthermore, in 91% of these cases, the victim felt that there was no one she could tell, and only 3% of these victims reported the abuse to the police (Silbert, 1984). Along with sexual indiscretions, the rates of pregnancy for abuse victims are higher than nonabused comparison groups (Boyer & Fine, 1992). For example, 66% of pregnant teenagers reported that they were abused at some time in their lives, and 62%

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78 reported that the sexual abuse occurred before their pregnancy (Boyer & Fine, 1992). In two separate studies of pregnant teenagers surveyed through social service agencies, 11% disclosed that they became pregnant as a result of sexual abuse (Boyer & Fine, 1992; DeFrancis, 1969). The results of two studies suggest that adult survivors of abuse have more long-term symptomology when compared with both clinical and nonclinical samples of nonabused adults. In one study, 47 adult survivors of incest who were participating in outpatient treatment were compared with 50 nonabused matched controls who were also in therapy (Meiselman, 1978). The author found that 64% of the incest victims reported marital conflicts in comparison to 40% of the controls (Meiselman, 1978). In addition, these survivors reported more sexual difficulties (24% vs. 8%)) and more physical problems (52% vs. 30%), and they were hospitalized more often than control groups (24% vs. 14%) (Meiselman, 1978). In another study, 40 female incest survivors in an outpatient setting were compared to 20 nonabused controls (Herman & Hirschman, 1981). The incest survivors exhibited more symptoms of negative self-concept, distrustfiilness, depression, anger, and feelings of isolation (Herman & Hirschman, 1981). In addition, they reported fantasies of power over men and fears of being inadequate mothers (Herman & Hirschman, 1981). While these symptoms appeared to continue as long-term effects of childhood abuse, the impact of therapeutic efforts is unknown. In addition to the effects described previously, researchers have found that some adult survivors exhibit long-term PTSD symptomology (Burgess & Holstrom, 1974; 1979; McLeer et al., 1988). For these victims, PTSD symptomology began in childhood

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79 and followed them into adulthood, thus suggesting an unremitting course of the disorder (McLeer et al., 1988). For survivors of childhood abuse, the fears, hypervigilence, and reexperiencing phenomenon endure as long-term effects through nightmares, flashbacks, and/or dissociative states (Herman, Russell, & Trocki, 1986). Similarly, in research with adult rape victims, 33-63% report ongoing PTSD symptoms that persisted for years after the assauh (Burgess & Holstrom, 1979; Ellis, Atkeson, & Calhoun, 1981; Kilpatrick, Veronen, & Resick, 1979; McCahill, Meyer, & Fishman, 1979). In addition to PTSD, some researchers have found an association between long-term childhood sexual abuse and the development of borderline personality disorder (Briere & Runtz, 1988a; 1988b; MacVicor, 1979; Wilber, 1984). In summary, despite methodological limitations, researchers investigating the shortand long-term effects of child sexual abuse have confirmed the presence of distressing symptomology. These symptoms may persist as long-term distressing effects, especially when the abuse involved penetrating acts by a father-figure over a long duration (Hartman, Finn, &. Leon, 1987). It is unknown, however, which treatment methods are recommended and utilized most often with child sexual abuse victims and whether early treatment interventions ameliorate the short-term symptoms and/or prevent the long-term damaging effects. In the following sections, the state of the art in treatment is described. Intervenin g in Child Sexual Abuse ra«;es In many sexual abuse cases, teachers, school counselors, family friends, and other relatives hear initial disclosures from child victims (Leahy, 1991). In 1965, American

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80 legislators passed the first child abuse reporting law which required physicians to report suspected physical abuse (Peterson & Urquiza, 1993). Since that time, the laws have expanded to include other forms of child maltreatment including sexual abuse, neglect, and emotional abuse. Today, every state in the United States has enacted laws requiring professionals to report alleged abuse as soon as possible (usually within 24 hours) to the local child protective services division of the State Department of Social Services (DePanfilis & Salus, 1992). The list of professionals required to make these reports includes not only physicians but also teachers, nurses, mental health professionals, social workers, day care providers, school officials, and other professionals who have regular contact with children (Peterson & Urquiza, 1993). These professionals are required to make reports "when one acquires knowledge of or observes a child under conditions that give rise to a reasonable suspicion of child abuse and/or neglect or when one has knowledge of or observes a child whom he or she knows has been the victim of child abuse and neglect" (Peterson & Urquiza, 1993, p. 1 1). The goals of these mandated reporting laws are to protect current and future victims from these forms of maltreatment. Following a report of sexual abuse, a child protective services worker will initiate an investigation. Eventually, this worker will classify the allegations of abuse as "confirmed," "indicated," or "unsubstantiated." In some cases, the investigator will refer the child for a medical/forensic examination. With the medical examination, forensic evidence is collected, and the physician assesses for evidence of genital trauma, sexually transmitted diseases, and/or pregnancy. If necessary, medical treatment may be provided.

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81 Cases identified as "indicated" or "confirmed" are referred to the therapeutic community for assessment and counseUng. During the social service investigation, a multidisciplinary child protection team may become involved in the case. These teams include individuals from varied disciplines including child protective services workers, teachers, therapists, doctors, advocators, and legal professionals. "The need for multidisciplinary teams emerged over 30 years ago from the realization that no one discipline can successfully intervene in cases of child abuse and neglect" (Peterson & Urquiza, 1993, p. 14). The first multidisciplinary teams were established in 1958 within hospital settings (i.e., the Pittsburgh Children's Hospital, the Children's Hospital in Los Angeles, and the University Hospital in Denver) (Peterson & Urquiza, 1993). These child protection teams focus on child abuse assessment, training, and research initiatives in the field (Peterson & Urquiza, 1993). Some child protection teams provide short-term therapy as well. Many communities continue to utilize child protection teams for multidisciplinary intervention in abuse cases. In order for this team approach to be successful, it is necessary for all professionals involved to coordinate their interventions and communicate on a regular basis (Baglow, 1990; Faller, 1993). When case conferences or team meetings are called to discuss a case, the team addresses the following questions: (a) Has child sexual abuse occurred?; (b) Who is the perpetrator?; (c) Is the child protected from future abuse?; (d) Does the child require an immediate medical examination?; (e) Is there a risk sufficient to warrant removing the child from the home?; (f) Will the case proceed to juvenile or criminal court?; (g) What is known about the individual and family

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82 functioning?; (h) What treatment methods are most appropriate in this case?; and (i) What treatment options are available to the family? (Baglow, 1990). Following an investigation of a substantiated report of sexual abuse, the social service agencies have four options. They may choose to (a) allow the family to remain intact, (b) remove or detain the offender, (c) remove the child from the home, or (d) remove both the child and the offender (Sgroi, 1982). "Assessment and counseling are not effective if the child continues to be abused or if the family environment is not supportive" (Conte & Berliner, 1981b, p. 603). Therefore, when a report of incestuous abuse is substantiated and the offender is in the home, rarely is the family left intact (Finkelhor, 1984). Juvenile Court hearings are initiated if there is a question about the child's safety and protection from further abuse. Usually, this occurs when the social service workers find that the nonoffending parent does not believe the child or cannot protect her (Martin, 1976). Following a Juvenile Court hearing, the child may be placed in the temporary care of a relative or a foster family. When this occurs, often the child feels alienated and unsupported by family members and punished for disclosing (Finkelhor, 1979). On the other hand, when the offender is removed, he is held responsible for the abuse and forced to demonstrate sufficient change before interacting with the victim and/or renaming home (Trepper &. Barrett, 1989). Depending on local laws, removing the offender means that he wall be incarcerated or forced to find another place of residence. A case proceeds to Criminal Court if the State's Attorney accepts the case and intends to prosecute the alleged offender (Faller, 1993). The penalties for first degree

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83 child sexual abuse in the United States range from a $500 fine and up to a year in prison (Virginia Law) to 1 to 50 years in prison (California Law) (Giaretto, 1976). A convicted offender may be imprisoned and/or mandated to attend therapy, depending on his motivation for treatment and other factors such as previous offenses, local attitudes about rehabilitation, and the available resources (Dixon & Jenkins, 1981). If he is not detained legally in prison, usually a convicted offender must find another place of residence and may be placed on house arrest after a certain time in the evening (Russell, 1986). In some cases, however, where resources are limited, a convicted offender remains in the home but is restricted to certain areas of the house (Parker & Parker, 1986). Probation and/or parole officers monitor the offender's compliance with these legal orders. Treatment for Child Sexual Abuse According to Herman, Russell, and Trocki (1986), "only a small percentage of abused children are ever seen by mental health or social agencies" (p. 1293). Finkelhor (1984) suggested that one out of every five cases comes to the attention of these professional agencies. However, the number of clinical treatment programs has increased rapidly in the last decade (Gomes-Schwartz, Horowitz, & Sauzier, 1985). In fact, the number of treatment programs for offenders and their families rose from 20 in 1976 to over 300 in 1981 (Bulkey, 1985). These specialized treatment centers are essenfial because many doctors, social workers, psychologists, and other clinicians are not trained or do not feel comfortable dealing with sexual abuse and/or incest (Hall & Gloyer, 1985). Treatment for child sexual abuse victims and their families often involves a complex and long-term process. Traditionally, there were three approaches in treating

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84 abused children identified by Colin (1979): (a) lay therapy including peer counseling and support groups, (b) professionally led group therapy, and (c) individual psychotherapy. As a fourth approach, systemic therapy is common (Madanes, 1990; Star, 1983). While there are varied therapeutic approaches for treating child sexual abuse, often they are polarized into two opposing "camps," victim advocacy and systemic therapy (Barrett, Sykes, & Byrnes, 1986). In the victim advocate approach, the rights of the child victim are emphasized and there is extreme pessimism about offenders in terms of rehabilitation (Larson & Maddock, 1986). Victim advocates (who may be employed in child protective service agencies or correctional institutions) typically advocate for the separation of the victim and offender, and they recommend individual treatment interventions (Larson & Maddock, 1986). Victim advocates assist the child and family by providing referrals, emotional support, and court accompaniment (Peterson & Urquiza, 1993). If the abuse occurred within the family, victim advocates do not support reunification and usually recommend long-term incarceration for the offender (Larson & Maddock, 1986). For the abused child, victim advocates emphasize individual and play therapy interventions. Other family members (i.e., nonoffending parents) may participate in group or individual therapy, but, in general, all therapeutic efforts are directed towards the child victim. To address the prevention of abuse, victim advocates target the socio-cultural contributors to violence against women and children (Friedrich, 1990). Therapists with a systemic orientation argue that sexual abuse is best understood and treated in the family context. For incestuous abuse, systemic therapists treat the

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85 incest as a symptom of other distorted elements in family functioning (Larson & Maddock, 1986). The causality is conceptualized as circular, and the incest is a result of dysfunctional family interactions over one or more generations (Trepper & Barrett, 1989). In this view, each family member is an integral part of the system, and the actions of each member influence every other member (Friedrich, 1 990). Therefore, family systems theorists encourage the participation of several or all family members in the assessment and treatment processes (Friedrich, 1 990). To prevent future abuse, the systemic therapist employs interventions to restructure dysfunctional interactional patterns and promote family change. While both the victim advocate and family systems approaches contain merit, the current trend in the field combines the efforts of both to promote a comprehensive, integrated, coordinated multisystems approach utilizing eclectic techniques (Forseth & Brown, 1981; Trepper & Barrett, 1989). The multisystemic model is derived from the humanistic family treatment model for sexual abuse developed by Henry Giarretto (1982a, 1982b). In addition, this approach draws from the work of the structural (MinucKin, 1974) and strategic (Haley, 1976; Madanes, 1990) schools of family therapy. As a multidisciplinary approach, it combines the theories and strategies of offender treatment, individual psychology, social learning theory, victim advocacy, group methodology, art and play therapy, behavior therapy, feminist family therapy, and skills training (Friedrich, 1990; Madanes, 1990; Martin, 1976; Trepper & Barrett, 1989). To provide comprehensive services for the child victim and the family, the multisystemic therapist implements group, individual, collateral, and family

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86 methodologies during various treatment phases. The course of treatment and the introduction of ahemate methodologies are dependent upon the needs of the victim, offender, and the family (Keller, Cicchinelli, & Gardner, 1989). When deciding on the direction of treatment, the multisystemic therapist determines how the abuse was maintained by the individual family members, culture, and society. In addition, the therapist considers the nature and degree of trauma, community resources, financial resources, limitations set by the court, and the family's motivation for treatment (Kempe & Kempe, 1984). For the child victim, the multisystemic therapist tailors interventions based on the child's age, developmental level, gender, and diagnosis (Fumiss, 1983). The muhisystemic model supports the interest and well-being of the child, yet views family involvement as essential for change (Trepper, 1990). Within the multisystemic approach, incest is viewed as a symptom of dysfunctional interactional patterns within the family and the contexts in which the family operates (Friedrich, 1990). Therefore, systemic factors beyond the nuclear family, including culture, society, extended family, and social support networks, are recognized and included in the treatment process. This approach is utilized with both intrafamilial and extrafamilial sexual abuse cases. In addition, practitioners and researchers report that physical abuse recovery is enhanced with the multisystemic treatment approach (Madanes, 1990; Trepper & Barrett, 1989). Giaretto (1982a, 1982b) identified treatment guidelines for a "Comprehensive Sexual Abuse Treatment Program" and created a self-help group facilitated by therapists called "Parent United." This program encourages a comprehensive continuum of

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87 therapeutic services including (a) individual counseling for the child, nonoffending parent, and offender, (b) dyad sessions with the nonoffending parent and the child, (c) marital counseling for the nonoffending parent and the offender, (d) dyad sessions with the offender and the victim, (e) family counseling, (f) group counseling for parents, offenders, victims, and siblings, and (g) self-help groups for parents and children (e.g., Parents United, Daughters and Sons United) (Giaretto, 1982b). While variations of this program have evolved over the last 15 years, "the organizing theme of every program is the development of a comprehensive and coordinated approach designed to meet the needs of all the family members" (Peterson 8c Urquiza, 1993, p. 30). The family members benefit by obtaining integrated services at one location so that they are not referred from one agency or clinician to another (Hall & Gloyer, 1985). Following disclosures of abuse, legal mandates, pressures by social service workers, and/or desperation and fear compel family members to seek therapeutic services. As a prerequisite to successful treatment, the therapist must develop a thorough diagnostic evaluation of all involved parties and define clear treatment goals (Leahy, 1991; Pittman, 1977). The offender's motivation is a key indicator of success, and the offender's rehabilitation is essential to the prevention of further abuse because unlike other criminal behaviors, pedophilic disorders do not decrease with age (Leahy, 1991). The treatment prognosis is poor for offenders who do not choose to attend therapy or request help but feel that they are being forced to seek treatment due to court orders (Leahy, 1991). The same is true for family members who feel that they are forced to attend therapy sessions when they would rather "handle it on their own" (Finkelhor,

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88 1979). To diffuse this sentiment, the therapist must inform the family that he/she is not "out to get them," but rather available to assist them in any way possible. The overall objectives for child sexual abuse treatment are healing and the prevention of future abuse (Faller, 1993). However, "therapy may be used to work on longstanding problems, to provide support during the crisis that surrounds the reporting of incest, and hopefully to prevent some of the sequellae that have been associated with incest" (Fumiss, 1983, p. 44). In particular, the therapeutic goals include (a) limiting the physical and emotional dysfunction experienced by the child, (b) improving the child's overall functioning and encouraging appropriate development, (c) ensuring that the child is protected from future abuse, and (d) restructuring dysfunctional family interactional patterns (Bentovim, Boston, & Van Elburg, 1987). These therapeutic goals may be accomplished through individual, group, and/or family therapy interventions. In some cases, treatment is provided by a team of therapists such that different therapists within an agency intervene at different stages in the recovery process (Faller, 1993). Individual Interventions According to Madanes (1990), during the early stages of treatment, individual interventions benefit all family members and introduce the recovery process. Each family member, especially the child, needs support for the initial disclosures and the chaos that follows (Mayer, 1985). Individual therapy sessions provide a forum for members to express their feelings about the abuse and the events following disclosure (Sgroi, 1982). In this sense, alliances are established to foster trust and a belief that change is both possible and desirable (Faller, 1993). Furthermore, in individual sessions, the therapist

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can provide insight into the general causes of abuse and help each member understand why the abuse occurred in their family. For the nonoffending parent, an exploration of the causes of sexual abuse is especially important. It may be difficult for the mother to accept and understand the abuse if the offender was her spouse or another close relative (Faller, 1993). The disclosure of incest differs from other family crises in that the mother is asked to believe something that she may not want to believe, to interpret something that is at best difficult for her to comprehend, and to resolve the conflict between her roles as central support figure to both her child and her male partner at a time when her own social, emotional, and economic supports may be at risk. (Everson et al., 1989, p. 198) According to Faller (1993), mothers are more supportive to the victim when they are no longer married to the offender. In some cases of incestuous abuse, social service workers find fault with mothers as well as perpetrators (Dietz & Craft, 1980). Even if it is not stated, the nonoffendmg mothers may sense this blame. As a result, some mothers ally with the offender, and both imite in feeling that they were falsely accused. Despite the fact that in one study 78% of the mothers reported that they were physically abused by the offender in the past, many do not believe the child victim, and they respond to disclosures of abuse with rejection, blame, and denial (Dietz & Craft, 1980; Everson et al, 1989; Herman, 1981; Summit, 1983). From the available data, anywhere from 44% to 73% of mothers are not supportive to their children who disclose abuse (Adams-Tucker, 1982; Meyer, 1985; Everson et al., 1989). More specifically, in a study of 88 families with child victims aged 6-17, less than 50% of the mothers were identified as "consistently supportive" to their children (Everson et al., 1989). In this

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90 study, almost 25% of the mothers supported the offender over the child victim (Everson etal., 1989). As discussed, several researchers have found that children who were not supported by their prunary caretakers were more likely to experience severe emotional and behavioral disturbances (Adams-Tucker, 1982; Everson et al., 1989; Fromuth, 1986; Tufts New England Medical Center, 1984). In fact, the degree of emotional support from the nonoffending parent was found to be a key factor in the child's adjustment following abuse (Conte &. Schuerman, 1988; Friedrich, 1990). Two separate studies reported finding that affective support fi-om parents served to protect child victims from long-term dysfunction and distress (Rutter, 1987; Runyan, Everson, Edelsohn, Desmond, Hunter, & Coulter, 1989). Bowlby (1973) found that self-esteem and coping were enhanced by positive and secure relationships with primary attachment figures, especially during times of crisis. Therefore, in early individual sessions, it is necessary for the therapist to assess the degree of maternal support for the victim. Next, the therapist must help the nonoffending parent understand the plight of the victim so as to avoid creating stress, shame, and guilt in the child (Peterson & Urquiza, 1 993). In addition to the degree of maternal support, other issues deserve exploration in these individual sessions with the nonoffending parent. In particular, the therapist will assess for dependency on the offender, substance abuse, past physical or sexual abuse, and depression (Faller, 1993). To cope with the aftermath of disclosure, nonoffending parents need information about what to expect emotionally, A mother's response to allegations of incest can range from anger, rage, guilt, and conftision to anguish, disbelief,

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91 and blame (Peterson & Urquiza, 1993). Nonoffending parents need to know how to express these intense emotions appropriately. Most importantly, nonoffending parents must be reminded to direct these emotions towards the alleged offender, not the child victim. Finally, nonoffending parents need accurate and clear information about legal processes and recommended courses of treatment for all involved family members. For the child victim, treatment should address the cognitive, emotional, and behavioral reactions to the sexual abuse and protection from future victimization (Faller, 1993; Finkelhor, 1986; Gehnas, 1983; Green, 1978; Jones, 1986; Steele & Alexander, 1981; Yates, 1982). It is particularly important for the therapist to address self-esteem, guilt, sexuality, and relational issues. The child's recovery process is enhanced by (a) victim/offender clarity, (b) an immediate disclosure, (c) a positive system response from the family and intervening professionals, (d) a respect for change, and (e) a belief that the abuse can be arrested and resolved (Conte & Berliner, 1988). Individual characteristics that mitigate against the harmful effects of abuse include (a) well-developed social skills, (b) ability to inhibit dysfunction and modulate behavior, and (c) sound cognitive capabilities such that school provides a much needed sense of mastery and support (Friedrich & Luecke, 1988). Areas of recovery are found in improved memory, affective expression, symptom mastery, self-esteem, peer relations, and family functioning (Lebowitz, Harvey, & Herman, 1993). Therapeutic interventions with child sexual abuse victims proceed through various stages of recovery (Lebowitz, Harvey, & Herman, 1993). While some victims will not successfully complete all the stages in the course of initial therapy, they may continue the

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92 process at a later time until full recovery is attained (Lebowitz, Harvey, & Herman, 1993). The key areas of intervention in individual therapy sessions with child victims are based in large part on the developmental stage of the child. The therapist may utilize a variety of therapeutic techniques in these individual sessions including those found in play therapy, art therapy, and bibliotherapy. For young children, individual play therapy is the treatment of choice because play is the natural medium of exchange for this age group (Fumiss, 1983). For victims who have become pseudomature as a result of the abuse, the therapist may encourage a therapeutic regression and promote child-like play to relieve the child from her role as a mother figure or seductive teen (Fumiss, 1983). In the first stage of recovery , safety must be established. In fact, "no other work should be attempted until this goal is achieved" (Lebowitz, Harvey, & Herman, 1993, p. 379). The therapist must cooperate with social service and legal authorities to ensure the child's safety which may require removing the child, the offender, or both. The child must be assured "a safe living situation, with adequate attention to survival needs and a carefully considered plan for self-protection" (Lebowitz, Harvey, & Herman, 1993). Once placement is established, the therapist will design primary interventions which stabilize the child's environment (Madanes, 1990). In addition, it may be necessary to secure a protector for the child. According to Garmezy (1983), children who overcome enormous adversity continue to implicate a positive social figure who remains constant and encourages the child's competence. In addition to a safe home environment, the child must feel safe in therapy. This is fostered through a relationship of trust and mutual respect. "Considerable attention

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93 must be paid to creating a genuinely respectful and collaborative relationship that can accept, legitimize, and contain traumatic affect, provide nurturance without infantilization, and address trauma-shaped perceptions and behaviors without shaming or disempowering the survivor" (Lebowitz, Harvey, & Herman, 1993, p. 382). The challenge to the therapist is to create circumstances in which the child has positive experiences with trustworthy adults in order to ameliorate the damage to the child's ability to trust. This may involve rehabilitating parents and/or creating opportunities for appropriate relationships with adults, for example with foster parents, mentors, or other relatives. An admonition to therapists is that they must be honest and dependable in order to create an atmosphere of trust. (Faller, 1993, p. 68) To establish trust further, the therapist must reassure the child that she is not at fault and that she was correct in reporting the abuse (Mayer, 1985). Subsequent therapeutic efforts should be directed towards relieving the child's sense of guilt and responsibility for the offense (Conte & Berliner, 1981b). The concepts of consent and mutuality are explored using the child's language (Parker & Parker, 1986). The child must understand that the responsibility lies with the offender no matter what the circumstances. In individual sessions, the therapist encourages the child to openly assign responsibility to the offender and confront distorted beliefs (Katz & Mazur, 1979). The child is supported in understanding what sexual abuse is and why it is harmful. In time, the child develops an appropriate cognitive framework from which to understand the abuse which becomes an integrated part of her history (Lebowitz, Harvey, & Herman, 1993). In early sessions, low self-esteem is addressed, and the therapist encourages the child and family to develop positive self-worth (Downs, 1993). Feelings of guilt, shame.

