Cultural Issues
Psychological and sexual behavior may be influenced by culture. That is to say that how people express psychological issues like depression, anxiety and anger may be a function of the cultural climate in which they live. Selena, who suffered from anxiety attacks, received different methods for expressing and coping with anxiety based on the cultural beliefs of her two environments. For instance, in the small seaport town she was brought up in, anxiety was likely defined as a “case of the nerves.” Selena would be told to calm down, have a drink, etc. to relax and find her balance. In a cosmopolitan city like, New York, Selena would be told to take prescription medication to suppress the anxiety and continue with her daily routine.
Even though Selena’s sex drive seemed low, her willingness to engage in casual and risky sex seemed high. Selena complained to her boss that “you’re not only not fucking me anymore, you’re fucking me” (Dolores Claiborne, 1995). The risk of having sex with her boss is two-fold: (1) it could compromise her job security if the relationship sours and (2) it could undermine how her peers view her, as it would be assumed that any advances she obtained resulted from having sex with the boss rather than ascending because of her skills. Sexual liaisons took place in the community where Selena was raised, including same-sex relationship, sexual abuse, etc. However, it was not polite to speak of such sexual acts publically. In cosmopolitan cities, sexual affairs are more acceptable, which is likely why Selena spoke freely and publically about her sexual past in front of co-workers. Selena’s new culture, as a cosmopolitan city woman influenced her sexual behavior and conversations about sex.
Psychological Issues
Psychological issues impact sexual behavior (Chromy, 2007). Issues like anxiety, depression, and fear can greatly inhibit a woman from allowing herself to engage in sex (Fowler & Wagner, 1993). Selena exhibited high levels of anxiety, which likely prevented her from establishing healthy and stable sexual relationship. According to Marano (2005), many survivors of childhood sexual abuse struggle in their effort to establish healthy sexual relationships. Women are often unable to move beyond the incident of abuse; afraid that they will be harmed again, they often shield themselves, thus preventing a potential partner from getting close. Selena, filled with repressed memories, had sex with her boss, but likely kept him at arms length, not allowing him to get close and establish true intimacy. Marano (2005) claims that women can establish healthy relationships once they “decide to stop being a victim” (p. 13). Selena did not identify herself as a victim; however, her anxiety attacks and reliance on drugs and alcohol to get balance suggests that her psychological issues were affecting her interpersonal relationships and as a result, her sexual behavior likely included sex without emotion, which left her feeling empty.
Understanding and Expressions of Human Sexuality
Adolescent Attitude
Children learn and establish their attitudes about sex from their social environments. Prior to being sexually abused, Selena’s understanding of human sexuality was probably like other girls her age – curious, uncertain, and neutral. Following Selena’s sexual abuse, her attitude shifted. Literature on childhood sexual abuse suggests that survivors establish a “Wall of Fear,” that shapes their attitudes toward sex and relationships (Oz, 2005). Selena developed anxiety, became withdrawn, and secretive after being sexually abused. These behaviors are coping mechanisms used to understand and justify the sexual abuse. Other traits Selena exhibited included a need to achieve, which abuse victims often adopt to “make up for the badness they feel is hidden inside" (Bass & Davis, 1988, p. 51).
Adult Attitude
As an adult, Selena’s attitude became much more negative, as her understanding of sex and its expressions shifted. Selena had repressed her memories of sexual abuse, but the pain still existed. As a result, Selena’s attitude about sex and relationships became pragmatic, focused on the ritual of sex for pleasure, devoid of intimacy, sentimentality or the promise of a deeper relationship. Selena’s adult attitude is expressed clearly when she echo’s a running theme in the movie, “sometimes being a bitch is all a woman has to hold on to” (Dolores Claiborne, 1995). The point being that, as a child, Selena could rely on being naïve, cute and hopeful, which could inspire people to provide for her. However, as an adult, Selena, much like Dolores, found that showing a strong face is what a woman needs to be taken seriously and get what she wants.
Best Approaches for Treating Survivors of Child Sexual Abuse
The two approaches best equipped to treat survivors of childhood sexual abuse include: (1) Uncovering, Abreaction and Catharsis and (2) Memory Work and Meaning. Spitzer and Avis (2006) outline each of these approaches and test them among a group of sex abuse survivors to see which approaches are most effective.
Uncovering, Abreaction and Catharsis
This approach is based on exposing repressed memories, releasing the associated emotions and realizing a feeling of catharsis as a result (Spitzer & Avis, 2006). Given that childhood sexual abuse survivors often have repressed memories, it is first necessary to uncover the memories in order to treat the survivor. Once the memory is exposed, the survivor is able to acknowledge the memory, and generate associated feelings. These feelings can then be expressed (i.e., abreacted). It is through the process of uncovering and abreacting that the survivor is able to gain a feeling catharsis. Oz (2005) calls the memories of abuse the “Wall of Fear,” and suggests that exposing and confronting the wall or memory is paramount to the treatment of most survivors.
