Psychotherapists? Perceptions of CSA Exploring Psychotherapists? Perceptions of the Impact of Childhood Sexual Abuse on Adult Intimate Relationships By Casey Bradford Student Number: 393097 Supervisor: Dr. Brett Bowman ?A research project submitted in partial fulfillment of the requirements for the degree of MA by coursework and Research Report in the field of Community-Based Counselling Psychology in the Faculty of Humanities, University of the Witwatersrand, Johannesburg, August, 2010.? 1 Psychotherapists? Perceptions of CSA Declaration I declare that this research report is my own, unaided work. It has not been submitted before for any other degree or examination at this or any other university. ______________________ Casey Lee Bradford 3 August, 2010 Word Count: 26, 838 2 Psychotherapists? Perceptions of CSA Acknowledgments To my supervisor Dr. Brett Bowman for all your support and guidance through this project, your never ending optimism and investment in both me and this project helped me to see the light at the end of the tunnel. To the MACC class of 2009, without you I would not have made it through this year. I would furthermore like to thank my parents for supporting me tirelessly all my life. A very appreciative thank you to Meggan and Kate, I would not have been able to complete this project without your generosity. Lastly, a thank you to all the participants who took part in this study, I would like to thank you for your cooperation and insight. 3 Psychotherapists? Perceptions of CSA Abstract Psychotherapists are one group of professionals that deal with cases of childhood sexual abuse. This study explores a sample of psychotherapists' perceptions of various aspects of childhood sexual abuse, with particular reference to how they perceive this form of abuse to impact on adult intimate relationships. The data was collected by using semi-structured interviews and analysed using thematic content analysis. Some of the main areas that were highlighted by the sample included the effects of childhood sexual abuse on all relationships and not just intimate relationships as well as how the victim-survivor relates to themselves and to the world. Although there is varied research regarding the impact of childhood sexual abuse, this study found that most of the participants perceived that CSA had a marked negative impact on the mental health of the victim-survivor and constrained their subsequent potential to form and sustain productive adult intimate relationships. 4 Psychotherapists? Perceptions of CSA Table of Contents Declaration?????????????????????????????2 Acknowledgments?????????????????????????...3 Abstract??????????????????????????????.4 Table of Contents??????????????????????????..5 Chapter 1: Introduction and Rationale?????????????????..8 1.1 Introduction????????????????????????...8 1.2 Research Aim????????????????????????9 1.3 Research Questions?????????????????????...9 1.4 Rationale?????????????????????????..10 Chapter 2: Literature Review?????????????????????.13 2.1. Introduction????????????????????????.13 2.2 Definition of Childhood Sexual Abuse??????????????13 2.2.1 Context of the Abuse?????????????????.15 2.2.2 Theoretical Understandings of Childhood Sexual Abuse???.16 2.3 Global Considerations????????????????????..18 2.4 Childhood Sexual Abuse in South Africa?????????????19 2.4.1 Cultural Considerations????????????????.20 2.5 Family??????????????????????????...23 2.6 Influence of Childhood Sexual Abuse??????????????..23 2.6.1 Adult Intimate Relationships??????????????.24 2.6.2 Sexual Dysfunction??????????????????25 2.6.3 The Influence of Childhood Sexual Abuse on Adult Psychological Health?????????????????.27 2.6.4 Self-Schema????????????????????...29 5 Psychotherapists? Perceptions of CSA 2.6.5 Influence of Childhood Sexual Abuse on Adult Physical Health?????????????????????.??29 Chapter 3: Method??????????????????????????.31 3.1 Research Approach??????????????????????.31 3.2 Participant Selection?????????????????????...32 3.3 Procedure??????????????????????????32 3.4 Data Collection Instrument???????????????????.33 3.5 Data Analysis????????????????????????..34 3.6 Issues of Self-Reflexivity and Representation????????????36 3.7 Ethical Considerations?????????????????????37 Chapter 4: Results and Discussion 4.1 Introduction?????????????????????????.39 4.2 Context???????????????????????????39 4.2.1 Definition and Impact (When is Abuse, Abuse?)