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94 and low self-esteem are replaced with positive and realistic views of self (Lebowitz, Harvey, & Herman, 1993). This is especially important because high self-esteem and ego strength assist children in coping with stress and trauma (Garmezy, 1983). Next, the therapist encourages the child to develop meaningful, safe, and appropriate relationships with others in order to secure feelings of attachment and reduce a sense of isolation. This begins with the therapeutic relationship. In fact, "the patient-therapist relationship offers the child the chance to have an intimate relationship with an adult, which is neither overwhelming nor self-serving, and one which may foster a sense of trust that the child has not previously experienced" (Fumiss, 1983, p. 45). Nonexploitive peer and adult relationships also serve to validate the child's self-worth. To assist the child in developing these relationships, peer group therapy may be introduced. In addition, family relationships may be renegotiated in concurrent family therapy sessions. Along with guilt and low self-esteem, other areas of affective recovery are addressed in individual sessions. Following sexual abuse, some children experience severe emotional reactions including intense fears and phobias (Faller, 1993). In order to treat a child victim's fears, the therapist must determine whether the child is in fact at risk of harm or further abuse (Faller, 1993). If the child is protected from harm, then the therapist can create situations in which the child gradually experiences her fears and gains mastery over her anxiety (Wheeler 8l Berliner, 1988). To address phobic reactions, the therapist may introduce behavioral systematic desensitization techniques in which the child gradually confronts her fears through a progression of activities from the least anxiety-producing towards the most feared situation/event.

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95 As the affective recovery process unfolds, the child will explore and disclose aspects of her sexual abuse in therapy in order to develop a sense of mastery over the experience (Lebowitz, Harvey, & Herman, 1993). The therapist may utilize art or play to help the child victim visualize, conceptualize, or reenact aspects of the abuse. "The purpose of the work is not primary catharsis but rather integration of the traumatic experience" (Lebowitz, Harvey, & Herman, 1993, p. 381). The child is encouraged to tell her story at her own pace in confidence and in the context of a trusting relationship with the therapist (Fumiss, 1983). In this sense, the child is encouraged to resolve the trauma as she begins to understand what happened and how it affected her. In time, the child demonstrates control over memories of the abuse so that she is not plagued by overwhelming or repressed memories. Finally, the child is able to recall memories of the abuse and link them with the appropriate affect. For young children, the work of this stage may surface through posttraumatic play (Terr, 1981a). This play consists of compulsive, repetitive, unimaginative, and almost hypnotic activity in which the child reenacts aspects of the trauma without paying attention to the presence of the therapist (Jones, 1986; Terr, 1981a). In time, the child is encouraged to identify the emotional aspects of her play as it relates to her feelings about the abuse. During this "reworking" stage, the therapist supports the child as she experiences a range of emotions including ambivalence, shame, guilt, betrayal, and powerlessness (Finkelhor, 1986; Lebowitz, Harvey, & Herman, 1993; Mayer, 1985). As this process unfolds, the victim is able to mourn her losses. With therapeutic support, the child

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96 assumes control over her emotions and is not plagued by extreme numbing or flooding (Faller, 1993). The victim may ventilate her feelings towards the offender by writing letters to him or practicing confronting him in sessions with the therapist. Eventually, PTSD symptomology and other emotional reactions are decreased with the exposure, processing, and integration of this therapeutic stage (Lebowitz, Harvey, & Herman, 1993). For many child victims, the emotional reactions following sexual abuse become manifest in behavioral problems. More specifically, child victims may exhibit aggressiveness, noncompliant and delinquent behaviors, running away, school problems, truancy, self-mutilation, suicidal gestures, substance abuse, eating disorders, hyperactivity, and difficulties with sleeping and toileting (Brown & Finkelhor, 1986; Elwell & Ephross, 1987; Faller, 1993; Friedrich, Urquiza, & Beilke, 1986; Mannarino & Cohen, 1986; Tufts New England Medical Center, 1984). To assist the child in overcoming this dysfunctional symptomology, the therapist can normalize some of these experiences as common reactions to abuse and help the child develop cognitive behavioral solutions (Faller, 1993). Furthermore, the counselor can assist the child in identifying and expressing the underlying emotional aspects of these behaviors and support the child in finding more appropriate means for expressing intense emotions (Faller, 1993). Finally, the therapist and the family can direct the child to become involved in age-appropriate peer activities. With ongoing therapy and family support, the child will achieve symptom mastery such that dysfunctional symptomology and residual effects are abated or they become manageable.

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97 In many cases, abused children react to sexual abuse with sexualized behaviors or sexual preoccupations (Cohen & Mannarino, 1988; Deblinger et al., 1989; Einbender & Friedrich, 1989; Kolko, Moser & Weldy, 1988). These children may reenact abusive situations v^ith toys or other children, or they may masturbate excessively. In therapy, the counselor will address sexual acting out as behavior that is under the child's control. In addition, the therapist and the nonoffending parent will teach norms regarding sexual activity, including appropriate and inappropriate types of touching. The counselor must be careful to avoid eliciting shame and encourage caretakers to do the same. When a sexual problem occurs, the therapist will teach caretakers to redirect the child's behavior and help the child become interested in age-appropriate play activities. As the child matures, other aspects of sexuality and the abuse deserve attention in therapy. In particular, it is recommended that when a child victim enters adolescence, she has the opportunity to process her feelings regarding her sexuality and the value of sex (Fumiss, 1983). The "damage" she feels as a result of the abuse must be addressed so that the child develops a healthy sense of self and avoids dysfunction in intimate relationships (Sgroi, 1982). Following sexual abuse, child victims may respond with anger, fear, adoration, or disgust towards men (Fumiss, 1983). These child clients need to discuss their feeling towards men and learn that not all men will abuse them. Over time, the child will learn to identify abusive situations and be able to relate positively with nonabusive men and boys. Along with sexual education, the therapist must educate the child and family about the prevemion of further abuse. Sexual abuse affects a child's ability to trust others in her

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98 world, especially if the offender was once a caretaker (Courtois, 1988; Finkelhor, 1980). Yet, despite this sense of distrust, studies indicate that most victims are at risk for further abuse (Peterson & Urquiza, 1993; Russell, 1986). In fact, 63% of child sexual abuse victims reported being sexually assaulted as adults (Russell, 1986). Therefore, the child must learn to recognize the signs of abusive situations and develop a plan for selfprotection. Family members must support this plan and take an active role in preventing ftiture abuse. Finally, as the recovery process unfolds, the victim assigns meaning to the abuse experience and views herself as a survivor (Lebowitz, Harvey, & Herman, 1993). The therapist may direct the child to create a "survivor mission" in which she actualizes her goals, dreams, and hopes for the future (Lebowitz, Harvey & Herman, 1993). At this stage, the therapist may recommend that the child continue with group or family therapy modalities and attend individual sessions only when needed. Long-term individual therapy is indicated for children who demonstrate psychopathological disturbances which preclude them from participating in group therapy (i.e., psychosis or mental retardation) (Fumiss, 1983). A limitation of individual therapy is that it does not help the child overcome feelings of isolation, shame, and deviancy (Fumiss, 1983). In addition, it does not allow child victims to work directly on problems with peer interactions or social skills (Furniss, 1983). On the other hand, group therapy is an ideal means for child victims to practice these skills.

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99 Group Interventions Most community agencies that treat sexual abuse offer therapy groups for the child victim and possibly for the offender, siblings, and nonoffending parents as well (Giarretto, 1982a). Group therapy is not recommended for a child victim's first encounter with therapy (Peterson & Urquiza, 1993). Usually, group therapy is indicated only after victims have addressed common abuse-related issues in individual therapy (e.g., distrust, shame, fears, and stigmatization) (Berliner, Urquiza, & Beilke, 1988; Faller, 1993; Peterson & Urquiza, 1993). In the early stages, "many of the issues that children initially encounter in dealing with their victimization are too personal, embarrassing, and painful to disclose and discuss within a group therapy setting" (Peterson & Urquiza, 1993, p. 36). Group interventions are most effective when implemented in conjunction with family and individual sessions (Forseth & Brown, 1981). However, group therapy is typically not indicated for preverbal children, children who are unable to express themselves, or children with extreme behavioral problems (e.g., hyperactivity, aggressiveness, and/or consistent sexual action out) (Peterson «fe Urquiza, 1993). In sexual abuse cases, group therapy can provide positive healing experiences. For the entire family, peer group feedback is both powerful and persuasive and often acts as a catalyst for change (Russell, 1986). "Participation in a group also enables the client to interact with group members who have resolved some issues and 'moved on' as well as with others who are struggling with issues the client may have mastered, thereby enabling the client to lend insight and support to others" (Peterson & Urquiza, 1993, p. 36).

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100 In the group environment, child sexual abuse victims are encouraged to practice assertiveness, social skills, and honest communication about their feelings. More specifically, victim therapy groups should focus on the following: (a) establishing trusting relationships, (b) engendering peer support, (c) encouraging open expression, (d) alleviating misappropriated guilt, (e) developing a realistic sense of self-competence, (f) learning about the appropriate and inappropriate uses of power, (g) learning about human sexuality and body image, (h) court preparation if necessary, (i) ventilating affect appropriately, (j) confronting maladaptive beliefs, (k) improving self-image and selfconcept, (1) reinforcing appropriate boundaries and family roles, (m) practicing prevention strategies, and (n) fostering insight and education about abuse and recovery (Martin, 1976; Sgroi, 1982). Group environments that empower members toward recovery are safe, supportive, and persuasive (Gagliano, 1987; Giaretto, 1982b). Sexual abuse therapy groups may be structured and time-limited, or long-term and open-ended ,depending on the member composition, available resources, and therapist training and style (Faller, 1993). Most group sessions are held weekly for 60 to 90 minutes (Gagliano, 1987). In early sessions, the rules of conduct and the group structure are established (Gagliano, 1987). In addition, early sessions should focus on building rapport and support among members so that members feel comfortable sharing their feelings. For child victim groups, art therapy activities and games assist them in discussions of the abuse issues (Fumiss, 1983). Often, it is necessary for the therapist to educate the group members about specific abuse-related issues (e.g., defining abuse, the law, and identifying the correct names for male and female body parts) (Gagliano, 1987).

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101 This will help group members with open discussions and disclosures. The children learn about sexual abuse and sexual offenders so that they have some insight into their problems. In order to relieve their sense of guilt, group members discuss and identify who is responsible for abuse. Other sessions focus on support figures, and each child should report that they have someone to tell about future abuse. According to Gagliano (1987), group therapy helps to alleviate guiU and pain by allowing children to share their experiences with other children who have been similarly traumatized. Child victims find comfort in the group when they realize the universality of their hurt, fear, and shame (Giarretto, 1982b). Talking to other children who have had similar experiences provides child victims with a sense of hope and reduces their feelings of isolation (Mayer, 1985). The amount of social support that individual members feel from their respective peer groups has proven to be closely related to successful recovery (Orenchuk-Tomiuk, Matthey, & Christensen, 1990). The peer support found in group therapy sessions renders this the most effective means for addressing low self-esteem in adolescents (Porter, Blick, & Sgroi, 1982). Within the power of the peer group, the child is encouraged to replace negative self-statements with more positive statements and clarify any role confusion following abuse (Porter, Blick, & Sgroi, 1982). On the other hand, a limitation of group therapy is that it does not alter serious individual psychopathology or affect the realities of dysfunctional family life (Fumiss, 1983).

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102 Family Treatment for Incestuous Abuse Most often, family therapy is the "culmination of the treatment process and is usually not undertaken until there has been a determination that reunification is in the victim's best interest" (Faller, 1993, p. 66). While family sessions may be held in conjuction with other treatment modalities, family therapy should not commence until individual therapeutic relationships have been established with key family members (Trepper & Barrett, 1989). Prior to sessions with the entire family, the members may participate in individual or dyad sessions in which they address relational issues. For the child victim, Pittman (1977) recommended utilizing parallel individual and family treatment methods. If individual sessions are held in concert with family therapy, the therapist allows the child to have a place to validate her feelings and discuss her perceptions of the family and family therapy process (Fumiss, 1983). Prior to family therapy, it is essential for the nonoffending parent to express her feelings about the abuse in individual sessions so that she can offer complete support to the child. According to Faller (1993), successfiil reunification following incestuous abuse rests largely on the mother's relationship with the victim. Interestingly, a good prognosis is suggested when the mother feels very guilty and the therapist must work to alleviate her sense of responsibility. . . . Conversely, a poorer prognosis is indicated when the mother sees herself as absolutely blameless and the therapist has to point out things that the mother might have done differently that could have prevented or minimized the abuse. (Faller, 1993, p. 71) In addition to individual sessions, it is important for mothers and victims to meet in dyad sessions prior to family therapy. This relationship may be vulnerable due to

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103 manipulations by the offender and acting out behaviors by the victim. In these dyad sessions, the nonoffending parent and the victim can explore and improve their patterns of communication. Next, they must discuss and practice how the victim will inform the mother of safety issues and how the mother will respond without disbelieving or blaming the child. It will be important for the mother and child to find mutually enjoyable experiences (Faller, 1993). Once the relationship is healed, the nonoffending parent can become a protector for the child. Realistic safety plans are developed and then shared vAih the entire family, including the offender (Faller, 1993). Family therapy can occur only if the child victim has some sort of operational family structure with members who are willing to attend sessions as a group (Fumiss, 1983). Family therapy can involve the child's family of origin or a substitute family (e.g., foster family or a group home family network). Often, it is helpftil to have sessions with these substitute families because victims tend to recapitulate their family conflicts even if they are not living in the home (Fumiss, 1983). Family therapy sessions that include the offender are possible only when the offender and nonoffending parent acknowledge the abuse and the offender accepts full responsibility for his actions (Barrett, Sykes, & Byrnes, 1986). Therapy with the incestuous family as a whole is not successfial when the child feels pressured to recant or defend herself about the abuse (Friedrich, 1990). If any family member denies that the abuse occurred, they should not be in the same room with the child victim, especially during early sessions (Trepper & Barrett, 1989). Instead, other family members will meet, and the denying member will continue in individual, marital, or group therapy until

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104 he/she is able to support the victim. Group therapy is very successful in breaking through this denial with offenders (Groth, 1979). Similarly, marital therapy is valuable if the nonoffending partner is willing to confront the other about the abuse and support the child (Friedrich, 1990). In family sessions, the therapist explores the systemic and interpersonal dynamics as well as the abuse and neglect dynamics. It is important for family members to be educated about these dynamics and the psychological and behavioral signs of abuse. Next, the victim and the family members can explore the cognitive aspects of why, how, and when the abuse occurred. Family members can share their emotional reactions to the abuse and the events following disclosure. In addition, family members can explore their behavioral reactions to the stress of the abuse and work together to eliminate any maladaptive behaviors. During these family sessions, the offender must apologize to the victim in order to relieve her sense of guilt (Leahy, 1991; Madanes, 1990; Trepper, 1990). Other family members will apologize as well for not preventing or stopping the abuse (Madanes, 1990). These sessions are essential to the child's healing in humbling the offender while empowering the child victim (Fumiss, 1983; Rencken, 1996; Trepper, 1986). Along with the cognitive and emotional healing, the therapist will address key areas of family restructuring. Most importantly, the family must cooperate as a unit to ensure the prevention of any future abuse. Concrete steps are outlined so that each member can learn to recognize preceding stressors that led the offender to abuse (Faller, 1993). Family consequences for re-abuse must be firm, clear, and consistent. According to some practitioners, the family

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105 must tell the offender that if he re-offends, he is expelled from the family (Madanes, 1990). Other legal ramifications may be enforced by probation officials and the offender should be reminded of these consequences. If the child and the offender are separated legally, intervening professionals may need to address the issues of visitation and reunification. In child sexual abuse cases, an offender should not have unsupervised visitation with the child until the child feels that she will be safe and the offender has been found to be of no risk by the professionals evaluating and treating him (Faller, 1993). Furthermore, if the child is going to testify in court, it may be in her best interests not to have visitation until after the trial (Faller, 1993). In some cases, child victims may not want visitation with the offender, and they should not be forced to see him. However, if visitation is appropriate and wanted by all parties (the victim, family, and offender), then it should progress in a planned, supervised manner and be monitored through therapy sessions. The Structure of Incestuous Families According to current theorists and researchers, incestuous families can be identified as a very homogeneous group (Peterson & Urquiza, 1993). In fact, the incestuous family structure and levels of fiinctioning are plagued with common areas of dysfunction. These dysfunctional patterns influence the emergence of abuse and the consequences that follow (Alter-Reid et al., 1987). The structure of any family system is bound by its roles, boundaries, coalitions, and hierarchical patterns (Minuchin, 1974). In addition, power, cohesion, family affect, and communication patterns affect the family structure and the degree of positive system

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106 functioning (Beavers, 1990). Modem systemic theorists recognize the importance of each of these factors in the change process. According to systems theory, these factors are interrelated, implying that a change in one area affects other aspects of the family structure. Following are descriptions of each structural component and how each becomes dysfunctional for the incestuous family. In addition, areas for therapeutic intervention are addressed. Boundaries. The MerriamWebster Dictionary (1987) defines a boundary as "something that indicates or fixes a limit." A family boundary is an invisible line or parameter, ranging fi-om rigid to permeable, which sets limits for the family (Beavers, 1990; Minuchin, 1974). The boundaries are enforced by family rules which define who may or may not enter the family, to what extent, and how often (Friedrich, 1990). In the incestuous family, boundaries are violated with respect to an individual's body, belongings, and personal space (Madanes, 1990). Often, there is a blurring of internal boundaries yet rigid boundaries with outside groups. The isolation of these closed systems increases the vulnerability for incestuous abuse (Finkelhor, 1986). According to Alexander (1985), the closed nature of these families prevents members from having contact with healthy and appropriate family models. Therefore, in therapy, boundaries must be realigned so that personal space is no longer violated and external support is encouraged and allowed. Usually, this requires separation of the victim and offender during the initial therapy process (Fumiss, 1983). Hierarchy . Hierarchy refers to the graduated system of membership in the family (Barrett, Sykes, & Byrnes, 1986). Most often, positions in the family hierarchy are