Memory Work and Meaning
The second approach focuses on shifting or reconstituting existing memories of abuse in order for the survivor to get their power back (Spitzer & Avis, 2006). It is important for survivors to express their experiences of abuse. Yet, according to Spizter and Avis (2006), expressing the abuse without offering a new framework or way of understanding the abuse, “might well impede client functioning without assisting healing.” (p. 182). Spitzer and Avis (2006) found that participants rated understanding the abuse and accepting that there was trauma as two of the most important aspects of their treatment. These results are consistent with other studies of childhood sexual abuse survivors, especially women, who find that understanding the abuse is an essential tool in moving beyond the crisis (Lubin, 2007).
Treatment Plan for Selena
To develop a treatment plan for Selena, it is first necessary to provide a description of Selena, her abuse, coping mechanisms and current stability. The treatment plan begins by offering a profile of Selena followed by the approach proposed for addressing Selena’s specific psychological disorders.
Profile
Selena is a woman in her early thirties with a high profile job. She is intelligent, highly communicative, and in good physical health. Selena’s father sexually abused her during adolescence. The abuse included forced sexual acts in public and private spaces. It is presumed that the abuse included petting and fondling without physical penetration. Also during adolescence, Selena’s father, the perpetrator, died in an accident. Many of the town’s people and police department believed that the mother had killed the father. Although the mother was not found guilty, Selena blamed the mother for her father’s death and expresses negative feelings about her family. Selena became extremely proactive about education and left the island to go away to college without returning. It has been fifteen years since she has seen her mother or the house in which she was sexually abused.
Approach
According to Lubin (2007) treatment plans should address all areas damaged by the abuse. This includes the psychological trauma (repressed memories and coping mechanisms), biological (hormone embalances), and social (relationship with her mother, sexual partners and friends). The theoretical approach to Selena’s treatment is based on current best practices in the field of child sexual abuse survivors, which addresses (1) frequency of treatment, (2) length of treatment, (3) group versus individual sessions, (4) counselor – survivor locus of control matching, and (5) gender of the therapist.
Frequency of Treatment
Brock, Mintz and Good (1997) discovered a relationship between how sexual abuse survivors view their family functioning and heightened signs of distress. Given that Selena views her family in such a negative light, it is recommended that frequent and special attention be paid to how she describes her family. The thought is that as Selena’s expressions of anger toward her family diminish so too will her feelings of distress.
Length of Treatment
Krulewitz (1982) found that women who were sexually assaulted in home, a space once thought to be safe, “show more pervasive and enduring disruption of normal patterns and require a longer period of time for recovery than do persons who are assaulted in a more public or less protected or secure environment.” Selena was abused in both private and public space, which suggests that she may require a longer treatment plan, given that she was abused and stripped of her control in both private and public spaces.
Group versus Individual Treatment
In terms of individual versus group therapy, it is recommended that Selena take part in a combination of the two. The literature suggests that group therapy is an especially effective treatment plan for survivors of child sexual abuse (Lubin, 2007). Selena endured what she likely interprets as a unique sexual abuse experience. By participating in group therapy with other survivors, Selena could come to realize there are others who faced similar types of abuse. Since Selena’s situation is also unique in that the sexual abuse was coupled by the loss of a parent, individual therapy sessions are also recommended to focus on Selena’s specific feelings about the sexual abuse and loss of her father.
Counselor – Survivor Locus of Control Matching
Foon (1986) found that matching the cognitive style of the therapist with that of the client facilitates faster recovery. Cognitive style or Locus of Control is about the manner in which people interpret events in their lives. This perspective offers two ways of seeing oneself in the world – internal or external. People with an internal orientation believe that events in their lives occur as a result of individual and internal decisions. Alternatively, people with an external orientation believe that forces outside of themselves are responsible for explaining their circumstances. Selena has an external orientation. She blames her mother, her father, her boss, etc. for her predicament. As such, Selena would be matched with a counselor who has a similar external orientation.
Gender of the Therapist
Research suggests that female survivors of sexual abuse are able to find comfort with and gain valuable treatment from male counselors (Fowler & Wagner, 1993). It is possible that female survivors are able to keep the negative feelings they have for their male perpetrator focused on the perpetrator and not project them to a male counselor. However, gender matching seems to be a more productive form of treatment for female survivors of sexual abuse (Fowler & Wagner, 1993). As such, Selena will be paired with a female counselor.
Summary of Selena’s Treatment Plan
Selena’s treatment plan will start with frequent visits that may be reduced as Selena shows signs of progress. It is expected that treatment will be on the longer end of the spectrum. Selena’s therapist will be a female with an external orientation. Selena’s treatment areas will focus on repairing psychological, biological and social trauma. The approach will utilize Spitzer and Avis’s(2006) Memory Work and Meaning, which focuses on redefining Selena’s traumatic events. Treatment will include individual as well as group sessions. Group sessions as indicated by Brabant and Forsyth (1996), should be aimed at “letting go of [the] secret and acknowledging the abuse to others” (p. 472). Additionally, exercise and nutrition recommendations will be prescribed, which, according to Vanderhaeghe (2008) will help Selena balance her hormones and reestablish a healthy libido.