???????39 4.2.2 Contact Specificity??????????????????...40 4.2.3 Family???????????????????????..44 4.2.4 Social and Cultural Considerations in the Definition of Childhood Sexual Abuse..????????????????47 4.3 Betrayal??????????????????????????...51 4.3.1 Boundaries and Trust??????????????????51 4.3.2 Disclosure??????????????????????.55 4.3.3 Body Betrayal/Arousal?????????????????..57 4.4 Sex?????????????????????????????61 4.4.1 Intimacy???????????????????????61 4.4.2 Sex Work??????????????????????..66 4.4.3 Sexual Dysfunction??????????????????..68 4.5 The Spectra of Damage????????????????????...69 6 Psychotherapists? Perceptions of CSA 4.5.1 Physical Manifestation?????????????????..69 4.5.2 Psychological Manifestations??????????????...70 4.5.3 Self-Schema?????????????????????..73 4.5.4 Relational Dynamic??????????????????..75 Chapter 5: Conclusion?????????????????????????.78 5.1 Introduction?????????????????????????..78 5.2 Summary of Research Findings?????????????????...78 5.3 Implications of the Findings???????????????????80 5.4 Limitations of the Study????????????????????...81 5.5 Future Directions???????????????????????.81 5.6 Concluding Comments?????????????????????.81 References??????????????????????????????83 Appendices Appendix A: Semi-structured Interview Schedule???????????93 Appendix B: Participant Information Sheet?????????????...94 Appendix C: Consent from for participants?????????????...96 Appendix D: Audio-recording and transcript consent form???????...97 7 Psychotherapists? Perceptions of CSA Chapter 1: Introduction and Rationale 1.1 Introduction The definition of childhood sexual abuse (CSA) is highly complex and variable and there seems to be little consensus around what exactly constitutes such abuse. To complicate matters further, it has been theorised that the definitions of CSA vary not only from country to country but across different cultures and more specifically, between researchers in the field (Noll, Trickett, & Putnam, 2003; Levett, 2004; Guma & Henda, 2004). Child abuse, of which CSA is a type, is understood differently across different areas of inquiry such as in academic research as well as by the general public, as expressed in areas such as the media. Another area in which CSA features is in legislation, in the form of legal documentation stating what constitutes child abuse, as a way to protect children from harm. Child abuse is thus defined in the Children?s Act 38 of 2005 as any form of harm or maltreatment that is deliberately inflicted on a child, where a child is considered to be any person under the age of 18. Furthermore, sexual abuse includes any act of forced sexual assault on a child for the gratification of another person, purposefully exposing a child to sexual activities or pornography or exploiting a child sexually for commercial gain (as cited in Richter & Dawes, 2008). CSA has a high prevalence in South Africa as reported in Matzopoulos and Bowman (2006). This prevalence is widely reported in public arenas, such as in South African newspapers that often report on cases of child abuse. Such articles have been found in the following newspapers; The Citizen, The Cape Argus, The Daily Dispatch and The Herald (EP Herald) to name a few (De Vries, 2008; Kalamane, 2008; Myoli & Wilkinson, 2008). This media coverage as well as the general increase in availability of literature on the topic of child abuse in the last few years is evidence of the fact that South African society is becoming more and more aware of the problem of CSA (Loeb, Williams, Carmona, Rivkin, Wyatt, Chin & Asuan-O?Brien, 2002). Pierce and Bozalek (2004) argue that although a historical record of child abuse does exist, only recently have the various 8 Psychotherapists? Perceptions of CSA forms of child abuse that occur, including sexual abuse, been defined as a societal problem. In a country in which oppression and violence have been, and still are rife today, this study represents a sample of psychotherapists' perceptions of CSA as psychotherapists frequently face challenges regarding this phenomenon and its perceived impact on their patients. Considering the high prevalence of CSA in the country, it stands to reason that mental health care workers, including psychotherapists, would form particular perceptions and understandings of CSA based on their observations and experiences of working in the field. As psychotherapists? perceptions of CSA are vital to the work that they do with patients who have abuse histories, this study will explore their insights in order to better understand the different professionals' perceptions of this phenomenon. The literature on the impact of CSA is vast and covers multiple impacts of CSA on health and well-being which encompasses both mental and physical