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107 delineated by age, power, and roles. In the so-called "functional" family, there are clear notions about membership, status, and measures for control of misbehavior by the parental subsystem (Trepper & Barrett, 1989). This is absent in incestuous families, and usually one person, the offender, makes all family decisions and is at the top of the hierarchy (Friedrich, 1990). As a resuh of the incestuous relationship, the "special" child, chosen by the offender, gains status and recognition and becomes elevated in the hierarchy (Madanes, 1990). In this family, the offender prohibits the nonoffending parent from gaining power through control and manipulation (Groth, 1979). In counseling these families, the therapist encourages members to realign hierarchical positions. The goal is a unified, empowered parental subsystem who has authority over the children without the misuse of power present in abusive situations (Trepper & Barrett, 1989). The new parental unit determines how they will make and enforce family rules, decisions, and discipline. In addition, appropriate sibling interactions are rewarded by the parental subsystem. Eventually, with this realignment, the family develops new rules of functioning and distributes power appropriate to the role definitions. Role Imbalance. Incestuous families are often characterized as having role imbalances (Gelinas, 1988). In this sense, family members do not function appropriately within their role definitions as fathers, mothers, or children. The blurring of generational boundaries and enmeshment encourage this role imbalance. Enmeshment is emotional closeness that restricts individuality and allows for the breakdown in the hierarchy (Beavers, 1990). As role definitions dissolve, the child becomes "parentified" or

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108 "spousified" (Minuchin, 1974). Furthermore, the longer these patterns are enacted in the family, the more embedded the dysfunction (Sgroi, 1982). This creates an imbalance in all interactions and in turn affects the entire family functioning. In incestuous families, there is a breakdown in the parental dyad and an estranged marital relationship (Larson & Maddock, 1986). The breakdown of this relationship may be a precursor to the abuse as a parent-child coalition replaces the parental subsystem. Therefore, therapeutic goals for family sessions are to restore appropriate role definitions and secure clear, functional hierarchical boundaries (Friedrich, 1990). During the course of treatment, parent-child coalitions must be disentangled and the parental unit empowered (Orenchuk-Tomiuk, Matthey, & Christenson, 1990). Power. According to systemic theorists, the power structure in a family is visualized on a continuum from chaotic to egalitarian (Beavers, 1990). Often, the power structure in the incestuous family is plagued with imbalance, rigidity, and/or chaos (Barrett, Sykes, & Byrnes, 1986). As such, the abuse of power tends to become a way of life and a dominant aspect of the family interactional patterns (Trepper, 1990). Children learn that power is an all-important aspect of interpersonal relationships and that "powerful people can make their own rules and change them without warning" (Sgroi, 1982, p. 32). For many victims of incest, as well as other family members, accommodation is used as a coping mechanism. In attempting to accommodate to the sexual abuse, the child learns to mistrust others while preventing interpersonal closeness and self-validation (Trepper & Barrett, 1989). The child learns that she cannot protect herself and either

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109 makes attempts to escape this reality (e.g., imaginary friends, multiple personalities, substance abuse, withdrawal) or masks any conflict (e.g., prides herself on popularity, makes eager attempts to please peers and aduhs) (Sgroi, 1982). Due to the nature of these families, the power structure must be examined, and areas of imbalance must be challenged in the therapeutic arena. The cultural, societal, and familial rules about power and sexuality must be explored in therapy. Implicit rules which alert the therapist to dysfunction include notions of control, perfection, blame, unreliability, "secrets," avoidance, and denial (Fossum & Mason, 1986). In therapy, the power structure is altered when the victim and other members learn to assert themselves and the offender learns to accommodate. A balance appropriate with the family roles is desirable. The therapist usually empowers the nonoffending parent as a strong decision maker and protector while weakening the offender's hold on the family (Barrett, Sykes, & Byrnes, 1986). The offender must acknowledge the abuse openly in family sessions and accept sole responsibility for the abuse (Fumiss, 1983; Madanes, 1990; Trepper & Barrett, 1989). This empowers the child victim and relieves her sense of guih (Fumiss, 1983). In addition, it is important for the mother to acknowledge her inability to protect the child and express her remorse about this. The nonoffending parent is encouraged to help the victim regain a sense of selfworth. Eventually, family members discover how to maintain healthy, trusting relations with themselves and others while improving personal power and self-esteem. Cohesion. Cohesion, like closeness, refers to the emotional bonding that family members have towards one another (Barrett, Sykes, & Byrnes, 1986). It is typically

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110 pictured on a continuum from disengaged to enmeshed (Minuchin, 1974). As described previously, typically there is enmeshment, or overinvolvement among members of the incestuous family (Madanes, 1990). Individuation is denied which inhibits member strength, power, and flexibility (Barrett, Sykes, & Byrnes, 1986). Boundaries are enmeshed and invasive within the family, yet there are rigid and distinct boundaries to the outside world. However, following disclosure, family members may disengage completely with each other due to legal interventions, shame, and/or overwhelming guilt. Adolescent victims often attempt to distance themselves from the family by withdrawing or making overt attempts to escape reality (e.g., substance abuse, suicide attempts, or running away) (Sgroi, 1982). With incestuous acts, individuals are stripped of their individuality and autonomy is denied (Madanes, 1990). Therefore, closeness is physically invasive and emotionally absent. When individuality is denied in a family, there is little emotional connection. A family is emotionally connected only when each member is empowered to become autonomous as individuals (Beavers, 1990). In counseling, the therapist encourages members to respect each other's personal privacy and decrease constricting family bonds (Friedrich, 1990). Family members teach each other how to develop and maintain healthy peer relationships. The family learns that these relationships are not threatening and will not lead to abandonment by the caretakers (Fossum & Mason, 1986). In addition, the nonoffending parent develops a new closeness with the victim which was absent during the time of the abuse (Finkelhor, 1984). The offending parent and the child will develop a new relationship that is not

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Ill exploitive and remains within the boundaries of their roles in the family as parent and child. Eventually, family members experience a closeness aligned to their roles, and they are encouraged to practice the appropriate means for expressing this closeness in therapy sessions. Adaptability . The amount of flexibility towards change in a family, or adaptability, is pictured on a continuum from rigid to chaotic (Haley, 1976). Incestuous families may adopt either stance. Rigid families are rule conscious, and they adhere to stereotypical sex-role expectations (Barrett, Sykes, & Byrnes, 1986). In contrast, chaotic families are ahnost structureless, without consistent rules and roles. In therapy, the rigid family is encouraged to allow flexibility into their structure while the chaotic family secures more order and consistency. Adaptability is directly related to the family's success in restructuring themselves when life cycle changes occur. The five family life stages are (a) couple formation, (b) families with young children, (c) families with schoolage or adolescent children, (d) families with grown children, and (e) couples experiencing old age and death (Minuchin & Fishman, 1981). Each of these transitional stages creates family stress as they disrupt the homeostasis. Restructuring, in light of these stages, requires flexibility in the rules for relating. Functional families are able to mobilize and access resources in response to the demands of both individual and family development (Possum & Mason, 1986). In therapy, the family learns to predict life stages and access the necessary resources so that they will adapt appropriately to life cycle changes. This in turn facilitates both individual and family growth.

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112 Clarity of Expression . Clarity of expression is evident when a family expresses feelings and thoughts honestly, respectfully, and directly (Beavers, 1990). In dysfunctional families, members do not listen to or accept another's opinion as manifest by contradictions, intemaptions, and/or confusion of meaning (Barrett, Sykes, & Byrnes, 1986). The incestuous family limits the free and open voice of others both within and outside the family (Trepper & Barrett, 1989). Communication centers around secrecy and indirect expression of affect. Secrecy related to sexual matters is especially evident in these families, often due to strong religious beliefs about sexual expression (Sgroi, 1982). In fact, children from abusive families were found to avoid discussions about their families, and they had difficulties expressing emotion (Kempe & Kempe, 1978). For these reasons, it often takes several months or even years before the child is able to disclose the abuse. This is compounded by the offender's threats to harm the victim or the family and the child's fears about family separation (James & MacKinnon, 1990). In addition, the "special secret" shared by the offender and the child endures through bribes, promises, and victim blame. As a result, fear, helplessness, and guilt force the child to "keep the silence" of abuse (Mayer, 1985). This lack of communication and the child's conftision about sexual issues allows the abusive behavior to continue (Peterson & Urquiza, 1993). In therapy, family members are encouraged to communicate openly and to respect the ideas, thoughts, and opinions of each member (Beavers, 1990). Direct communication is encouraged, and all secrets must be voiced (Madanes, 1990). Secrets between the offender and the children are dangerous and must not be tolerated in these families

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113 (Madanes, 1990; Sgroi, 1982). Family members must regain their sense of "having a voice" and feel empowered to speak for their needs. The parental subsystem must "hear" their children and respond appropriately to their needs. Listening skills and empathy are practiced in family sessions and at home. Finally, in marital therapy sessions, the couple will explore sexual expressiveness and how they plan to teach their children healthy sexual attitudes (Friedrich, 1990). Negotiation . Negotiation and conflict resolution are essential components to any functional system (Beavers, 1990). Before effective negotiation can occur, family members must acknowledge and accept responsibility for their own past, present, and future actions (Barrett, Sykes, & Byrnes, 1986). In the incestuous family, the victim, rather than the offender, feels responsible for the abuse and for keeping the family together. Most victims truly believe that the abuse is their fault or that they "could have done something" to stop the abuse (Finkelhor, 1979). In therapy, all family members are taught that the responsibility remains with the offender and that a child could in no way prevent the abuse, given the circumstances. Accordingly, the offender must accept complete responsibility for the abuse and apologize to each family member (Madanes, 1990). By owning this responsibility, it is more difficult for the offender to rationalize future abuse. According to Beavers (1990), negotiation involves the active participation of all members in utilizing resources, personnel, and time efficiently to solve a problem. The effectiveness of the family in negotiating conflict is an indicator of overall family health and adaptability (Beavers, 1990). In incestuous families, the power differential prohibits

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114 effective negotiation and conflict resolution. Family members deny or avoid problem solving, and attempts at open negotiation are often sabotaged. In therapy, members are taught to negotiate openly and have opportunities to practice these skills. As a family learns to allow direct, clear communication, they allow for conflict resolution and change. Accordingly, growth and adaptation derive from the necessary resolution of conflict (Haley, 1976). Family Affect. Within most families, there is a broad range of expressed emotion accompanied by spontaneous interactional tones (Haley, 1976). However, sexually abusive families, in general, have a limited range of affective expression and certain feelings are discouraged or denied (Larson & Maddock, 1986). The family is "stuck," or less spontaneous, and the overall mood and emotional tone is depressed and hopeless in nature (Beavers, 1990). There is a complete absence of understanding another's experience and a denial of emotions. The resulting relationships are utilized for selfgratification only. If the sexual abuse continues, eventually the child victim learns to use relationships to meet personal needs and avoids empathic encounters (Parker & Parker, 1986). The therapeutic goals are to expand the emotional range while supporting open expression and spontaneous interaction. Again, the family is encouraged to practice empathic encounters with each other both in sessions and at home. The offender's ability to empathize with the victim and identify his emotional state during an urge to abuse is essential to relapse prevention (Groth, 1979). Family members learn that all emotion is acceptable if expressed appropriately.

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115 Other Therapeutic Interventions In addition to individual, group, and family therapy, clients and their families may be referred to parenting classes, parent aid programs, in-home family counseling, substance abuse treatment, and/or self-help programs (Peterson & Urquiza, 1993). Termination of treatment is appropriate when the risks of fiirther abuse are reduced to an acceptable level and the treatment goals for recovery and prevention are achieved (Baglow, 1990). It is clear, according to the literature, that a progression of therapeutic modalities over time is recommended. As described above, these treatment methods represent ideal therapy under ideal circumstances in which all areas of recovery are addressed. In reality, however, sexual abuse victims may be offered only one mode of intervention addressing only a handful of therapeutic issues. The purpose of this research is to identify which methods of treatment are recommended for children abused by a relative or a nonrelative offender when the treatment provider is identified as either a school counselor, mental health counselor, or a family therapist. In the following section, the available data on treatment efficacy are discussed. Treatment Studies "Treatment begins by developing a therapeutic relationship, evaluating the overall functioning of the client, and planning treatment goals and intervention strategies based on the initial and ongoing assessment of client needs" (Peterson & Urquiza, 1993, p. 7). Therapeutic services for children and their families may include crisis intervention and referral, brief therapy (10 to 12 weeks), or long-term therapy. Treatment modalities for

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116 child sexual abuse can be classified according to six models of service delivery: (a) individual counseling, (b) lay therapy, (c) self-help interventions, (d) group therapy, (e) children's play therapy, and (f) family therapy (Berkeley Planning Associates, 1 977; Peterson & Urquiza, 1993). While varied services are available, "orchestration of treatment in the child's best interest is a genuine challenge. . . it is often difficult to know how to proceed because there are so few outcome studies of treatment effectiveness" (Faller, 1993, p. 59). Early research on the overall effectiveness of counseling compared therapeutic interventions with no treatment at all. The overall finding was that therapy was indeed better than no treatment (Eysenck, 1985). However, the investigative focus has expanded to include "what treatment, by whom, is most effective, for this individual with that specific problem, and under which set of circumstances?" (Paul, 1967, p. 1 1 1). According to some experts, "the state of the art of treating mcestuous abusers and victims is insufficiently developed to dictate which treatment is most effective" (Dixon & Jenkins, 1981, p. 220). It is difficuh to examine the individual effects of therapy because modem treatment efforts are newly developed and nonstandardized, incorporating individualized interventions based on client needs (Keller, Cicchinelli, & Gardner. 1989). Furthermore, there is no one diagnosable pattern for abuse victims and no standardized instruments designed specifically for this population. For these reasons, there is little empirical data on client status preand posttreatment. In a study of 553 clinical programs in America for the treatment of child sexual abuse, 55% provided individual, group, family, and dyad therapy (Keller, Cicchinelli, & Gardner, 1 989). In 3 1% of the programs, the primary mode of intervention was

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117 individual therapy, and group or family modalities were added when appropriate (Keller, Cicchinelli, & Gardner, 1989). In 3% of the programs, only individual services were provided (i.e., victim advocacy programs), and 2.5% provided only group therapy (i.e., offender group treatment programs) (Keller, Cicchinelli, & Gardner, 1989). The clinicians in these programs reported using a variety of techniques including those found in insight therapy, play therapy, behavior modification, art therapy, social skills training, psychoeducation, relapse prevention, and cognitive restructuring (Keller, Cicchinelli, & Gardner, 1 989). In addition, 47% of the programs had a crisis hot line, and over 25% provided emergency support services (Keller, Cicchinelli, & Gardner, 1989). In this study, less than half (44%) of the programs reported that they used standardized instruments regularly to assess client needs and/or treatment progress (Keller, Cicchinelli, «&. Gardner, 1989). In addition, only 38% of these programs used standardized measures to assess client status posttreatment (Keller, Cicchinelli, & Gardner, 1989). As a result, the available research evaluating treatment efficacy is replete with ethnographic research methods or clinical case studies (Cohn & Daro, 1987). "The lack of an empirical base which can be used to evaluate the behavioral and psychological condition of abused children has forced clinicians to rely on case histories and subjective impressions to evaluate both the problem and treatment outcome" (Basta & Peterson, 1990, p. 555). Research on treatment efficacy is limited by the use of small, nonrepresentative samples, nonstandardized or inadequate measures, insufficient control of extraneous variables, poorly defined outcome variables, narrow investigations examining limited

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118 intervention strategies, and lack of follow-up data (Cohn & Daro, 1987; Dixon & Jenkins, 1981). Therefore, the results should be examined with caution (Dixon & Jenkins, 1981). In this section, outcome research on offender treatment, victim treatment, and family therapy are presented. Offender Treatment For child sex offenders, it is apparent that incarceration alone does not extinguish the problem because of evident high recidivism rates (Finkelhor, 1984). On the other hand, therapy appears to reduce the rate of repeat offenders. In fact, researchers have found that offenders who participated in therapy had an 1 8% recidivism rate compared to a 43% rate for untreated offenders (Marshall & Barbaree, 1988). In cases of incest, only 8% of those who participated in treatment re-offended compared to 22% of untreated controls (Marshall & Barbaree, 1988). It is important to note, however, that these recidivism statistics cover only those offenders who were "caught" committing new offenses. In addition, these data do not demonstrate the long-term effectiveness of treatment efforts for offenders. Most often, sexual offenders are treated with behavioral methods in either individual or group therapy (Dixon & Jenkins, 1981). Behavioral techniques used with this population include assertiveness training, thought stopping, systematic desensitization, covert sensitization, and covert sensitization with aversion relief (Dixon & Jenkins, 1981). "In the treatment of aduU males for incestuous child sexual abuse, behavior therapy has attempted to change the target of sexual arousal of the abuser to more age-appropriate persons, to decrease inappropriate sexual arousal, and to eliminate

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119 social skills deficits through training procedures" (Dixon & Jenkins, 1981, p. 215). According to case study research with offenders, multicomponent treatment methods encompassing multiple goals are more effective than single treatment methods (Brownell, Hayes, & Barlow, 1977; Dixon & Jenkins, 1981; Miller & Haney, 1976). More comprehensive research results are found in federally funded treatment studies focusing on all aspects of child abuse and neglect (Cohn & Daro. 1987; Dubowitz, 1990). In these studies, both qualitative and quantitative methods were utilized to determine the relative efficacy of varied treatment approaches with abusive and neglectful parents (Berkeley Planning Associates, 1982; Cohn & Daro, 1987). The Berkeley Planning Associates (1977) studied 1 1 treatment programs between 1974-1977 serving over 1,724 parents of children who were either abused (physically and sexually) or neglected (72%) or considered in high risk categories for abuse (28%). The clients were not randomly assigned to these programs but instead attended the programs that were most convenient in terms of location (Dubowitz, 1990). To measure outcome, the researchers utilized the therapist's impressions regarding the client's propensity to re-offend during or following treatment. More specifically, dependent variables included clinician judgments regarding whether abuse or neglect occurred during the course of treatment, the likelihood of future maltreatment following termination, progress in overall functioning, and the extent to which behavioral and psychological difficulties were diminished at the time of termination (Berkeley Planning Associates, 1977, 1982; Cohn &. Daro, 1987). In each of these sUidies, multiple

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120 comparison groups were used to compare subjects with similar presenting problems receiving one type of treatment with subjects involved in other types of treatment. In regards to the success of treatment efforts, in one study 51% of the parents experienced an improvement in at least half of their presenting problems, and 30% showed improvement on all of their presenting problems (Cohn & Degraaf, 1982). In addition to child maltreatment, presenting problems included financial difficulties (80%), marital conflict (74%), social isolation (67%), substance abuse (54%), spousal abuse (42%), and employment problems (36%) (Cohn & Degraaf, 1982). In the Berkeley study (1977), following treatment interventions, 42% of the parents were seen as having reduced their risk for maltreatment. For the sexual offenders, clinicians judged that 70% of the sample were unlikely to re-offend (Cohn & Degraaf, 1982). However, between 30% and 47% of the parents had a reoccurrence of abuse (physical or sexual) while in treatment (ABT Associates, 1 98 1 ; Berkeley Planning Associates, 1977; Cohn & Degraaf, 1982). This does not mean that these parents were not rehabilitated eventually, but it does suggest that overall treatment efforts were not successful in protecting children from fiiture maltreatment (Cohn & Daro, 1987). Kempe and Kempe (1978) estimated that in work with abusive parents, 20% will not successfully complete treatment, and the child will not be returned to their care; 40% will be rehabilitated and no longer abuse their children; and 40% will no longer physically abuse or neglect their children but, they will continue to abuse the children emotionally despite therapy. In the Berkeley study (1977), the strongest predictor of recidivism was the severity of the case at the time of intake, which included the maltreatment history and the

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121 degree of family stress and dysfunction noted by the clinician. Age, race, sex, and socioeconomic status did not predict outcomes, yet improved status was found more often in parents who did not abuse drugs or alcohol (Berkeley Planning Associates, 1977). In addition, when the offenders were separated from the children while in therapy (i.e., the child or the offender was removed from the home), the interventions were more effective (Cohn & Daro, 1987; Cohn & Degraaf, 1982). In regard to the type of interventions, it was found that lay therapies (e.g., in home advocates) and self-help groups (e.g.. Parents Anonymous) in conjunction with traditional therapeutic approaches (e.g., individual therapy) resulted in more positive treatment outcomes for parents (Berkeley Planning Associates, 1977). Lay therapy services are provided by lay persons who are not licensed but may have some training or supervision by credentialed professionals (Dubowitz, 1990). In the Berkeley study (1977), over 50% of the subjects who received lay therapy improved. In fact, the researchers found that no other model of treatment achieved greater than a 40% rate of success (Berkeley Planning Associates, 1977). These results are similar to another study with abusive parents in which lay therapy, when compared to standard therapeutic approaches, was marginally more successful, particularly in the first 6 months of treatment (Homick & Clarke, 1986). These findings are significant because lay therapy interventions are less costly than traditional therapeutic interventions and possibly more accessible to larger numbers of clients (Dubowitz, 1990). Generally, the costs for lay therapies are $40 to $50 per hour less than other therapies, and some support groups are free of charge (e.g.. Parents

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122 United) (Dubowitz, 1990). While lay therapy was found to be beneficial, it is advised that professional backup and supervision be provided (Cohn, 1979; Cohn & Daro 1987). Along with the successful treatment outcomes for lay therapies, researchers have found that the attrition rate was lower for lay therapy participants (Homick & Clarke, 1986). In fact, 74% of the abusive and neglectful parents who participated in lay therapy remained in treatment for 12 months compared to 50% of the parents who were involved in traditional interventions led by professional therapists (Homick & Clarke, 1986). The length of treatment is significant because adults who participated in therapy less than 6 months were more at risk for future abuse and the treatment outcomes were lower (Berkeley Planning Associates, 1977; Cohn & Degraaf, 1982). However, clients who remained in therapy for over 1 8 months demonstrated fewer positive results, suggesting a diminishing rate of return on services over time (Cohn & Daro, 1987; Cohn & Degraaf, 1982). Therefore, it is recommended that parents attend and participate in treatment between 6 and 18 months (Cohn & Daro, 1987). In two studies, group therapy and parent education classes as supplemental services were found to effect positive outcome, especially for physically abusive parents (Berkeley Planning Associates, 1977; Cohn & Degraaf, 1982). In fact, it was found that abusive parents who participated in group counseling were 27% less likely to re-offend than those parents who did not receive group services (Cohn & Degraaf, 1982). This is similar to other findings in which client outcomes were higher for group therapy participants when compared to clients not receiving group therapy (Bean, 1971; Berkeley Planning Associates, 1982; McNeil & McBride, 1979; Moore, 1982).