Personal Attitudes
Modifications to Professional Practice
A great deal of empathy must go into treating Selena. The counselor must be aware of the symptoms displayed by Selena and how these symptoms are affecting her life. Even if the counselor was not abused themselves, they need to understand what Selena has and is going through. Although the counselor’s personal beliefs may be strong towards and against child abuse, the objectivity of therapy is not to force the client into thinking ill of their abuser but rather to let the client identify what they believe about their abuser and how their thought mesh with their beliefs and social norms they have created. Abuse here is defined as excessive physical violence or any form of sexual contact. The attitude the counselor must have when treating Selena is that human beings are not meant to hold onto the crises they face, but instead to understand the situation and move forward with their lives. The counselor should obtain notes and, if possible, a consultation with her physician or psychiatrist to discuss what therapy is bringing and how, as therapy continues, to manage Selena’s medication to best fit her.
To counsel Selena affectively, the counselor would need to set aside their beliefs during session and focus on Selena’s progress with moving on in her life. This is not to suggest that such a shift in orientation would be easy or successful. The counselor must also understand that internal control may not be a possibility for Selena. The external factors that are pressing on Selena are what is controlling her. If the counselor has a view of internal control, (what is thought is what happens), than they opposing external control must be understood and until internal control can be achieved, but only if Selena decides to use internal control to control her life.
Steps that would be taken to achieve this include (1) developing vocabulary, which focuses on understanding external forces acting upon a person, rather than the natural internal vocabulary, which focuses on taking responsibility for life events. (2) Recording and reviewing the first few sessions to ensure that judgment of Selena or inadvertently trying to push her in a direction to be more like the counselor is not taking place. Finally, (3) the counselor would need to monitor Selena’s group therapy sessions in order to better understand the vocabulary Selena and others like her use to make sense of their abuse. These words and phrases would then be integrated into the vocabulary of the session so that the counselor could create a bridge to facilitate Selena’s interpretation of the abusive events of her childhood.
Merging Personal and Professional Attitudes
A professional attitude of a counselor is that objectivity is essential to treating every client. Along with being objective, the counselor would approach all of their clients with an open mind without passing judgment. Additionally, the counselor would keep client information confidential, even when asking for assistance if the case is challenging. Although the counselor’s world view of internal control and Selena’s world view of external control are completely opposite, the counselor’s view should not be a hindrance but rather a benefit to session. This is the case because when Selena describes her abuse, the counselor would be more attuned to her devices for escape, which prevent her from confronting the memories of her abuse. The counselor should insist to Selena that she is making herself a victim and that she needs to move on. Instead, the counselor would validate Selena’s anger toward her abuser. Once she acknowledges the feelings she has towards her abuser, the counselor would steer her to a conclusion that is in line with Selena’s worldview, yet still allows her to move beyond the pain. That is, once she acknowledges the trauma, identifies it as wrong. The counselor can than work on reframing the events so that Selena can understand and move on from it. This reframing would include pointing to how Selena actually had power in the moment of abuse. The focus would to help Selena regain her power within the traumatic memory so that she can have a new outcome when the memory resurfaces.
References:
Bass, E. and Davis, L. (1988) The Courage to Heal: A Guide for Women Survivors of Child Sexual Abuse. New York: Harper & Row.
Brock, K, Mintz, L., & Good, G. (1997). Differences Among Sexually Abused and Nonabused Women From Functional and Dysfunctional Families. Journal of Counseling Psychology, 44, 425-432.
Chromy, S. (2007). Sexually Abused Children Who Exhibit Sexual Behavior Problems: Victimization Characteristics. Brief Treatment and Crisis Intervention, 7, 25-33.
Foon, A. (1986). Effect of Locus of Control on Counseling Expectations of Clients. Journal of Counseling Psychology, 4, 462-464.
Fowler, W. & Wagner, W. (1993). Preference for and Comfort With Male Versus Female Counselors Among Sexually Abused Girls in Individual Treatment. Journal of Counseling Psychology, 40, 65-72.
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LeBlanc, J., Brabant, S., & Forsyth, C. (1996). The Meaning Of College For Survivors Of Sexual Abuse: Higher Education And The Older Female College Student American Journal of Orthopsychiatry, 66, 468-473.
Lubin, H. (2007). Group and Individual Therapy for Childhood Sexual Abuse Survivors. International Journal of Group Psychotherapy, 57, 257-262.
Oz, S. (2005). The “Wall of Fear”:The Bridge Between the Traumatic Event and Trauma Resolution Therapy for Childhood Sexual Abuse Survivors. Journal of Child Sexual Abuse, 14, 23-47.
Rathus, S.A., Nevid, J.S., Fichner-Rathus, L. (2011). Human sexuality in a world of diversity (8th ed.). Boston, MA: Pearson.
Spitzer, B. & Avis, J. (2006) Recounting Graphic Sexual Abuse Memories in Therapy: The Impact onWomen’s Healing. Journal of Family Violence, 21, 173-184.
Schwartz, N. (2008). Genes, Hormones, And Sexuality. Gay And Lesbian Review Worldwide, January/February, 21-23.
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