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123 For sexual offenders, group therapy is particularly beneficial (Resnick & Peters, 1967). With group interventions, researchers have found that offenders were able to change their negative attitudes towards probation officials, improve their self-esteem and work performance, regain employment if previously unemployed, and decrease the rates of re-arrest (Resnick & Peters, 1967). Furthermore, positive results were found with both structured and nonstructured group formats (Marcus & Conway, 1971). In a second study by the Berkeley Planning Associates (1982), 19 clinical programs were evaluated using standardized measures to gather data on client demographics, maltreatment type, client functioning at the time of intake and termination, and the type of treatment provided. Therapeutic services included crisis intervention, temporary shelter, parent education, psychotherapy, and case management interventions including help with housing and employment. Following treatment, the researchers found that 55% of the abusive parents improved their understanding of child development and 47% demonstrated improved self-esteem (Berkeley Planning Associates, 1982). However, over 50% of the parents were judged by their clinicians as likely to maltreat their children in the future (Berkeley Planning Associates, 1982). Specific to sexual abuse treatment, clinicians believed that 70% of the offenders demonstrated overall improvement (Berkeley Planning Associates, 1982). In fact, the sexual offenders had the lowest recidivism rates during the course of treatment (19%) as compared to neglect cases in which the reoccurrence was 66% (Berkeley Planning Associates, 1982). These findings indicate that treatment efforts are more successful for sexual offenders than physically abusive or neglectful parents. However, the reason for these findings is unclear.

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124 Victim Treatment For child victims of abuse and neglect, between 50%-70% showed an improvement in symptomology following treatment (Berkeley Planning Associates, 1982; Cohn & Degraaf, 1982). More specifically, in one study of 1,600 child and adolescent victims, over 70% improved in all functional areas during treatment (Cohn & Degraaf, 1982). For these clients, treatment efforts involved a wide variety of services including individual therapy, group counseling, therapeutic day care, speech and physical therapy, and medical services. However, the differential effects of these interventions were not evaluated in this study. In the Berkeley study (1982), over 50% of the children in treatment (N = 70) demonstrated improvement in the developmental, emotional, or socialization areas targeted for therapy. In particular, child clients demonstrated improvements in encopresis/enuresis (66%), sleeping problems (65%), chronic health problems (54%), expressive language deficiencies (62%), attention span (50%), lack of trust (67%), and vandalism (61%) (Berkeley Planning Associates, 1982). The most improved results were obtained through individual therapy, group counseling, and therapeutic day care. Adolescent clients demonstrated the most improvement from skill development classes, temporary shelter, and group therapy interventions. In particular, adolescent clients showed improvement in sleeping problems (63%), eating problems (42%), feelings that they deserved the maltreatment (72%), depressed feelings (70%), suicidal gestures (68%), and violent behavior (58%) (Berkeley Planning Associates, 1982).

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125 In two smaller studies, data were collected specifically for sexually abused child clients. In one study of incest victims (aged 4-15), nine children participated in an outpatient treatment program (Browning & Boatman, 1977). The children presented with the following complaints: somatic concerns, anger, fear, running away, sexual promiscuity, inability to sleep alone, depression, intense religiosity, and rationalization of the abuse (Browning & Boatman, 1977). Two of the children were removed from the home, and two participated in family therapy. All of the children were involved in individual counseling, and some participated in collateral sessions with the nonoffending parent. Following 6 months of treatment, five victims demonstrated symptom relief and terminated treatment (Browning & Boatman, 1977). In addition, several of the mothers who complained of depression during the intake reported an improvement following 6 months of collateral therapy (Browning & Boatman, 1977). On the other hand, some of the child victims who did not participate in treatment reported that their sleep disturbances were eliminated (Browning & Boatman, 1977). However, it is unclear whether other areas of distress continued for those clients without therapeutic intervention. In another study of eight child sexual abuse victims (aged 3-7), initial assessments using the Child Behavior Checklist (Achenbach, 1991a, 1991b) revealed that three of the children had elevated scores for the internalizing scales, including depression, withdrawal, somatic complaints, and sexual behavior problems (Friedrich & Reams, 1987). Another three subjects had elevated scores for the externalizing, internalizing, and sexual problem

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126 scales (Friedrich & Reams, 1987). Five of the eight children participated in individual treatment with the principal investigator or team of therapists. The researchers found that the children who participated in individual therapy improved their overall social and behavioral functioning ,and their presenting problems decreased as reported by parents and therapists (Friedrich & Reams, 1987). However, there was variability in the course of improvement. For example, some children showed improvement and then regressed, while others showed improvement in some areas but not in others. The authors suggested that a variable course of improvement is part of posttraumatic recovery for abused children (Friedrich & Reams, 1987). They concluded that when the children were encouraged to deal directly with the abuse issues, they frequently resolved them over time (Friedrich & Reams, 1987). More importantly, the authors found that those children who did not participate in therapy did not improve but instead "deteriorated with almost every assessment" (Friedrich & Reams, 1987, p. 169). The children who did not receive treatment frequently had parents who rejected them or who had their own unresolved histories of sexual abuse (Friedrich & Reams, 1987). Other researchers found that when the family members did not believe that the abuse occurred or when there were disagreements about the allegations, there was an increased tendency for these families to drop out or refuse treatment (Bentovim, Boston, & Van Elburg, 1987). Parental belief about the abuse appears to dictate whether a child will participate in and successfully complete therapy (Bentovim, Boston, & Van Elburg, 1987). Furthermore, child victims who do not receive therapy appear to respond by increasing the intensity of their acting out behaviors (Friedrich 8c Reams, 1987).

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127 In a study of sexually abused children in London (N = 180), group therapy which lasted between 12-15 weeks provided positive outcome results. In this study, 47% of the victims participated in and completed children's group therapy, and 27% attended some group sessions (Bentovim, Boston, & Van Elburg, 1987). The overall group goals were to help the victims understand and cope with the abuse and disclosure while learning selfprotection skills (Bentovim, Boston, & Van Elburg, 1987). Following treatment, the researchers found that the child participants were able to demonstrate assertiveness skills and avoid revictimization (Bentovim, Boston, & Van Elburg, 1987). However, some of the children who demonstrated sexual behavior problems during the initial assessments were found to have moderate or slight problems of this nature at follow up (Bentovim, Boston, & Van Elburg, 1987). It appears that sexual behavior problems require ongoing, direct interventions. For adult survivors, early case study research indicated that psychoanalysis combined with hypnotherapy successfully eliminated long-term dysfunction (Peters, 1976; Woodbury & Schwartz, 1971). In these case studies, the presenting complaints included suicidal ideation, marital/relational difficulties, running away, and sexual problems (Peters, 1976; Woodbury & Schwartz, 1971). All of these researchers concluded that ventilation of affect and reconstruction of the personality were essential to the treatment process (Peters, 1976; Woodbury & Schwartz, 1971). Other researchers found that catharsis, especially in conjunction with hypnosis, appeared to be therapeutic (Dixon & Jenkins, 1981). However, the number of sessions required to eliminate

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128 distressing symptomology using these methods was anywhere between 1 1 sessions and 18 years (Dixon & Jenkins, 1981). Other researchers investigated the long-term effects of abuse for adult survivors who were not in therapy Qi= 152) (Herman, Russell, & Trocki, 1986). The authors found that almost 50% of the participants judged themselves to be either "entirely" or "mostly" recovered from the abuse (Herman, Russell, & Trocki, 1986). However, standardized psychological measures were not utilized to determine the extent of recovery. In addition, it is unknown how many of these survivors participated in therapy as children and how it may have affected their recovery as adults. Family Treatment For family therapy interventions, early evaluative studies demonstrated that these approaches can successfully rehabilitate incestuous families and prevent a reoccurrence of abuse (Kroth, 1979). Using the multisystemic approach, therapists reported greater rates of recovery and prevention than with individual approaches to the treatment of incest (Friedrich, 1990; Orenchuk-Tomiuk, Matthey, & Christensen, 1990). More specifically, outcome results after a 10-year follow up indicate that less than 1% of the families treated with the mukisystemic model reentered the social service system as a result of child abuse (Trepper & Barrett, 1989). According to these data, the recidivism rate is less than 1%. Similarly, Giarretto (1982b) reported that his Child Sexual Abuse Treatment Program has treated over 4,000 incestuous families, and 90% of the victims have returned home with a recidivism rate of only 1%. However, these data were collected from subjective reports, not rigorous evaluation using sound methodology.

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129 In a large study in London of 120 sexually abusive families, 46% completed family treatment, and 36% participated in some therapy sessions (Bentovim, Boston, & Van Elburg, 1987). In this study, 10% of the child victims participated in individual treatment, and 47% completed group therapy (Bentovim, Boston, & Van Elburg, 1987). In addition, 9% of the parents attended separate mothers' and fathers' groups which took place parallel to children's groups. These individual and group sessions lasted anywhere from 3 months to a year. Family therapy sessions involved the entire family, including the offender even if he was incarcerated. The authors found that in 70% of the cases that remained in treatment, there was an observed positive structural change in the family (Bentovim, Boston, & Van Elburg, 1987). In family therapy research, successful outcomes were achieved when the focus was on redefining roles and boundaries to allow for individuation and differentiation among members while clarifying communication patterns (Eist & Mandel, 1968; Machotka, Pittman, & Flomenhaft, 1967). Others found that a positive therapeutic relationship and an active role for the therapist were essential to change (A wad, 1976). In the Bentovim, Boston, and Van Elburg study (1987), the combination of individual, group, and family modalities proved moderately successful. In 61% of the cases, there was an overall improvement in the victim's circumstances as reported by the family social worker (Bentovim, Boston, & Van Elburg, 1987). On the other hand, in 24% of the cases, the social worker thought that the family situation had not changed, and in 10% it was thought to be worse (Bentovim, Boston, & Van Elburg, 1987). In 15% of the cases it was not clear whether subsequent abuse occurred, and in 69% of the cases

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130 there was not re-abuse (Bentovim, Boston, & Van Elburg, 1987). These findings are similar to others in which 70% of sexual offenders demonstrated improvement and were judged as unlikely to re-offend (Berkeley Planning Associates, 1982; Cohn & Degraaf, 1982). Like other studies, however, these results are limited by the fact that only subjective measures of social workers' perceptions following the closing of the case were used. Conclusion According to Mayer (1985), with individual therapy alone, child victims will continue to experience some of the negative effects of sexual abuse as adults. Others reported that offenders who participated in individual therapy only are subject to a high recidivism rate (Trepper & Barrett. 1989). Furthermore, based on case study research, family therapy alone did not eliminate the abusive patterns, and eventually the child victim was removed from the home for protection (Molnar & Cameron, 1975). Therefore, experts contend that a combination of treatment efforts offered in conjunction with the prosecution of the offender and proactive safety measures lead to successful outcomes (Bentovim, Boston, & Van Elburg, 1987; Brownell, Hayes, & Barlow, 1977; Cohn & Daro, 1987; Dixon & Jenkins, 1981). Overall, the research data suggest that abusive and neglectful families fare better when a comprehensive package of services is provided to address both individual and interpersonal needs (Berkeley Planning Associates, 1982; Cohn & Daro, 1987; Cohn & Degraaf, 1982). A comprehensive package maximizes client gains and appears to be cost effective in the long run. The recommended treatment approach begins with individual

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131 counseling for all parties and then marital and dyad sessions in addition to family and group sessions (Giarretto, 1976). Do treatment providers today recommend a comprehensive package of services for child victims and their families or do practitioners rely on the one method of intervention they believe to be successful and within their area of expertise? Does the recommended course of treatment vary when the offender is a relative versus a nonrelative? Following is a description of the methodology for this study which attempted to answer these questions.

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CHAPTER III METHODOLOGY Child sexual abuse is a problem of huge proportions in America. There are several theoretical models for treating abused children in order to prevent long-term dysfiinction and future abuse. It is unknown, however, which treatment methods are actually put into practice with this population. Therefore, the primary purpose of this study was to determine which professional counselors (school, mental health, and family) recommend which methods of treatment (individual, group, and/or family therapy). Conclusions were dravra regarding the most common practices among each professional group. These conclusions will assist future clinicians in planning and administering therapeutic interventions with child sexual abuse victims. The secondary purpose of the study was to determine whether there were different treatment recommendations based on a specific mediating variable, namely, the child's relationship with the offender (i.e., relative vs. nonrelative). The two offender categories were addressed as separate hypotheses. Ultimately, it was the purpose of this study to determine which therapeutic methods are recommended and utilized most often for each offender type and how this varied across the counselor groups. The research methodology is described in this chapter. Included are descriptions of the research design, sample, instruments, research procedures, data analyses, and methodological limitations. 132

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133 Research Design Approximately 1 ,000 active members of the American Counseling Association from various geographic regions across the United States were asked to participate in this research. The Professional Profile Questionnaire and the Treatment Recommendations Questionnaire were utilized to gather data from which to evaluate the null hypotheses. The Professional Profile Questionnaire (PPQ) was used to collect demographic data including the professional counselor's age, gender, ethnicity, and highest academic degree (Appendix A). The Treatment Recommendations Questionnaire (TRQ) describes a potential child client who is seeking treatment with the participating counselor (Appendices B and C). There are two forms of the TRQ. Form A contains a scenario describing a female victim who is abused by her natural father (Appendix B), and Form B describes a child abused by a nonrelative swim teacher (Appendix C). The remainder of each hypothetical scenario reads exactly the same. Half of the sample of counselors received Form A and half received Form B. The participating therapists were asked about their recommended course of treatment for the child victims described in each scenario. More specifically, counselors were asked what primarv mode of intervention they would recommend (individual, group, or family therapy). Next, the counselors were asked how essential each counseling type is for the resolution of the abuse. These responses were rated according to a scale of 1 = "not at all important" to 10 = "essential" to the resolution process.

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134 The information from the PPQ was correlated with data collected from the TRQs. Comparisons were made to determine the differences among the therapist groups based on the child's relationship with the offender as described in each scenario. The ultimate goal of the study was to further the research in the field about the types of tteatment recommended for child sexual abuse victims in order to enhance professional training and service delivery. Sample The American Counseling Association (ACA) is an "educational, scientific, and professional organization whose members are dedicated to the enhancement of the worth, dignity, potential, and uniqueness of each individual and thus to the service of society" (ACA, 1988, p. 1). The ACA is a nonprofit, professional, and educational organization open to mdividuals across the United States and in 50 foreign countries. There are nearly 60,000 members whose primary work is in the area of counseling and human development (ACA, 1995). These professional counselors may be employed in schools, colleges, mental health agencies, community agencies, rehabilitation clinics, business/industry, private practice, and/or employment/human resource settings (ACA, 1995). Active members of the American Counseling Association (ACA) must complete a membership application, pay a membership fee, provide proof of academic degrees if requested, and agree to abide by the ACA Ethical Standards (ACA, 1995). American Coundeling Association members can be classified as (a) professional, (b) regular (members who are interested in the organization but do not have the professional academic qualifications for professional membership), (c) student (enrolled at least

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135 half-time in a graduate counseling program), or (d) retired (individuals over 60 who are retired and have had ACA memberships for at least 5 years previously) (ACA, 1995). Professional members must hold at least a master's degree in counseling or a closely related field from an accredited college or university. For this study, only ACA professional members were included in the population of subjects. Under the ACA umbrella, there are 1 7 national divisions including those specific to assessment; adult development and aging; college counseling; counselors and educators in government; counselor education and supervision; gay, lesbian, and bisexual issues in counseling; humanistic education and development; multicultural counseling; mental health counseling; rehabilitation counseling; school counseling; spiritual, ethical, and religious values in counseling; group work; addictions and offender counseling; marriage and family counseling; career development; and employment counseling (ACA, 1995). American Counseling Association members are required to belong to at least one divisional association. There are separate fees for each division. Professional members of the American School Counselor Association (ASCA), American Mental Health Counselors Association (AMHCA), and the International Association of Marriage and Family Counselors (lAMFC) were included in the population of subjects. Members of ASCA are employed in school counseling settings or related areas, and they are interested in activities having an impact on a student's success and well-being (ACA, 1995). Members of AMHCA are dedicated to the delivery of quality mental health services to varied mental health populations including children and families (ACA, 1995). Members of lAMFC work primarily with marriage and family

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136 counseling (ACA, 1995). These groups were chosen because they often are employed in clinical or school settings in which children are potential clients. Furthermore, due to their chosen client focus and areas of clinical expertise, these professional counselor groups encounter sexually abused children more often than the other organizational affiliate groups of ACA. The sample for this study was drawn from the population of active professional ACA members who belong to either ASCA, AMHCA, or lAMFC. To date, there are 6,705 ASCA members, 6,243 AMHCA members, and 6,910 lAMFC members (ACA Membership Status Report, July, 1, 1997). A random sample of 333 school counselors, 333 mental health therapists, and 334 family counselors was generated from the ACA computer directory. This included professionals working in varied settings including private practice, hospitals, social service agencies, schools, outpatient clinics, and other public/private based settings. The researcher sent the research packets to these 1,000 professional counselors. The participants were encouraged to participate in order to further the knowledge in the field. At the conclusion of the data collection, there were responses from 169 school counselors, 200 mental health counselors, and 101 family therapists. Instruments There were two instruments used to collect data in this study. Both were designed for utility and brevity as well as ease in administration and scoring. The validity and reliability for these instruments are not established. In addition, the instruments do not contain empirically based scales and normative data based on large representative

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137 samples. Instead, the test questions and the hypothetical scenarios were developed from a thorough review of the literature. This is a limitation of the study, and the results should be interpreted with caution. To date, there is no available standardized measure of knowledge and professional practice for child sexual abuse treatment providers. While no single measure can assess a practitioner's recommendations and level of expertise in this area, the data collected from the Professional Profile Questionnaire and the Treatment Recommendations Questionnaires can provide a picture of the current trends in the field and how this varies according to profession. Since no other instruments are available, these methods were best suited to answer the research questions. The Professional Profile Questionnaire (PPQ) was designed to collect demographic data for each participant counselor (Appendix A). In particular, the PPQ asked for subjects' primary ACA affiliation, gender, age, ethnicity, and highest educational degree. The Treatment Recommendations Questionnaire (TRQ) asked the subjects for their recommended course of action by identifying which of the three modes of therapy they would employ initially (i.e., individual, group, or family counseling). Then, each participant therapist was asked how important each mode of therapy is to the resolution of the abuse. Scores were obtained for the primary treatment modality and the ratings for each method. The children described in the Treatment Recommendations Questionnaires were abused by either a father (Form A) or a nonrelative male swim teacher (Form B). As described in the hypothetical client scenarios, the Department of Social Services has

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138 labeled the allegations of abuse as "confirmed," and the child is referred to the participating therapist for counseling. This excludes cases in which the allegations are considered "unsubstantiated" which usually require more investigation prior to therapy. In addition, the child victim is described as a female who is 10 years old. Since the average age of child sexual abuse victims is 10 years (Crewdson, 1988; Finkelhor, 1986; Finkelhor et al, 1990), this age was chosen for investigation. The recommended treatment outcomes may vary with a different age child. In this study, only female survivors were investigated. While victims include both males and females, it is estimated that females are sexually abused almost 4 times as often (Finkelhor, 1984). The hypothetical scenario does not describe the child victim's race. Of the total number of reported sexual abuse victims, 77.4% are Caucasian; 1 1 .1% are African American; 8.9% are Hispanic; and 2.7% represent other ethnic backgrounds (DePanfilis, 1986). It was expected that the recommended course of treatment would not vary greatly based on the victim's race. As described in the TRQ, the abuse is said to have progressed over a period of 1 year prior to disclosure. In most cases, the abuse continues over a period of time and progresses in severity (Brownmiller, 1975; Groth, 1979; Hoorwitz, 1983; Morrow & Sorell, 1989; Vander Mey & Neff, 1982). Disclosures are usually tentative or desperate attempts for help, and the full story is unknown prior to therapy (Crewdson, 1988; Mayer, 1983; Summit, 1983). Therefore, in this scenario, the therapist was not given much information about the nature of the abuse. The child disclosed aspects of the abuse

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139 to her fifth-grade teacher. Most often, child victims disclose to a trusted individual and usually not the mother (Leahy, 1991; Mayer, 1983; Russell, 1983). According to the TRQ, the child and the offender no longer have contact; social services is involved in the case; and the social services worker has determined that the child's mother is able to protect her from further abuse. Given this scenario, safety concerns would not be paramount for the counselor. In most actual child sexual abuse cases, there is no physical harm to the child (DeJong, 1985). Therefore, there are no medical problems or concerns for the hypothetical child clients. Since safety and medical issues would take precedence over therapeutic issues (Lebowitz, Harvey, & Herman, 1993), these were stabilized already. In this sense, the client is truly ready to begin treatment rather than focusing on pretreatment issues. There is no one symptom universal to all sexual abuse victims (Faller, 1993; Finkelhor, 1987). Therefore, the researcher chose three of the most common difficulties for child victims in this age group. In particular, withdrawal (Adam-Tucker, 1982; Basta & Peterson, 1990; Blumberg, 1981; Friedrich, Urquiza, & Beilke, 1986; Kolko, Moser, & Weldy, 1988; Sgroi, 1982; Gale et al., 1988; Yates, 1982), school problems (Einbender & Friedrich, 1989; Elwell & Ephross, 1987; Tong, Gates & McDowell, 1987), and sleep disturbance (Browne & Finkelhor, 1986; Elwell & Ephross, 1987; Mannarino & Cohen, 1986) are consistently cited in the literature. The offender in this study is male and has a previous relationship with the child as either her father or her swim teacher. This depiction was chosen since 98% of all reported offenders are male (Finkelhor et al., 1990; Gelinas, 1983; National Center on

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140 Child Abuse and Neglect, 1978), and in 80% of the cases, the offender is known to the child (Peters, 1976). According to the literature, the child's relationship with the offender affects the actual course of the abuse, resultant symptomology, and the recovery process (Basta & Peterson, 1990; Benedek & Schetky, 1986; Downs, 1993; Finkelhor, 1979; 1986; Herman, Russell, & Trocki, 1986; Mrazek & Kempe, 1981; Mrazek & Mrazek, 1981; Phelan, 1986; Sirles, Smith, & Kusama, 1989). Therefore, the child's relationship with the offender was examined as the chief mediating variable. In the TRQ hypothetical profile, the case is pending legal action. According to the available data, 40% of sexually abusive famiUes are referred for prosecution (Russell & Trainor, 1984), yet less than 25% of child victims actually testify in court (Rogers, 1980; Runyan et al., 1988). Since legal status is rarely definitive in actual cases of child sexual abuse, it was not clearly delineated for the participating counselors. The impact of pending and actual court testimony on the recovery process is unknown. As described in the scenario, the child victim's mother supports and believes her. While this may not be true in all cases, this is an integral part of the family's commitment to therapy, and it makes the child the center of treatment as opposed to the mother and her disbelief. According to the literature, support from the nonoffending parent is crucial to a child victim's recovery (Adams-Tucker, 1982; Bowlby, 1973; Conte & Berliner, 1981b; Conte & Schuerman, 1988; Everson et al., 1989; Friedrich, 1990; Fromuth, 1986; Peterson & Urquiza, 1993; Tufts New England Medical Center, 1984). Finally, the therapist was to assume that client cooperation and the financial cost for treatment were

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141 not a problem for either family described in the TRQ. Since these factors could alter the course of treatment, they were controlled (Kempe & Kempe, 1984). Research Procedures The researcher requested permission and obtained approval from the University of Florida Institutional Review Board to proceed with the study as proposed. Following this approval, the researcher sent research packets to professional counselors across the United States who were active members of ACA. A random sample of professional practitioner's in each of the three divisional categories (ASCA, AMHCA, and lAMFC) was generated by the ACA marketing department. The researcher paid a fee to obtain this random sample which included the names and addresses of 1,000 potential subjects. A minimum of 100 professional members from each counselor group was expected to participate. The professionals were selected to participate if they were (a) active ACA members (e.g., their membership status is active), (b) professional members belonging to either ASCA, AMHCA, or lAMFC, and (c) willing to participate in this study. The researcher sent each participating professional counselor the research packet to include the PPQ and TRQ. Instructions for completing these instruments was outlined clearly for each participant therapist. The research packets contained (a) a transmittal letter (Appendix D), (b) the PPQ (Appendix A), (c) the TRQ (Form A or Form B) (Appendices B and C), and (f) a self-addressed, postage-paid envelope for return of the instruments. Half of the participants in each group received the TRQ Form A and half received Form B.

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142 If willing to participate, the professional counselor read the instructions and completed the PPQ and TRQ. The therapists were asked to complete these questionnaires fully and determine treatment recommendations as if this were their own client. The completed PPQ and the TRQs were mailed back to the researcher for scoring. A final deadline of 3 weeks after the requested date of return was set. Questionnaires arriving after the final deadline were not included in the data analyses. Data Analyses A profile of the population of participating therapists was developed from the demographic questionnaires. The means and standard deviations or frequencies and the intercorrelations of the demographic data were calculated. These data about the nature of the sample will aid practitioners and other researchers in making future comparisons. In addition, with these data, the researcher was able to determine which of these variables needed to be statistically controlled in later analyses. Chi-square analyses and a one-way ANOVA were be used to determine how the demographic variables for each professional grouping and the offender's relationship with the hypothetical child client affected the recommended course of treatment. Appropriate follow-up tests were used to detect the significance of the interactions among these variables. Limitations of the Study The design for this research study was not a true experimental one in which all extraneous variables were controlled. Instead, the hypotheses were tested using survey research methods. Survey research methods were chosen in place of a controlled

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143 laboratory setting which would have limited the number of subjects and proved impractical for this research. There are several limitations inherent in the scope of the study including the instrumentation and chosen population. The researcher made attempts to narrow limitations and employ as much time and money as possible for the study. There are limitations in the instrumentation in that the PPQ and the TRQ were designed specifically for this study and are without the advantage of normative data. However, because there are no standardized instruments designed to detect differences in child sexual abuse treatment recommendations, the researcher developed these instruments using data available from the literature. The researcher did not choose to utilize a battery of tests due to economic and time constraints. The researcher was aware that the time to complete a survey is limited for professional counselors. Therefore, the researcher made the assessment packets as brief as possible. Limitations of the TRQ also are found in the fact that the practitioners supply subjective reports of "what they would recommend" under ideal circumstances. This may not be what happens in reality due to constraints with time, money, client cooperation, availability of services, and work setting philosophy. Furthermore, in many cases, more than one method of initial intervention is recommended when treating child sexual abuse victims (Friedrich, 1990; Trepper «fe Barrett, 1989). On the TRQ, however, the counselors were asked to choose one preferred method of treatment from a list of three options (individual, group, or family therapy). As a result, the conclusions about therapeutic methods are limited. The goal of this research, however, was to begin to

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144 understand how a counselor's chosen field of practice affects the chosen course of treatment for child sexual abuse victims. The researcher hoped to reduce areas of bias and obtain a diverse and representative sample by surveying a large number of professional counselors across the United States. The disadvantage in long distance surveys is that the researcher had less control over administration and compliance. In addition, the sample for this study was a volunteer one including only those therapists who were willing to participate. While the sample of professionals was chosen randomly, the scope of this study was limited to those professionals who returned the completed instruments. Therefore, the results cannot be generalized to all practicing professional counselors in each of the three groups.

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CHAPTER IV RESULTS This study investigated differences in preferences for methods of counseling intervention with sexually abused children. A sample of school, mental health, and family counselors was dravra from the American Counseling Association based on the criteria described previously. Data were gathered using the Professional Profile Questionnaire and the Treatment Recommendations Questionnaire (Appendices A, B, and C). A random sample of 1,000 ACA members was sent the research packets. Half of the sample in each counselor group was sent Form A of the Treatment Recommendations Questionnaire (Appendix B) and half was sent Form B (Appendix C). Form A described a female child abused by her natural father, and Form B described abuse by a nonrelated swim teacher. A total of 226 participants returned Form A and 244 returned Form B. Descriptive statistics were generated and the hypotheses tested. The results of the data analyses are presented in this chapter. Participants A total of 470 ACA members participated in this study by fully completing the instruments, resulting in a 47% return rate. The return rates by group are presented in Table 1. An analysis of the demographic data from the Professional Profile Questionnaires is presented in Tables 2 and 3. 145

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146 Table 1 Comparison of the Return Rates by Counselor Group Number Number Pecent Participant Type Sent Returned Returned 1. ASCA(SC) 333 169 50 2. AMHCA(MHC) 333 200 60 3. lAMFC (MFC) 334 101 30 Total 1,000 470 47 Table 2 Participant Ages Counselor Type N Mean Age S.D. Cell % SC 164 40.98 10.56 36 MHC 195 44.92 11.39 42 MFC 99 43.64 11.18 22 Total 458 43.23 11.17 100 There were 169 school counselor (SC), 200 mental health counselor (MHC), and 101 marriage and family counselor (MFC) respondents. In AC A, there are currently 6,705 ASCA, 6,243 AMHCA, and 6,910 lAMFC members (ACA, 1997). While

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147 lAMFC is the largest of these three ACA groups, they had the lowest response rate (N = 101). However, the sample sizes were large enough for legitimate data analyses. Table 3 Participant Demographic Characteristics Question N Cell % Gender: 1. Male 118 25.1 2. Female 352 74.9 Ethnicity: 1. AfricanAmerican 12 2.6 2. AsianAmerican 5 1.1 3. Native American 3 0.6 4. Hispanic/Latino 9 1.9 5. White American 432 91.9 6. Other 9 1.9 Highest Educational Degree: 1. Doctorate 74 15. 7 2. Master's 347 73.8 3. Bachelor's 28 6.0 4. Specialist 21 4.5 5. Other 0 0

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148 The demographics of the resultant sample closely resemble the most recent AC A demographic data. In particular, 75% of the sample was female and 25% male. Similarly, ACA members are 70% female and 30% male (ACA, 1997). Also in this study, 429 White American participants comprised 92% of the sample. Ninety percent of ACA members who volunteered to report their ethnicity to ACA are White American. Other ethnicities were not represented by large numbers. There were only 12 African-Americans, 8 Asian-Americans, 3 Native Americans, 9 Hispanic/LatinoAmericans, and 9 who belonged to an "other" category. This is similar to ACA data, however, in which only 5% of members are African-American and approximately 6% belong to other ethnic groups, excluding White and African-American groups (ACA, 1997). According to the most recent membership data, 1 8% of ACA members have doctoral, 68% have master's, 10% bachelor's, and 3% specialist degrees (ACA, 1997). Similarly, 16% of the sample for this study had doctoral, 74% master's, 6% bachelor's, and 4.5% specialist degrees. The category for "other" on the professional profile questionnaire was eliminated from the data analyses because there were no respondents who reported this category. Table 4 presents the cross tabulations for each degree by counselor type. The master's group was the largest (N = 347). In fact, 80% of the SC, 71% of the MHC, and 69% of MFC had master's degrees. The second largest grouping was those with doctorates, which comprised 7% of SC, 21% of MHC, and 20% of MFC groups, respectfully.

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149 Table 4 A Cross Tabulation of Degree bv Counselor Type Counselor Type Degree SC MHC MFC Total Doctorate 12 42 20 74 Master's 136 141 70 347 Bachelor's 10 12 6 28 Specialist 11 5 5 21 Total 169 200 101 470 In regard to age, 1 2 participants chose to not to report their ages. The mean age of the remaining participants was 43 years (see Table 2). The youngest participant was 22 and the oldest 77. Similarly, ACA reports indicate that their members range from 22 to over 77 years old. Forty percent of ACA members are between the ages of 47 and 56 years, and 25% are between 36 and 46 years (ACA, 1997). The median age for the participants was 45 years. Two age groupings were developed from which to analyze the data. Age Group 1 included those participants age 22 through 44. Age Group 2 included participants age 45 through 77. See Table 5 for the cross tabulations of age groupings across the three counselor types.

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150 Fifty four percent of the SC were in Age Group 1 and 46% in Age Group 2. MHC had 42% in Age Group 1 and 58% in Age Group 2. MFC had 51% in Age Group 1 and 49% in Age Group 2. On the whole, no age or age group was represented more frequently than any other. Table 5 Cross Tabulation of Age Grouping bv Counselor Type Counselor Type Age Group SC MHC MFC Total Group 1 88 82 50 220 (22-44 years) Group 2 76 113 49 238 (45-77 years) Total 164 195 99 458 Results of Testing the Hypotheses Seven primary null hypotheses and 15 secondary hypotheses were tested through data analyses computed by using the SPSS for Windows, Version 7.0, Statistical Program (SPSS, 1995). Primarily, analyses of variance (ANOVA) tests and chi-square tests were computed. For post hoc comparisons, Scheffe's test was used. The Scheffe test was used because it is a conservative test and much less sensitive to violation of distribution normality (Glass & Stanley, 1970).

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151 Hypotheses 1 The first null hypothesis stated, There is no association between counselor type, form for the Treatment Recommendations Questionnaire, and the primary counseling intervention recommended. A chi-square test was computed to examine the relationships among the counselor type (SC, MHC, MFC), the form (Form A = father as offender; Form B = nonrelative swim teacher as offender), and the primary mode of intervention recommended (individual, group, or family counseling). Table 6 reveals that the chi square for form (.689 with 1 df) was not significant (p = .406) for this analysis. However, counselor type and mode were significant (p = .000). Therefore, this null hypothesis was rejected. Table 6 Chi-Sauare Test Statist ics for Counselor Tvpe. Form, and Mode of Recommended Intervention Counselor Type Form Mode Chi square df Assumptive Significance 32.736 2 .000 .689 1 .406 221.047 3 .000

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152 A cross tabulation of counselor type by mode of intervention was conducted to determine where the significance lies. As presented in Table 7, 54% of the participants chose individual counseling as the primary mode, 20% chose to refer, 1 8% chose family, and 8% chose group. Sixty-five percent of the MHC chose individual as the primary mode compared with 40% of SC and 22% of MFC. The scores for the group therapy mode were lowest; 10% of MHC chose group as primary, 7% of SC and 6%> of MFC. Thirty-four percent of MFC chose family as the primary mode compared to 20%) of MHC and 6.5% of SC. The SC had the highest percentage for referral (46%) compared with 5.5% for MHC and 6% for MFC. Table 7 Cross Tab ulation of Counselor Type bv Mode of Recommended Intervention Counselor Type Mode SC MHC MFC Total Individual 68 129 55 252 Group 12 20 6 38 Family 11 40 34 85 Referral 78 11 6 95 Total 169 200 101 470

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153 Hypothesis 2 The second null hypothesis stated, There is no difference in the rating for individual counseling based on form. A one-way analysis of variance (ANOVA) was computed to determme whether the form made a difference in the rating for individual counseling. Form A describes the offender as the child's father (N = 226). In Form B, the offender is described as a nonrelative swim teacher (N = 244). There was a statistically nonsignificant F value (F = .967) for this analysis. Therefore, this null hypothesis was not rejected. Hypothesis 3 Hypothesis 3 stated. There is no difference in the rating for group counseling based on form. The ANOVA fmdings indicate that the F value was not significant (F = .878). Therefore, this null hypothesis was not rejected. Hypothesis 4 Hypothesis 4 stated. There is no difference in the rating for family counseling based on form. The results of the ANOVA computation revealed a statistically nonsignificant F value (F = .305). This null hypothesis was not rejected. Hypothesis 5 Hypothesis 5 stated. There is no difference in the rating for individual counseling based on counselor type.

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154 A one-way analysis of variance (ANOVA) was computed to determine whether the counselor groups rated the importance of individual therapy significantly different. As seen in Table 8, a statistically significant (F — 5.293; g — .005) main effect F value resulted from this analysis. Therefore, null hypothesis 5 was rejected at the .05 alpha level. Table 8 Analvsis of Variance for Individual Therapy Rating Sum of Squares df Mean Square F Significance Between Groups 36.505 2 18.252 5.293 .005 Within Groups 1603.461 465 3.448 Total 1639.966 476 A Scheffe post hoc multiple comparison test was computed to determine where the differences lie. In particular, there were significant differences found in the SC and MHC ratings of individual therapy = .014). Table 9 also shows that significant differences were found between SC and MFC (q = .038). There were no significant differences found between the MHC and MFC for the individual counselinj ratings.

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155 Table 9 Post Hoc Comparisons for Ratings for Individual Therapy Dependent Variable: Individual Mean Standard Counselor Type Difference Error Significance sc MHC .5732* .195 .014 MFC .6011* .234 .038 MHC SC -.5732* .195 .014 MFC 2.782E-02 .227 .992 MFC SC -.6011* .234 .038 MHC -2.78E-02 .227 .992 * E< .05. A comparison of the mean scores for this analysis (Table 10) reveals that the SC group rated individual therapy highest (9.38, SD = 1.30) when compared to the MHC (8.81, SD = 21 1) and MFC (8.78, SD = 2.10) groups. Table 10 Means and Standard D eviations for the Ratings for Individual Therapv bv Counselor Type Counselor Type N Mean SD SC 167 9.3832 1.2975 MHC 200 8.8100 2.1086 MFC 101 8.7822 2.0957 Total 468 9.0085 1.8740

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156 Hypothesis 5 a Hypothesis 5a stated, There is no difference in the rating for individual counseling based on gender. A one-way analysis of variance (ANOVA) was computed, and the F ratio (F = 40.04) presented in Table 1 1 was significant = .000). Therefore, the null hypothesis was rejected. Table 11 Analysis of Variance for Individual Therapy Rating by Gender Sum of Mean Squares df Square F Sig. Between Groups 129.758 1 129.758 40.039 .000 Within Groups 1510.208 466 3.241 Total 1639.966 467 According to the mean scores as presented in Table 12, females rated individual counseling significantly higher than males (9.3 vs. 8.1). A cross tabulation of counselor type by gender (Table 13) revealed that 85% of the SC were female, as were 72.5% of the MHC and 63% of the MFC. As found in the data analysis for hypothesis 2, school counselors rated individual therapy higher than the other two groups.

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157 Table 12 Means and Standard Deviations for Individual Therapy Ratings bv Gender Gender H Mean SD Range Male 118 8.1017 2.3071 (7.6811-8.5223) Female 350 9.3143 1.5946 (9.1466-9.4819) Total 468 9.0085 1.8740 (8.8383-9.1788) Table 13 A Cross Tabulation of Counselor Type bv Gender Gender Co-Type Male Female Total SC 26 143 169 MHC 55 145 200 MFC 37 64 101 Total 118 352 470 Hypothesis 5h Hypothesis 5b stated, There is no difference in the rating for individual counseling based on ethnicity.

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158 The F ratio for this ANOVA across ethnic categories (F = .891) was not significant = .487); therefore, null hypothesis 5b was not rejected. Hypothesis 5c Hypothesis 5c stated, There is no difference in the rating for individual counseling based on the highest degree held. A one way analysis of variance (ANOVA) revealed significant differences in the ratings for individual therapy based on degree = .008). Therefore, hypothesis 5c was rejected. As shown in Table 14, the F ratio was 4.015. The "other" category was eliminated from the data analysis because no participants checked this category. Table 14 Analysis of Variance f or Individual Counselirif; Rating hv Highest Degree Held Sum of Squares df Mean Square F Sig. Between Groups 41.495 3 13.832 4.015 .008 Within Groups 1598.470 464 3.445 Total 1639.966 467

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159 Post hoc tests were performed to determine where the significance lies. As presented in Table 15, the Scheffe test revealed a significant difference between the doctorate and master's groups = .013). Table 15 Post Hoc C omparisons for Highest Degree Held and Ratines for Individual Therapy Dependent Variable: Individual Rating Mean Standard Degree Difference Error Significance Doctorate Master's .7872* .239 .013 Bachelor's -1.0279 .418 .111 Specialist .5147 .460 .740 Master's Doctorate .7872* .239 .013 Bachelor's .2407 .371 .936 Specialist .2725 .417 .935 Bachelor's Doctorate 1.0279 .418 .111 Master's .2407 .371 .935 SpeciaHst .5132 .540 .825 Specialist Doctorate .5147 .460 .740 Master's .2725 .417 .935 Bachelor's .5132 .540 .825 * E< -05. The mean scores as presented in Table 16 show that counselors with a bachelor's degree rated individual counseling the highest (9.37). Also, counselors with a doctorate

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160 rated individual counseling lower (8.34) than the master's (9.13), bachelor's (9.37), or specialist (8.86) groups. Table 16 Means and Standard Deviations for Individual Counseling Ratings bv Highest Degree Held Degree n Mean SD Doctorate 73 8.3425 2.3047 Master's 347 9.1297 1.7726 Bachelor's 27 9.3704 1.5229 Specialist 21 8.8571 1.8516 Total 468 9.0085 1.8740 Hvpothesis 5d Hypothesis 5d stated, There are no significant interactions among counselor type, gender, ethnicity, and degree for the ratings for individual counseling. Because 92% of the sample was White American, the ethnicity variable was not included in this analysis of variance. Instead, the interactions for counselor type, gender, and degree were examined for their effects on the ratings for individual therapy. A factorial ANOVA was computed. As shown in Table 17, significance was found in the 3-way interactions only (F = 2.558, q = .019).

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161 Table 17 Analysis of Variance for Individual Counseling Rating by Counselor Type. Gender, and Highest Degree Held Sum of Mean Squares df Square F Sig. Main Effects Combined 28.874 6 4.812 1.519 .170 Co-Type .304 2 .152 .048 .953 Gender 12.001 1 12.001 3.788 .052 Degree 3.950 3 1.317 .416 .742 2Way Interactions Combined 38.235 11 Co-Type* Gender 3 -Way Interactions Co-Type Gender* Degree Model Total 2.455 Co-Type* Degree 23.043 Gender* Degree 11.873 48.628 3.476 1.227 3.841 233.244 23 10.141 1639.966 467 3.512 1.097 .362 .387 .679 1.212 .299 3.958 1.249 .291 8.105 2.558 .019 3.201 .000 *E < .05.

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162 Hypothesis 5e Hypothesis 5e stated. There is no relationship between age and the rating for individual counseling. To determine the relationship between age and the rating for individual therapy, a one-way analysis of variance (ANOVA) was computed. Due to the spread of the participants' ages, age categories were created for statistical analyses. Age Group 1 included participants aged 22 through 44, and Age Group 2 included ages 45 through 77 years. As illustrated in Table 18, there was a statistically significant (F = 5.535, £ = .019) F value for this variable. Table 18 Analvsis of Variance f or Individual Counseling Rating hv Age Group Sum of Squares df Mean Square F Sig. Between Groups 19.440 19.440 5.535 .019 Within Groups 1594.551 454 3.512 Total 1613.991 455

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163 The mean scores as presented in Table 19 indicate that counselors under age 44 rated individual therapy higher (9.22) than those over age 44 (8.81). Null hypothesis 5e was rejected. Table 19 Means and Standard Deviations for Individual Counseling Rating bv Age Group N Mean SD Range Age Group 1 (22-44 years) 219 9.2192 1.5789 (9.0089-9.4295) Age Group 2 (45-77 years) 237 8.8059 2.1104 (8.5358-9.0760) Total 456 9.0044 1.8834 (8.8311-9.1777) Hypothesis 6 Hypothesis 6 stated, There is no difference in the rating for group counseling based on counselor type. A one-way analysis of variance (ANOVA) was computed to test this hypothesis. Table 20 reveals a statistically significant (F = 7.71, p = .001) F value. A post hoc Scheffe test as presented in Table 21 shows that there were significant differences for group rating found between the SC and MHC groups (p = .001). In addition, there were significant differences found between the SC and MFC groups (p = .035).

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164 Table 20 Analysis of Variance for Group Counseling Rating bv Counselor Type Sum of Squares df Mean Square F Sig. Between Groups 120.448 2 60.224 7.710 .001 Within Groups 3632.133 465 7.811 Total 3752.581 467 Table 21 Post Hoc Comparisons for Counselor Type and Ratings for Groun Counseling Dependent Variable: Group Rating Schefife Mean Standard Counselor Type Difference Error Significance SC MHC 1.1137* .293 .001 MFC .9160* .352 .035 MHC SC -1.1137* .293 .001 MFC .1977 .341 .845 MFC SC .9160* .352 .035 MHC .1977 .341 .845 *C<.05.

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165 A comparison of mean scores (Table 22) demonstrates that SC rated group significantly higher (7.14) than the MHC (6.03) or MFC (6.23). Therefore, the null hypothesis was rejected. Table 22 Means and Standard Deviations for Group Counseling Ratings by Counselor Type Counselor Type N Mean SD Range SC 167 7.1437 2.6028 (6.7461-7.5414) MHC 200 6.0300 2.8758 (5.6290-6.4310) MFC 101 6.2277 2.9356 (5.6482-6.8072) Total 468 6.4701 2.8347 (6.2126-6.7276) Hypothesis 6a Hypothesis 6a stated. There is no difference in the rating for group counseling based on gender. A one-way analysis of yariance (ANOVA) was computed. The results of this analysis indicated that there was not a statistically significant F yalue (F = 1.777, p = . 1 83) for the gender yariable. Therefore, the null hypothesis was not rejected.

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166 Hypothesis 6b Hypothesis 6b stated, There is no difference in rating for group counseling based on ethnicity. A one-way analysis of variance (ANOVA) was computed to test this hypothesis. Table 23 presents the results which indicate a statistically significant F value (F = 3.115, E = .009). Table 23 Analvsis of Variance for Group Counseling Rating bv Ethnicity Sum of Squares df Mean Square F Sig. Between Groups 122.392 5 24.478 3.115 .009 Within Groups 3630.189 462 7.858 Total 3752.581 467 The null hypothesis was rejected, and a post hoc Scheffe test was computed to examine where the differences lie (Table 24). In particular, there were significant differences between AfricanAmericans and White Americans {q = .014). An exammation of the mean scores as found m Table 25 shows that African-Americans rated group therapy much lower (3.42) than White Americans (6.54). It is important to note, however, that the cell sizes for the nonwhite ethnic groups were

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167 Table 24 Post Hoc Comparisons for Ethnicity and Ratings for Group Counseling Ethnic Group Mean Difference Standard Error Significance African Asian Native Hispanic White Other Asian African Native Hispanic White Other Native African Asian Hispanic White Other Hispanic African Asian Native White Other White Other African Asian Native Hispanic Other African Asian Native Hispanic White -2.5833 -3.9167 -3.0278 -3.1229* -3.8056 2.5833 -1.3333 -.4444 -.5395 -1.2222 3.9167 1.3333 .8889 .7938 .1111 3.0278 .4444 -.8889 -9.51E-02 -.7778 3.1229* .5395 -.7938 9.509E-02 -.6827 3.8056 1.2222 -.1111 .7778 .6827 1.492 1.809 1.236 .820 1.236 1.492 2.047 1.564 1.261 1.564 1.809 2.047 1.869 1.624 1.869 1.236 1.564 1.869 .944 1.321 .820 1.261 1.624 .944 .944 1.236 1.564 1.869 1.321 .944 .700 .457 .308 .014 .094 .700 .995 1.000 .999 .987 .457 .995 .999 .999 1.000 .308 1.000 .999 1.000 .997 .014 .999 .999 1.000 1.000 .094 .987 1.0000 .997 .991 *E<05.

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168 much smaller. There were only 12 participants in the AfricanAmerican group compared with 430 in the White American group. Table 25 Means and Standard Deviations for Group Counseling Ratings bv Ethnicity Ethnic Group H Mean SD African-American 12 3.4167 3.1467 Asian-American 5 6.0000 4.1833 Native American 3 7.3333 1.1547 Hispanic/Latino 9 6.4444 2.6510 White American 430 6.5395 2.7948 Other 9 7.2222 2.2791 Total 468 6.4701 2.8347 Hypothesis 6c Hypothesis 6c stated, There is no difference in the rating for group counseling based on highest degree held. To determine the relationship between degree and the rating for group counselinj a one-way analysis of variance (ANOVA) was computed. The results revealed a statistically nonsignificam F value (F = 2.20). This null hypothesis was not rejected.

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169 Hypothesis 6d Hypothesis 6d stated, There are no significant interactions among counselor type, gender, ethnicity, and degree for the ratings for group counseling. Again, the ethnicity variable was not included in the data analyses due to the fact that 92% of the sample were from the White American category. A factorial ANOVA was computed to examine the interactions among the remaining variables. No significant interactions were found. Hypothesis 6e Hypothesis 6e stated. There is no relationship between age and the rating for group counseling. A one-way analysis of variance (ANOVA) was computed, and the F value was found to be statistically nonsignificant (F = .006, q = .936). Therefore, the null hypothesis was not rejected. Hypothesis 7 Hypothesis 7 stated. There is no difference in the rating for family counseling based on counselor type. A nonsignificant F value (F = 2.476) was found for this analysis using a one-way analysis of variance (ANOVA). This null hypothesis was not rejected. Hypothesis 7a Hypothesis 7a stated,

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170 There is no difference in the rating for family counseling based on gender. A one-way analysis of variance (ANOVA) was computed to test this hypothesis. The F value (F = 2.12) was not significant. Therefore, this null hypothesis was not rejected. Hypothesis 7h Hypothesis 7b stated There is no difference in the rating for family counseling based on ethnicity. Again, a one way ANOVA was computed and revealed a non-significant F value (F = .436). This null hypothesis was not rejected. Hypothesis 7c Hypothesis 7c stated, There is no difference in the rating for family counseling based on highest degree held. The results of the one-way ANOVA indicate that the F value for this analysis was nonsignificant (F = 2.052). Therefore, this null hypothesis was not rejected. Hypothesis 7d Hypothesis 7d stated. There are no significant interactions among counselor type, gender, ethnicity, and degree for the rating for family counseling. The ethnicity variable was eliminated from this analysis. A Factorial ANOVA was computed. Table 26 shows that the interactions between counselor type and degree were significant (p = .009). This null hypothesis was rejected.

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171 Table 26 Analysis of Variance for the Family Counseling Ratings bv Counselor Type. Gender, and Highest Degree Held Family Rating Sum of Squares df Mean Square F Sig. Main Effects (Combined) 175.906 6 29.318 1.627 .138 Co-Type Gender Degree 48.509 8.843 82.288 2 1 3 24.255 8.843 27 429 1.346 .491 1 523 .261 .484 908 2-Way Interactions (Combined) 406 298 11 36 936 .\jLj Co-Type* Gender 9.519 2 4.759 .264 .768 Co-Type* Degree 309.990 Z.oOo nno .uuy Gender* Degree 40.562 3 13.521 .751 .522 3-Way Interactions Co-Type* Gender* Degree 86.743 6 14.457 .803 .568 Model 804.048 23 34.959 1.941 .006 Total 8802.692 467 18.849

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172 Hypothesis 7e Hypothesis 7e stated, There is no relationship between age and the rating for family counseling. Again, due to the variance in the ages, two age group categories were used to test this hypothesis. A nonsignificant F value was found (F = .765), and the null hypothesis was not rejected. A cross tabulation of family counseling rating by degree by counselor type is presented in Table 27. From this analysis of the data, it appears that the MFC who had either a doctorate or a specialist degree rated family the highest (10.00). In fact, 80% of the MFC who had a doctorate and 80% of the MFC with a specialist degree rated family counseling as a 10. In addition, 67% of MFC with a bachelor's degree rated family as a 10. Only 31% of the total number of SC rated family counseling as a 10. In comparison, 38% of MHC and 49% of MFC rated family as a 10. It is interesting to note that the lowest score for counselors with specialist degrees was 7.0. The lowest scores for bachelor degrees was 3.0 compared to 0.0 for masters degrees and 1 .0 for doctorates. Furthermore, 52% of bachelors rated family somewhere under 5.0 compared with 38% of the doctorates, 28% of the master's group and 0% of the specialist group. An examination of the mean scores for family rating by counselor type (Table 28) reveals that MFC rated family the highest (9.04) in comparison to SC (7.93) and MHC groups (7.98).

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173 Table 27 Cross Tabulation of Family Counseling Rating bv Degree and Counselor Type Co-Type Doctorate Master's Bachelor's Specialist Tota SC Rating .00 1 1 1 nn 1 .UU 1 1 2 2.00 1 1 J.UU 3 3 4.00 3 3 5.00 2 10 2 14 6.00 1 7 3 11 7.00 3 14 17 8.00 1 35 2 6 44 9.00 16 1 1 18 10.00 3 45 1 4 53 Total 11 136 9 11 167 MHC Rating .00 3 3 l.UU 2 2 2.00 4 1 5 3.00 3 3 4.00 2 3 2 7 5.00 3 8 2 13 6.00 7 1 8 7.00 3 13 1 1 18 8.00 2 28 4 1 35 9.00 7 23 1 31 10.00 19 52 2 2 75 Total 42 141 12 5 200

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174 Table 27-continued. Co-Type Doctorate Master's Bachelor's Specialist Total MFC Rating .00 2 2 1.00 1 1 2.00 1 1 3.00 1 1 4.00 2 2 5.00 7 7 6.00 1 7 8 7.00 16 1 8 8.00 1 13 1 15 9.00 7 7 10.00 16 25 4 4 49 Total 20 70 6 5 101

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175 Table 28 Means and Standard Deviations for Family Counseling Rating by Counselor Type Counselor Type N Mean SD SC 167 7.9281 2.1073 MHC 200 7.9850 2.4091 MFC 101 9.0396 8.2570 Total 468 8.1923 4.3416 Furthermore, as shown in Table 29, the mean scores for doctorates (9.15) and specialists (9.0) showed higher family ratings than the master's (8.01) and bachelor's groups (7.26). Table 29 Means and Standard Deviations for Familv Counseling Ratine bv Hiehest Degree Held Degree N Mean SD Doctorate 73 9.1507 9.5706 Master's 347 8.0144 2.2133 Bachelor's 27 7.2593 2.1943 Specialist 21 9.0000 1.0488 Total 468 8.1923 4.3416

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CHAPTER V DISCUSSION According to experts in the field, one in three female children experience sexual abuse before reaching adulthood (Finkelhor, 1986, 1979; Herman & Hirshman, 1981; Russell, 1988). The damaging emotional effects of child sexual abuse are well documented, and between 46% and 95% of victims eventually exhibit problematic symptomology (Browne & Finkelhor, 1986; Friedrich, Urquiza, & Beilke, 1986; Gale et al., 1988; Mannarino & Cohen, 1986; Mian et al., 1986). In many cases, these abused children are referred to a counselor to treat the resultant symptomology. Treatment for child sexual abuse may involve individual, group, and/or family therapy. It is unclear, however, which therapies are recommended most often by which professional counselors for which particular child clients. The data collected from this research begin to address these issues. The primary purpose of this study was to determine whether therapist-chosen field of pracfice (school, mental health, or marriage and family counseling) was associated with the type of treatment recommended (individual, group, or family) for female child sexual abuse victims. The child's relationship with the offender (father vs. nonrelated swim teacher) was introduced as a moderating variable. This chapter includes evaluations of the 176

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177 hypotheses, discussion of the results, limitations, recommendations for further study, and conclusions. Evaluation and Discussion of the Results Hypothesis 1 Hypothesis 1 stated that there would be no association between counselor type (school, mental health, or marriage and family counselor), the form of the Treatment Recommendations Questionnaire (TRQ), and the primary counseling intervention recommended for a female child sexual abuse victim. The results indicate that the form for the TRQ was nonsignificant. Therefore, the primary mode of counseling chosen was not affected by whether the offender was described as a relative (Form A) or nonrelative (Form B). However, there was a statistically significant association between counselor type and the primary mode of therapy chosen. Fifty-four percent of the participants chose individual therapy as the primary mode of counseling regardless of the child's relationship with the offender. These findings are in support of the literature suggesting that counselors initiate individual therapy for all family members first and only later introduce alternate therapies (Madanes, 1990). In a study of 553 child sexual abuse treatment programs across the United States, 31% reported using individual therapy as the primary mode, and group or family interventions were added when appropriate (Keller, Cicchinelli, & Gardner, 1989). Treatment experts recommend that victims participate in individual counseling initially so that they feel support as they are introduced to the recovery process (Madanes, 1990; Mayer, 1985; Sgroi, 1982). Also, within the context of an individual therapeutic relationship, child

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victims feel safer to express their feelings about the abuse (Lebowitz, Harvey, & Herman, 1993; Mayer, 1985). Practitioners and researchers report positive results using individual therapy with abused clients (Friedrich, 1990; Friedrich & Reams, 1987; Madanes, 1990). In one small study of young sexual abuse victims (N = 8), the overall social and behavioral functioning was improved with individual therapy (Friedrich & Reams, 1987). In addition, the presenting problems, which included withdrawal, somatic complaints, sexual acting out, and depression, were decreased in severity of presentation (Friedrich & Reams, 1987). While the course of recovery was varied, the children who participated in individual treatment showed greater improvement than those who did not receive counseling (Friedrich & Reams, 1987). It is unknown, however, whether other therapies would have proven similar results. In the present study, it also is unclear whether the data are specific to abused children or if the participating therapists treat all child clients with individual as the primary counseling mode. Further data are needed to clarify the meaning of the results. Following individual therapy, 20% of the participants chose to refer the clients described on the TRQ. These data may be explained by the fact that many counselors feel undertrained or unqualified to treat abuse victims (Dietz & Craft, 1980). Due to the sensitivity of the issues and the legal ramifications involved with these cases, child sexual abuse treatment is becoming more and more specialized. Presumably, these clients would be referred to a counselor with specialized training in child sexual abuse treatment and/or the ability to provide longer term comprehensive services. Of the counselors who chose

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179 to refer, 46% were school counselors. This finding is not surprising since the school setting usually does not allow for long-term psychotherapy. While some school counselors may have participated in training specific to recognizing the signs of child abuse and making official reports to child protective services, they may be less versed in treatment. Following referral, 1 8% of the participants chose family counseling as the primary mode and 8% chose group therapy. Most experts would agree that it is not ideal to begin child sexual abuse treatment initiatives with group therapy (Peterson & Urquiza, 1993). Group therapy should not be introduced until child victims have addressed sensitive abuse-related issues in the context of an individual therapeutic relationship (e.g., distrust, shame, fear, and stigmatization) (Berliner, Urquiza, & Beilke, 1988; Faller, 1993; Peterson & Urquiza, 1993). Furthermore, group initiatives are considered most effective when they are implemented in conjunction with individual and family sessions (Forseth & Brown, 1981). Despite these recommendations, 10% of MHC chose group as the primary mode along with 7% of SC and 6% of MFC groups. Group therapy may be appealing for some practitioners because it is less costly and often requires less time and intensity of interaction. When insurance providers dictate the length of treatment, group therapy may be seen as the most practical and efficient counseling method. Group therapy is valued as a medium because it allows children to share common experiences and reduce their feelings of isolation (Gagliano, 1987). According to Mayer (1985), group counseling can foster a sense of peer support and understanding. In one study, group therapy proved to successftilly increase assertiveness skills and the children

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180 avoided revictimization (Bentovim, Boston, & Van Elburg, 1987). It is unclear, however, whether a group of this type will ultimately prove successful and promote healing for the children over time. The practitioners in the current study who chose group counseling as the primary method of intervention may have found group counseling to be successful in their own work with abuse victims. However, the participants were not asked to describe the type of group introduced, how long it would be conducted, and which, if any, other therapies would be introduced as well. This is an area for further research. The rates of recommendation for group therapy were not altered significantly by the child's relationship with the offender. According to some experts, many abuse-related issues are too personal, shameful, embarrassing, and painful to disclose in a group setting (Peterson & Urquiza, 1993). Incestuous abuse presents even greater shaming effects along with intense feelings of guilt and betrayal following disclosures (Adams-Tucker, 1982; Burgess & Holstrom, 1978; Everson et al., 1989; Herman, Russell, & Trocki, 1986; Summit, 1983). Adams-Tucker (1982) found that children abused by their fathers had more severe diagnoses and were more likely to be placed in inpatient facilities (Adams-Tucker, 1982). In this study, these factors did not appear to influence the choice for group treatment. Therefore, those therapists who recommend group therapy as the primary mode apparently believe it is useful for children abused by relatives or nonrelatives. Eighteen percent of the participants chose family therapy as the primary mode of intervention. Again, this was not influenced by the fact that one offender was the child's father. In cases of incest, researchers reported greater rates of recovery and prevention

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181 with a multisystemic approach as opposed to individual therapy approaches (Friedrich, 1990; Madanes, 1990; Orenchuk-Tomiuk, Matthey, & Christensen, 1990). Yet, according to case study research, family therapy alone did not eliminate abusive patterns in families (Molnar & Cameron, 1975). Family therapy represents the "culmination of the treatment process and is usually not undertaken until there has been a determination that reunification is in the victim's best interest" (Faller, 1993, p. 66). Furthermore, family therapy can occur only if the child's family is willing to attend sessions and sees value in meeting as a group (Fumiss, 1983). In this study, it is unclear whether the family is willing and able to reunite without further abuse. Therefore, the participating therapists may view family initiatives as secondary until more information is obtained. On the other hand, it is possible that these resuhs indicate that only 18% of the respondents feel competent and comfortable providing family therapy services, or only 1 8% are in a position where family therapy is possible. Some victim-oriented treatment providers believe that sexual offenders should be treated by separate programs designed specifically for offenders. A final explanation may be that family is not seen as valuable to the healing process as individual counseling. These therapists may have found in their own practice that resolution is better achieved through individual methods. Further inquiry is needed to determine the explanation for these findings. While the primary mode of therapy was not affected by the child's relationship with the offender, there were significant differences between the counselor groups. For example, 34% of the MFC chose family therapy as the primary mode compared to 20%

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182 of MHC and 6.5% of SC. It was expected that MFC would choose family therapy more often since it is their chosen field of practice and presumably their area of expertise. However, a majority of family therapists did not choose family therapy as the primary mode. Again, it may be that most of the respondents, including the MFC, begin with individual and only later introduce family therapy. On the other hand, work settings and legal constraints with abuse cases may prohibit family therapy. The participants were not asked where they work or how their work settings influence the types of therapy introduced. In addition, there was not space on the TRQ to describe who would be involved in each type of therapy. Some work settings may not allow the offender to be included in treatment; therefore, the participating MFC chose individual therapy as the primary mode. It may be that another agency (e.g., the department of corrections) provides family therapy after the offender has attained certain initial treatment goals. For the MHC group, 65% chose individual as the primary mode, 20% chose family, and 10% group. The referral rates were low for MHC (5.5%) and MFC (6%) compared to SC (46%). Forty percent of SC chose individual, 7% chose group, and 6.5% chose family. The MFC group chose individual therapy most often (55%), then family (34%), and group (6%). According to these results, if a child client enters the office of a school counselor, she is likely to be referred to or participate in individual therapy. If the same client enters the office of a MHC, she will participate in individual counseling most often and possibly family counseling. If the child enters the office of a MFC, she will also participate in individual therapy most often but have a greater chance of participating in family therapy. This is valuable information for clients and referral agencies.

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183 Hypothesis 2 Hypothesis 2 stated that there would be no significant differences in the ratings for individual therapy based on the Form of the TRQ (Form A or Form B). The directions on the TRQ asked participants to read a client scenario and rate the importance of individual, group, and family therapy using a scale of l="not at all" to 10="essentiar' to the resolution of the abuse issues (Appendices B and C). In Form A, the offender is described as the child's father, and in Form B, the offender is a nonrelated swim teacher. For hypothesis 2, the F value was not significant (F = .967). An examination of the mean scores showed that the individual ratings for Form B were slightly higher (9.09), but not significantly higher, than Form A (8.92). In addition, the data revealed that when the offender was related to the child, family therapy was more evenly dispersed with individual (8.31 for family and 8.92 for individual), yet less so when the offender was not related to the child (8.09 for family and 9.09 for individual). Therefore, for a nonrelative offender, it is more probable that individual therapy would be introduced. When the offender is the child's father, individual and/or family therapy are more likely. Hvpothesis 3 Hypothesis 3 stated that there would be no significant differences in the ratings for group counseling based on the form of the TRQ. A nonsignificant F value (F = .878) was found, and the hypothesis was not rejected. The mean scores for group therapy were 6.49 for Form A and 6.45 for Form B; little difference was found. Overall, group therapy was rated much lower than either family or individual counseling regardless of form. According to the literanire. group interventions are best suited for later stages in

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184 therapy and are most effective when they are used in conjunction with other modalities (Forseth & Brown, 1981; Peterson & Urquiza, 1993). Therapists in practice may agree with these recommendations and, therefore, rated group lower than the other two therapies. Hypothesis 4 Hypothesis 4 stated that there would be no significant differences in the ratings for family therapy based on the form of the TRQ. A nonsignificant F value was found (F = .305), and the null hypothesis was not rejected. The mean scores were 8.31 for Form A and 8.09 for Form B. Although family therapy was rated slightly higher when the offender was a family member, it was not significantly higher. These results were surprising since abuse by a father introduces many interrelated family issues. It might have been expected that a child client abused by her father would be involved in family therapy more often than a child abused by a non-relative swim teacher. Hypotheses 2, 3, and 4 related to the form of the TRQ in which the relationship with the offender was introduced as a moderating variable. Presumably the child's relationship with the offender would significantly affect the results. Yet, form did not make a difference in the ratings for individual, group, or family counseling. According to the literature on child sexual abuse treatment, successftil outcomes are attained through comprehensive services which address both the individual and interpersonal needs (Bentovim, Boston, & Van Elburg, 1987; Berkeley Planning Associates, 1982; Brownell, Hayes, & Barlow, 1977; Cohn & Daro, 1987; Cohn & Degraaf, 1982; Dixon & Jenkins, 1981). Most often, a continuum of care is recommended where child victims begin in

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185 individual and eventually participate in group and/or family therapy as needed (Giarretto, 1976; Madanes, 1990). The participating therapists may agree that it is necessary to begin treatment with individual counseling, and, therefore, they could not rate other therapies as high until working further with the child victim. More inquiry is needed into the reasoning behind the ratings since they were not affected by the child's relationship with the offender. Hypothesis 5 The fifth hypothesis stated that no significant differences would be found in the ratings for individual counseling based on counselor type. A significant difference (p = .005) was fovmd, and null hypothesis 5 was rejected. In support of the literature, all the counselor groups rated individual therapy high (total mean = 9.01) regardless of form. The data revealed that SC rated individual therapy significantly higher (9.38) than either the MHC (8.81) or MFC (8.78) groups. There were no significant differences found between the MHC and MFC groups. The directions on the TRQ state, "Please respond to the following questions as if this child is coming to your office as a client for treatment Please answer all the questions as fully as possible within the realm of your work position, expertise, and the services offered where you work" (Appendices B and C). Most often, school counselors provide individual consultation, evaluation, and short-term therapy. Individual therapy may be most appealing to school counselors because of the realm of their work environment. In addition, school counselors may have more concentrated training in individual techniques over group or family. On the other hand, it could be that SC believe

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186 that individual is more essential to the resolution process than any other therapeutic modality. The MHC and MFC are trained to provide varied therapies, and it is likely that other therapies could be introduced in their work settings. When other therapies are valued, individual may not be rated as high. As a result, MHC and MFC may have rated individual counseling lower than SC because they have more training in other areas of treatment and more flexibility in their work settings. Future research inquiries could determine the extent to which advanced training and work setting affect the ratings for particular therapies. Hvpothesis 5 a Hypothesis 5a stated that no significant differences would be found in the ratings for individual counseling based on gender. A significant F ratio was found (£ = .000), and the null hypothesis was rejected. The results indicate that female respondents rated individual therapy significantly higher (9.31) than males (8.10). Of the total number of female respondents, 41% were from the SC group. In contrast, only 22% of the males included SC. The fact that SC rated individual therapy higher than the other two groups may explain these results. Furthermore, a large portion of the male participants (47%) were in the MHC group. On the whole, 30% of MHC chose either group or family therapies as the primary mode compared to 40% of MFC and only 14% of SC. Finally, 36% of the males in this study had doctoral degrees compared to only 9% of the females. These data indicate that counselors with doctorates rated individual therapy lower than counselors with other degrees.

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187 Hypothesis 5b Hypothesis 5b stated that there would be no significant differences in the ratings for individual therapy based on ethnicity. A nonsignificant F value was found (2 = .487), and the null hypothesis was not rejected. There was no evidence to indicate that ethnicity had an effect on the ratings for individual therapy. However, since 92% of the sample was White American, it is impossible to draw definitive conclusions about ethnicity. Hvpothesis 5c Hypothesis 5c stated that there would be no significant differences in the ratings for individual therapy based on highest degree held. There were significant differences found (e = .008), however, and null hypothesis 5c was rejected. In particular, significant differences were found between the doctorate and master's groups (e = .013). Counselors with doctorates rated individual therapy lower (8.34) than specialist (8.86), master's (9.13), or bachelor's level participants (9.37). According to these data, counselors with higher levels of education and possibly more specialized training (doctorates and specialists) rated individual therapy lower than other counselors. Participants with the least amount of schooling (bachelor's), rated individual the highest. Counselors with doctoral degrees typically have more experience and, therefore, may be more comfortable working with multiple clients simultaneously (e.g., group or family). Furthermore, more formal education may mean more exposure and acceptance of alternate therapies or more opportunity to provide varied services within the work setting. On the other hand, those practitioners with more education may believe that individual therapies are not as

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188 essential to the resolution process, and it is possible that they are less optimistic about complete resolution regardless of the therapeutic mode. According to the data, 80% of SC had master's and only 7% had doctorates. This is significant since school counselors rated individual therapy higher than the other counselor groups. Doctorates rated individual and group therapy lower than master's level counselors, but they rated family therapy higher than any other group. Fifty-seven percent of the participants with doctorates were from the MHC group along with 27% from the MFC and 16% from the SC group. Bachelor's level participants rated individual and group higher than any other counselor group, but family therapy was lowest for bachelor's. The bachelor's were spread evenly across counselor groups; approximately 6%) of each group had bachelor's degrees. It may be assumed that participants with higher degrees regard family therapy as more essential and utilize it more often. Therapists with less education utilize individual therapies and techniques more often. This information is useful for referral sources and clients entering treatment. Hypothesis 5d Hypothesis 5d stated that there would be no significant interactions among counselor type, gender, ethnicity, degree, and the ratings for individual counseling. Since 92% of the sample was White American, the ethnicity variable was not included in the data analysis. Significance was found in the three-way interactions between counselor type, gender, and degree = .019). The data indicate that female participants with doctorates rated individual therapy higher (9.03) than male doctorates (7.83). In addition, master's and bachelor's level

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189 females rated individual higher (9.34, 9.77) than males with similar degrees (8.24, 7.60). Male counselors with specialist degrees were the only group of males who rated individual counselmg higher than females (9.25 vs. 8.78). Yet, 52% of the counselors with specialist degrees were SC. Female SC rated individual higher (9.55) than male SC (8.50). Similarly, female MFC (9.27) and MHC (9.1 1) rated individual higher than the male MFC (7.95) and MHC (8.02) groups. The male doctoral level MFC group appeared to rate individual therapy lowest, while the mean scores for female bachelor's level SC were highest. These data imply that gender, degree, and counselor type will in fact determine the type of treatment recommended. This suggests that gender, therapist training, and chosen field of practice are more predictive of the therapeutic modality than the individual client scenario. Therefore, therapy choice may not be client driven but rather therapist driven. Hvpothesis 5e Hypothesis 5e stated that there would be no significant differences in the ratings for individual counseling based on age. A statistically significant F value was found (£ = .019), and the null hypothesis was rejected. A comparison of mean scores revealed that counselors under age 44 rated individual therapy higher (9.22) than those over age 44 (8.81). These resuks may be explained by the fact that school counselors had the lowest mean age (41) compared to the MHC (45) and MFC (44) groups. As stated previously, the SC group rated individual therapy higher than the other two groups. On the other hand, age, education, and experience may allow counselors more time for specialized training in child sexual abuse treatment. Since the current treatment literature recommends

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190 a continuum of varied services for the child and family, individual therapy may not be rated higher than other therapies. Furthermore, more experience and age may correlate with more flexible work settings in which therapists have the opportimity to introduce alternate modes of treatment. A final explanation may be that younger counselors are more optimistic about treatment while older counselors have more realistic ratings about the resolution of abuse. Here, too, further inquiry is needed to determine why younger counselors rated individual therapy higher. Hypothesis 6 Hypothesis 6 stated that there would be no significant differences in the ratings for group counseling based on counselor type. A statistically significant F value was found (2 = .001), and the null hypothesis was rejected. More specifically, there were significant differences found between SC and the other two groups. The SC group rated group therapy significantly higher (7.14) than the MFC (6.23) or MHC (6.03) groups. The MHC and MFC groups seemed to be closely aligned, which may be the result of similar training, education, and/or work environments. These results may be explained by the fact that mental health and family counselors are more likely to engage in long-term psychotherapy. Since school counselors are not able to provide long-term therapy, group work is a valuable alternative. School counselors have an obviously different work setting and possibly less specialized training in child sexual abuse treatment. In this research, participants were not asked how much child sexual abuse treatment training they had completed.

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191 Overall, the combined ratings for group therapy (6.47) were lower than either the individual (9.01) or family therapy ratings (8.19). Therefore, group therapy is considered less essential to the healing process. This finding is consistent with the literature recommendation that group therapy be introduced only after individual therapeutic relationships are formed, and it may not be appropriate in all cases. While group treatment is valuable as an adjunct mode of sexual abuse therapy, it should not be the sole treatment method utilized since group counseling does not alter individual psychopathology or dysfunctional family patterns (Furniss, 1983). Hypothesis 6a Hypothesis 6a stated that there would be no significant differences in the ratings for group counseling based on gender. A nonsignificant F value was found (p = . 138), and the hypothesis was not rejected. Unlike the findings for individual therapy, gender did not make a difference in the ratings for group counseling. Hypothesis 6h Hypothesis 6b stated that there would be no significant differences in the ratings for group counseling based on ethnicity. A statistically significant F value (2 = .009) was found, and the null hypothesis was rejected. The data analysis revealed significant differences between the AfricanAmerican and White American groups (q = .014). According to the mean scores, AfiicanAmericans rated group therapy significantly lower (3.42) than White Americans (6.54). The range for the White Americans was from 6.28 to 6.80. In contrast, the range for the AfricanAmericans was from 1.42 to 5.42. On the TRQ, a rating of 1 was described as "not at all essential" to healing. However, it is

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192 important to note that there were only 12 AfricanAmerican respondents compared to 430 White Americans. Therefore, the resuhs should be interpreted with caution. As a group, African-Americans rated individual therapy highest (8.50), followed by family (6.67), and then group therapy (3.42). White Americans rated the importance similarly but with higher mean scores (9.04 for individual, 8.22 for family, and 6.54 for group). The AfricanAmerican group had either master's degrees (N = 10) or doctorates (N = 2). Overall, doctoral (5.86) and master's (6.49) level participants rated group therapy lower than bachelor's (7.30) or specialists (7.05). While counselors with higher levels of education and training may use alternate modes of therapy more often, these participants did not demonstrate that group therapy was valued as much as family or individual. Participants with doctoral or master's degrees utilize group therapy less often because of their work settings or because they have found it to be less helpfiil over time. It is possible that a counselor with a doctoral degree working in a clinic or private practice does not see enough child sexual abuse victims at one time to utilize group therapy. Therefore, group was not rated as "essential" to healing. It is unclear whether these resuhs highlight a cultural difference in regards to the use of group therapy or if the data are particular to these 12 AfricanAmerican respondents. Further information is needed to interpret the results fully. Hvpothesis 6c Hypothesis 6c stated there would be no significant differences in the ratings for group counseling based on highest degree held. A nonsignificant F value was found (p = 2.20), and the null hypothesis was not rejected. An examination of the mean scores

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193 revealed that counselors with bachelor's degrees rated group therapy higher (7.30) than participants with specialists (7.05), master's (6.49), or doctoral (5.86) degrees. Hypothesis 6d Hypothesis 6d stated that there would be no significant interactions found among counselor type, gender, ethnicity, and degree for the ratings for group counseHng. The ethnicity variable was not included in the data analysis since 92% of the sample was comprised of one ethnic group. No significant interactions were found, and the null hypothesis was not rejected. Therefore, the ratings for group counseling were not affected significantly by counselor type, gender, and degree. Regardless of these variables, group therapy had low ratings. Hypothesis 6e Hypothesis 6e stated that there would be no significant differences in the ratings for group therapy based on age. The data analysis revealed a nonsignificant F value, and the hypothesis was not rejected. Therefore, age did not affect the ratings for group therapy. Hypothesis 7 Hypothesis 7 stated that there would be no significant differences in the ratings for family therapy based on counselor type. A nonsignificant F value (£ = 2.476) was found, and the null hypothesis was not rejected. It is interesting that no significant differences were found among the counselor groups since family therapy was the only therapy type identified as one group's area of expertise. This research did not include therapists who belong to the ASGW (Association for Specialists in Group Work) yet

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194 members of the lAMFC (International Association of Marriage and Family Counselors) were included. It could be expected that members of lAMFC (MFC) would have significantly higher ratings for family therapy simply because of their chosen field of practice. While significance was not found, an examination of the mean scores revealed that MFC did rate family therapy higher (9.04) than the MHC (7.98) or SC (7.93) groups. However, as found for hypothesis 1, only 34% of MFC chose family therapy as the primary mode of counseling. These data indicate that MFC value family therapy, yet they recommend individual as the primary mode of treatment. Overall, the mean scores for family therapy were higher than those for group, yet lower than individual. The high scores may indicate that a majority of counselors, regardless of their affiliation in AC A, value family therapy with these clients. It is interesting that school counselors and mental health counselors rated family therapy similarly. This finding was not expected since family therapy is within the usual realm of mental health counseling but not necessarily school counseling. Many school counselors may see their role as an advocate for the student/client, not the family unit. For this hypothesis, however, MHC and SC were aligned closely. For the other hypotheses, MHC and MFC were more closely aligned and had distinct ratings from the SC group. In regards to family therapy, it appears that the MHC and SC groups agree on the value of this medium with abused clients.

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195 Hypothesis 7a Hypothesis 7a stated that there would be no significant differences in the ratings for family therapy based on gender. The F value was not significant (F = 2.12), and the null hypothesis was not rejected. Gender did not affect the ratings for family therapy. Hypothesis 7b Hypothesis 7b stated that there would be no significant differences in the ratings for family therapy based on ethnicity. A nonsignificant F value was found (F = .436), and the hypothesis was not rejected. While there were significant differences found in the ratings for group based on ethnicity, none were found for family therapy. Hypothesis 7c Hypothesis 7c stated that there would be no significant differences in the ratings for family therapy based on highest degree held. The F value was nonsignificant (F = 2.052), and the null hypothesis was not rejected. This finding was unlike the results for individual therapy in which degree made a difference in the ratings. Since most of the MFC have master's degrees (69%) or doctorates (20%), it might have been expected that these therapists would have more experience with family therapy and rate it significantly higher than the other counselor groups. This was not found. Hypothesis 7d Hypothesis 7d stated that there would be no significant interactions among counselor type, gender, ethnicity, degree, and the ratings for family therapy. Again, the ethnicity variable was eliminated from this analysis. There were significant interactions

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196 found between counselor type and degree for the family therapy ratings (2 = .009). Therefore, the null hypothesis was rejected. According to the data, MFC rated family therapy higher (9.04) than the other two counselor groups (7.93 for SC and 7.98 for MHC). Counselors with doctorates (9.15) and specialists (9.0) rated family therapy highest while bachelor's level participants rated family therapy lowest (7.26). The low rating for bachelor's level participants could be explained by the fact that most undergraduate counseling/psychology programs focus on individual psychology, and most bachelor's level counselors have limited knowledge in family treatment for child sexual abuse. The significant differences in the ratings appear to relate to education level, specialized training, and counselor type. MFC with doctoral or specialist degrees rated family therapy highest, and SC with bachelor's degrees rated family therapy lowest. It appears that family therapists with doctorates are more vested in family therapy than other doctorate groups. In fact, of all the participants with doctorates, 80% of MFC, 45% of MHC, and 27% of SC rated family therapy as "essential" (10.00) to the resolution process. According to these results, a client is more likely to engage in family therapy with a doctoral level MFC. Regardless of degree, SC are less likely to involve the child in family treatment. Hvpothesis 7e Hypothesis 7e stated that there would be no significant differences in the ratings for family therapy based on age. A nonsignificant F value (F = .765) was found, and the null hypothesis was not rejected. Therefore, age did not affect the family therapy ratings.

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197 Limitations This study focused on three specific counselor groups (ASCA, AMHCA, lAMFC) within the American CounseHng Association. For economic and practical reasons, the entire population of counselors or mental health treatment providers could not be investigated. As a result, the research findings can be generalized only for other professional counselor populations similar to the resultant sample. In particular, the researcher was not able to compare the results with professional psychiatrists or psychologists. Subsequent research may allow for these studies across the helping professions. The demographics of the resultant sample, however, closely resemble the demographics of the entire ACA population. Therefore, the size and demographics of the sample allow for generalizations to the broader ACA population and possibly to other populations of treatment professionals. Implications and Recommendations for Further Research Prior to this study, the effects of therapist-chosen field of practice on the chosen therapeutic modality for female child sexual abuse victims was largely unknown. The current state of the art in the treatment literature recommends a continuum of services beginning with individual therapy, then dyad sessions, and later group and family interventions (Friedrich, 1990; Madanes, 1990). Individual therapy is valuable regardless of the child's relationship with the offender. Similarly, the results of this study indicate that regardless of the offender status and counselor type, individual initiatives are primarily recommended and considered essential to the resolution process. Family therapy was considered secondar}-, and group was rated as least essential. Family

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198 therapy was not rated as high as individual despite the fact that one group of counselors identify themselves as family therapists. In addition to the three treatment modalities, a large percentage of the participants chose to refer the hypothetical clients. It is unclear, however, who the clients would be referred to for counseling. It would be interesting to determine how many of the participating counselors feel qualified to treat child abuse victims. In addition, how many have had specific training in child sexual abuse treatment? Future research efforts could examine the relationship between the amount of child sexual abuse training and the chosen treatment methods. The child's relationship with the offender was introduced as a specific moderating variable. The offender status did not, however, affect the ratings for the various therapies or the preferred mode. Future research could determine whether other client-moderating variables would affect the recommended treatment. For example, would the severity of the abuse or the degree of maternal support significantly affect the results? Furthermore, it is unknown whether the participating therapists would treat all child clients, regardless of the presenting problem, with individual counseling as the primary mode. The data gathered from this study support the notion that therapy is more counselor driven rather than client driven. Overall, there was consensus among the three counselor groups. It is unknown, however, whether the recommended therapies correspond with those actually provided by the participating counselors. What therapists recommend and what they actually practice could be evaluated using available accepted measures. However, it also would be

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199 useful to have a standardized measure to evaluate counselor knowledge of child sexual abuse and the treatment focus areas. Counselor knowledge scores could then be compared with client status pre-and posttreatment. This information would be valuable since it is unknown whether the recommended therapies are in fact successful in alleviating symptomology over time. The field would benefit from future research efforts including large, longitudinal studies of actual child sexual abuse victims who are assessed prior to and posttreatment. In this study, significant differences were found in the ratings for individual counseling based on gender, age, degree, and counselor type. In particular, female counselors rated individual therapy higher than males, and younger counselors rated individual higher than counselors over age 44. Higher degreed counselors rated individual lower and family therapy higher. Finally, SC rated individual therapy higher than the MHC or MFC groups. It is unknown whether these findings would be similar for other client groups. For example, would younger female SC rate individual therapy as high for a child with hyperactivity? Further research inquiry could determine whether these findings are specific to sexually abused clients or other client groups as well. For group therapy, there were significant differences in the ratings based on ethnicity and counselor type. The data revealed that African-American counselors rated group therapy lower than White American counselors. In this study, 92% of the sample were White American. Future research efforts should include larger numbers of counselors in each ethnic minority group to determine the validity of these results.

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200 Further inquiry also is necessary to determine whether the AfricanAmerican group truly rated group therapy significantly lower. While group therapy was rated low by all counselor groups, SC rated it the highest. This finding may indicate that school counselors utilize group therapy more often. Future research could examine the use of group therapy and the efficacy of this medium with abuse victims. In addition, subsequent research endeavors could include members of the ASGW to compare their group treatment ratings with the other counselor groups. The least significant differences were found for family therapy; significance was found in the interactions between counselor type and degree only. In addition, only 18% of the counselors chose family therapy as the primary mode. These findings could indicate that relatively few counselors feel that family therapy should be used as the primary counseling method simply based on the merits of family therapy with abuse victims. On the other hand, it could indicate that few counselors feel comfortable to provide family therapy or few may recommend family therapy because of work setting and/or the legal issues involved with these cases. More open-ended research techniques, such as interviews, could clarify the meaning of these results. In an interview format, counselors would have the freedom to describe when family therapy initiatives would be introduced and under what circumstances. This research did not allow the participants to describe the specific therapies recommended. It would be useftil to know the primary treatment goals, how the counselors would achieve those goals, and who would be involved in treatment. Some

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201 practitioners may recommend family therapy with the offender, some may not. Further research inquiries could determine how many therapists utilize a multisystemic treatment approach. For this study, the researcher chose to investigate only the most common therapeutic modalities-individual, group, and family therapy. The researcher was not able to explore the use of specific techniques such as art or play therapy. Subsequent research endeavors may investigate more specific techniques such as these. Finally, the extent to which work setting dictates the type of therapy recommended is unknown. The directions on the TRQ asked participants to answer the questions within the realm of their present work environments. Therefore, the mode of recommended therapy may have been influenced by the counselors' current work settings. Subsequent research endeavors should evaluate the importance of work setting in relation to the recommended course of treatment. Conclusions Completion of this study has resulted in an increased understanding of common recommendations for the treatment of female child sexual abuse victims. The recommended course of treatment was not altered significantly by the child's relationship with the offender. In addition, there were few significant differences found among the three counselor groups. In fact, all three counselor groups rated the importance of each therapy in similar order with similar rating scores. There were, however, significant differences found in the therapy ratings based on particular counselor demographics.

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202 Based on these findings, there are several implications for clients, referral agencies, and practitioners who treat child abuse victims. Experts in the field recommend individual therapy as a preliminary mode of intervention with child sexual abuse victims. The results of this study fully support this recommendation. The use of individual treatment was not affected in any way by who the offender was but was affected by the particular counselor's degree and chosen field of practice. For example, SC rated individual counseling higher than the other two groups, and it was rated as the primary mode of therapy most often. MHC rated individual therapy high, but they saw value in family therapy as well. MFC chose individual therapy primarily, yet family therapy was rated as more essential to the healing process than individual. Group therapy was rated lower by all counselor groups. It can be assumed, therefore, that group treatment is used less often with these clients. The overall results indicate that, regardless of counselor type, child victims will most likely participate in individual counseling. If the counselor is a White American, bachelor's-level school counselor, group treatment is more likely. Specialized training and formal education increase the degree to which family therapies are valued and utilized. Therefore, for family therapy, a referral to a MHC or MFC with a master's or doctoral degree is appropriate. The overall results indicate that it is helpful for clients and referral agencies to know what types of treatment they desire and choose a therapist accordingly. Finally, it is important to recognize that a large number of counselors chose to refer these clients. Perhaps child sexual abuse treatment is becoming or should be a distinct area of specialization. Specific course work and postgraduate training could be

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203 designed for counselors certified as child abuse treatment providers. Such professional credentialing would help to ensure more standardized and effective treatment practices for all child sexual abuse victims.

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APPENDIX A PROFESSIONAL PROFILE QUESTIONNAIRE Directions: Please complete this form fully. Read each question carefully and provide answer for every question. Thank you. 1 . With which of the following ACA divisions is your primary affiliation: American School Counselors Association American Mental Health Counselors Association International Association of Marriage and Family Counselors 2. What is your current age? 3. Gender (check one): Male Female 4. Ethnicity (check one): African-American ^AsianAmerican ^Native American Hispanic/Latino-American White-American Other 5. Education (Please check the highest degree earned): Doctorate Master's Bachelor's Educational Specialist/Certificate of Advanced Studies Other, please specify 204

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APPENDIX B TREATMENT RECOMMENDATIONS QUESTIONNAIRE, FORM A Directions: Please read the brief description below. Please respond to the following questions as if this child is coming to your office as a client for treatment. The information about the exact nature of the abuse is limited since this is so often the case with child victims. Please answer all the questions as fully as possible within the realm of your present work position, expertise, and the services offered where you work. Lindsey Allie is a 10-year-old girl who has experienced sexual abuse by her natural father who is divorced from her mother. The abuse occurred while Lindsey had weekly visitation with her father. The abuse progressed over a period of one year until Lindsey disclosed aspects of the abuse to her fifth-grade teacher. Lindsey told her teacher that her father "does things to her private parts and she wants it to stop." The appropriate authorities were contacted, and the abuse was confirmed by investigators. Lindsey no longer has visitation with her father while the case is pending legal action. Lindsey lives with her mother and 7-year-old brother who believe that the abuse occurred. The social services worker believes that Lindsey's mother is able to protect her from future abuse. Lindsey and her mother enter your office for treatment. The family is willing to cooperate and enroll in whatever therapies you deem necessary. Money is not an object of concern for the family. Lindsey has had no prior treatment, and she reports no medical problems or concerns. According to the social service worker, Lindsey's academic 205

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206 performance has declined in the last year, she is withdravsai, and her mother reports that she has difficulty sleeping. 1 . If this child was a potential client for you, which among the following would you suggest should be the primary counseling mode for the child: Individual Counseling (i.e., sessions with the child alone using individual techniques and theories of counseling). Group Counseling (i.e., the child will participate in a children's therapy group for her abuse). Family Counseling (i.e., the family will participate in family therapy sessions in which the family is working on systemic goals to resolve the abuse issues). Referral 2. Please use a scale of l=not at all to 10=essential to indicate how important you think it would be for this child to have each of the following types of counseling in order to eventually achieve successful resolution of the issues associated with child sexual abuse. Individual Counseling (i.e., sessions with the child alone using individual techniques and theories of counseling). Group Counseling (i.e., the child will participate in a children's therapy group for her abuse). Family Counseling (i.e., the family will participate in family therapy sessions in which the family is working on systemic goals to resolve the abuse issues).

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APPENDIX C TREATMENT RECOMMENDATIONS QUESTIONNAIRE, FORM B Directions: Please read the brief description below. Please respond to the following questions as if this child is coming to your office as a client for treatment. The information about the exact nature of the abuse is limited since this is so often the case with child victims. Please answer all the questions as fully as possible within the realm of your work position, expertise, and the services offered where you work. Sarah Smith is a 10-year-old girl who has experienced sexual abuse by her swim teacher at the local community center. The abuse occurred while Sarah had private weekly swim lessons with the swim teacher. The abuse progressed over a period of one year until Sarah disclosed aspects of the abuse to her fifth-grade teacher. Sarah told her teacher that her swim teacher "does things to her private parts and she wants it to stop." The appropriate authorities were contacted, and the abuse was confirmed by investigators. Sarah no longer has contact with the swim teacher and the case is pending legal action. Sarah lives with her mother and 7-year-old brother who believe that the abuse occurred. The social services worker believes that Sarah's mother is able to protect her from further abuse. Sarah and her mother enter your office for treatment. The family is willing to cooperate and enroll in whatever therapies you deem necessary. Money is not an object of concern for the family. Sarah has had no prior treatment and she reports no medical problems or concerns. According to the social service worker, Sarah's 207

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208 academic performance has declined in the last year, she is withdrawn, and her mother reports that she has difficulty sleeping. 1 . If this child was a potential client for you, which among the following would you suggest should be the primary counseling mode for the child: Individual Counseling (i.e., sessions with the child alone using individual techniques and theories of counseling). Group Counseling (i.e., the child will participate in a children's therapy group for her abuse). Family Counseling (i.e., the family will participate in family therapy sessions in which the family is working on systemic goals to resolve the abuse issues). Referral 2. Please use a scale of 1 =not at all to 1 0=essential to indicate how important you think it would be for this child to have each of the following types of counseling in order to eventually achieve successful resolution of the issues associated with child sexual abuse. Individual Counseling (i.e., sessions with the child alone using individual techniques and theories of counseling). Group Counseling (i.e., the child will participate in a children's therapy group for her abuse). Family Counseling (i.e., the family will participate in family therapy sessions in which the family is working on systemic goals to resolve the abuse issues).

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APPENDIX D LETTER OF TRANSMITTAL FOR PARTICIPATING COUNSELORS To whom it may concern: I am a doctoral candidate in the Department of Counselor Education at the University of Florida. I am conducting research for my Ph.D. on treatment interventions with sexually abused children. I will be sampling professional members of the American Counseling Association. As you may know, there are few, if any, large scale studies on child sexual abuse treatment. I hope to obtain valid and reliable results that add to the existing research so that we may provide appropriate and effectual therapeutic services for these clients. I am asking for your participation in this study. To participate, you must first read this informed consent letter. You may call me at the number listed above if you have any comments or questions. My Doctoral Committee Chairperson is Dr. Larry Loesch, Ph.D. His phone number is 352-392-073 1 . For questions or concerns about your rights as a research participant, you may contact the University of Florida Institutional Review Board at P.O. Box 1 12250, UF, Gainesville, Florida 3261 1-2250. You will be asked to complete a demographic form and a brief questionnaire. The questionnaires should not require more than 10 minutes to complete. I realize that your time is extremely valuable. Therefore, I made the assessment packets as brief as possible. All responses are anonymous and only group scores will be published. You are asked to voluntarily participate. You may withdraw your consent at any time without penalty or prejudice. You do not have to answer any question you do not wish to answer. There are no anticipated risks, direct benefits, or compensation for participation. As the supervisor of a hospital-based sexual assault center, I realized the need for data on the current state of the art in the field of child sexual abuse treatment. I feel confident that the results of this research will prove valuable for counselors. I hope that you are willing to participate in this research endeavor. I appreciate your time and consideration. Please send the completed instruments in the envelope provided by July 1, 1997. Sincerely, Cheralyn Payton Leeby, M.Ed., Ed.S. 209

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216 Deblinger, E., McLeer, S.V., Atkins, M.S., Ralphe, D., & Foa, E. (1989). Post-traumatic stress in sexually abused, physically abused, and non-abused children. Child Abuse and Neglect . 13(3), 403-408. DeFrancis, V. (1969). Protecting the child victim of sex crimes committed by adults . Denver, CO: American Humane Association. DeJong, A.R. (1985). The medical evaluation of sexual abuse in children. Hospital and Community Psychiatry . 36, 509-512. Densen-Gerber, M. (1977). The big issue . New York: Odyssey House. DePanfilis, D. (1986). Literature review on sexual abuse . Washington, DC: U.S. Department of Health and Human Services. DePanfiHs, D., & Salus, M.K. (1992). A coordinated response to child abuse and neglect: A basic manual . Washington, DC: U.S. Department of Health and Human Services, Administration for Children and Families. De Young, M. (1982). The sexual victimization of children . Jefferson, NC: McFarland & Company. Dietz, C.A., & Craft, J.L. (1980). Family dynamics of incest: A new perspective. Social Casework . 61, 602-609. Dixon, K.N., Arnold, L.E., & Calestro, K. (1978). Father-son incest: Underreported psychiatric problem? American .Journal of Psychiatry . 135 . 835. Dixon, J., & Jenkins, J.O. (1981). Incestuous child sexual abuse: A review of treatment strategies. Clinical Psychology Review . 1, 21 1-222. Donaldson, M.A., & Gardner, R. (1985). Diagnosis and treatment of traumatic stress among women after childhood incest. In C.R. Figley (Ed.), Trauma and it's wake : The study a nd treatment of Post-Traumatic Stress Disorder (pp. 356-377). New York: Brunner/Mazel. Downs, W.R. (1993). Developmental considerations of the effects for childhood sexual abuse. Journal of Interpersonal Violence . 8r31. 331-345 Dubowitz, H. (1990). Costs and effectiveness of interventions in child maltreatment. Child Abuse and Neglect . 1 4. 1 77-1

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218 Finch, S. 1982. Sexual disturbances in children. Medical Aspects of Human Sexuality . 16, 92Z-92SF. Finkelhor, D. (1979). Sexual victimization of children . New York: Free Press. Finkelhor, D. (1980). Long-term effects of childhood sexual victimization in a non-clinical sample . Durham, NH: Family Research Laboratory. Finkelhor, D. (1983). Removing the child: Prosecuting the offender in cases of sexual abuse. Child Abuse and Neglect . 7(2). 195-205. Finkelhor, D. (1984). Child sexual abuse: New theory and research . New York: Free Press. Finkelhor, D. (1986). A sourcebook on child sexual abuse . Newbury Park, C A: Sage PubUcations. Finkelhor, D. (1987/December). The trauma of sexual abuse: Two models. Journal of Interpersonal Violence . 2(4), 348-366. Finkelhor, D., & Browne, A. (1985). The traumatic impact of child sexual abuse: A conceptualization. American Journal of Orthopsvchiatrv . 55, 530-541. Finkelhor, D., & Browne, A. (1986). Initial and long-term effects: A conceptual framework. In D. Finkelhor (Ed.), A sourcebook on child sexual abuse (pp. 180-198). Newbury Park, CA: Sage Publications. Finkelhor, D., & Hotaling, G.T. (1984). Sexual abuse in the National Incidence Study of Child Abuse and Neglect: An appraisal. Child Abuse and Neglect. 8, 23-32. Finkelhor, D., HotaHng, G., Lewis, I.A., & Smith, C. (1990). Sexual abuse in a national survey of adult men and women: Prevalence, characteristics, and risk factors. Child Abuse and Neglect . 1 4. 19-28. Forseth, L.B., & Brown, A. (1981). A survey of intrafamilial sexual abuse treatment centers: Implications for intervention. Child Abuse and Neglect . 5,177-186. Fossum, M. A., & Mason, M. (1986). Facing shame: Families in recovery . New York: W.W. Norton & Company.

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234 Terr, L.C. (1991). Childhood traumas: An outline and overview. American Journal of Psychiatry . 148 . 10-20. Timnick, L. (1985/August 25). Twenty -two percent in a survey were child abuse victims. Los Angeles Times , p. 1 . Tompkins, J. B. (1940). Penis envy and incest: A case report. Psychoanalytic Review . 27.319-325. Tong, L., Oats, K., &. McDowell, M. (1987). Personality development following sexual abuse. Child Abuse and Neglect . 11, 371-383. Trepper, T.S. (1990). In celebration of the case study. Journal of Family Psychotherapy . 1(11 5-13. Trepper, T.S., & Barrett, M.J. (1989). Systemic treatment of incest: A therapeutic handbook . New York: Brunner/Mazel. Tsai, M., Feldman-Summers, S., & Edgar, M. (1979). Childhood molestation: Variables related to differential impacts on psychosexual functioning in adult women. Journal of Abnormal Psychology . 88, 407-417. Tufts New England Medical Center, Division of Child Psychiatry. (1984). Sexually exploited children: Services and research project, final report for the Office of Juvenile Justice and Delinquency Prevention. Washington, DC: U.S. Department of Justice. Vacc,N.A.,&Loesch, L.C. (1987). Counseling as a profession . Muncie, IN: Accelerated Development Inc. Vander Mey, B.J., & Neff, R.L. (1982). Adult-child incest: A review of research and measurement. Adolescence . 17, 7 1 7-73 5 . Walker, L.E. (Ed.). (1988). Handbook on sexual abuse of children: Assessment and treatment issues . New York: Springer Publishing Company. Ward, E. (1984). Father daughter rape . London: The Women's Press. Weinburg, S.K. (1955). Incest behavior . New York: Citadel. Weiss, E.H., & Berg, R.F. (1982). Child victims of sexual assault: Impact of court procedures. Journal of the American Academy of Child P.svchiatrv 71 rs^ sn.SI «

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BIOGRAPHICAL SKETCH Cheralyn Payton Leeby was bom to Carolyn Mayers and Marty Payton on February 26, 1966, in l ansdale, Pennsylvania. She has an older sister, older brother, and younger brother in addition a large extended family of cousins, nieces, and nephews. Cheralyn graduated from Princeton Day School in 1984. Then, she attended Vanderbilt University in Nashville, Tennessee, where she earned a bachelor's degree in 1988 and a master's degree in human development counseling in 1989. Cheralyn continued her education at the University of Florida where she enrolled in the Department of Counselor Education to pursue a doctoral degree in agency, correctional, and developmental counseling with a specialization in marriage and family therapy. She earned a Specialist in Education in 1990. Cheralyn is licensed in Florida as a Mental Health Counselor and Marriage and Family Therapist. In addition, she is a Certified Professional Counselor in the State of Maryland and a Virginia Licensed Professional Counselor. Cheralyn began working in the mental health field in 1983 and has varied clinical experience working predominantly with children and families. Cheralyn began working with survivors of abuse in 1988, and in her most recent position, she was the director of a large, hospital-based sexual assault center. Cheralyn has created two therapeutic games for children: "Going to Court" and "Safety Sense with Sam and Sally B. Safe." 236

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237 Cheralyn's professional interests include counseling, supervision, teaching, training, writing, program development, and therapeutic game development. She currently spends the majority of her time with her husband and son. Chase. Her knowledge of child development has proven to be extremely valuable while raising her 22-month-old son. Cheralyn hopes to continue writing, developing therapeutic aids, and eventually teaching at the graduate level.

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I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Larry GjjCoesch, Chairperson Professor of Counselor Education I certify that 1 have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Peter A. D. Sherrard Associate Professor of Counselor Education I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Elizabeth Bondy Associate Professor of Instrtfction and Curriculum I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Sandra F. Seymour ^ Associate Professor of Nursing

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This dissertation was submitted to tlie Graduate Faculty of the College of Education and to the Graduate School and was accepted as partial fulfilhnent of the requirements for the degree of Doctor of Philosophy. May 1998 /^^-g^£-.^^^e^ G^ 7^rJ)(S^cc^<^ Dean, College of EdiuJation Dean, Graduate School