health aspects (Meston, Rellini & Heiman, 2006; Heiman & Heard-Davidson, 2004; Andrews, Corry, Slade, Issakidis & Swanston, 2004). A study by Colman and Widom (2004) yielded results indicating a direct correlation between CSA and later adult sexual dysfunction or sexual problems, but specifically noted a distinct difference in stability and quality of relationships between abused and non-abused participant groups. Heiman and Heard- Davison (2004) report that the findings regarding the impact of CSA on sexual functioning are mixed, depending on various aspects of the inquiry such as methodology, definition and contextual variables. Loeb et al. (2002) argue that CSA is one factor which could contribute to sexual dysfunction in adulthood and so it ought to be considered that CSA may be only a part of the etiological understanding of sexual dysfunction. Furthermore, Greenwald, Leitenberg, Cado and Tarran (1990) found in a community sample of women (that is non-clinical and non-student sample) that there was no significant difference in adult sexual functioning between the abused group and the non- abused group. It was however noted that there was an evident long-term psychological impact. It is therefore apparent that the resultant impact of CSA on various areas of adult functioning is vast, multifaceted, and contentious. 9 Psychotherapists? Perceptions of CSA On the other end of the theoretical spectrum, Levett (2003) argues that the belief that CSA has a deleterious effect on psychological functioning could in fact cause victim- survivors to search for and even create effects. She further argues that viewing CSA as having a damaging effect may create a discourse which becomes a self-fulfilling prophecy. In other words, the way that people talk about CSA, that is, in a way which indicates that it is a harmful experience, could influence victim-survivors to view their experience as damaging and they may develop psychological problems as a result of such talk, rather than as a consequence of the abuse itself. There is a relative lack of information regarding professionals? and especially psychologists? perceptions of CSA with much of the research focused on the level of training possessed by professionals dealing with CSA cases (Hibbard & Zollinger, 1990). However there is some literature regarding professionals? perceptions of CSA. Trute, Akins and MacDonald (1992) found these perceptions to be directly related to a professional?s gender. It is argued here that regardless of the reason - gender or otherwise, professionals? beliefs about CSA will ultimately impact on treatment as well as diagnosis (Gore-Felton, Arnow & Koopman, 1999). 1.2. Research Aim This study explored psychotherapists? perceptions of the impact of childhood sexual abuse on adult intimate relationships. In keeping with this aim, a qualitative approach was adopted in which a wealth of information was gathered through the use of semi-structured interviews, and analysed using thematic content analysis. To this end a number of research questions guided the study, these are listed below. 1.3. Research Questions 1). How does a given sample of psychotherapists define CSA? 2). What are the perceptions of the influence of CSA on adult intimate relationships according to a given sample of psychotherapists? 10 Psychotherapists? Perceptions of CSA 3). What are the perceptions of the influence of CSA on adult psychological health as perceived by a given sample of psychotherapists? 4). What are the perceptions of a given sample of psychotherapists of the influence of CSA on adult physical health? 1.4. Rationale In South Africa, the reported prevalence of neglect and ill-treatment of children has increased by 55.1% from 2001-2008 according to the South African Police Service Crime Statistics for 2008 (SAPS, 2008). Although the above-mentioned statistic is not specific to CSA, it is inferred that CSA would be a part of the reports for neglect and ill-treatment to children, as CSA is a form of ill-treatment of children. There is an exceptionally high prevalence of childhood abuse in South Africa, including but not limited to sexual abuse, despite the progressive legislation in place (Matzopoulos & Bowman, 2006). As much as 40.8% of all reported rape in the country is committed against children. Between 1 April 2004 and 31 March 2005, 22 486 children were raped and 1569 were indecently assaulted (Matzopoulos & Bowman 2006). South Africa is recognised as having one of the best child rights environments in the world, yet the reported rates of abuse are exceptionally high (Richter & Dawes, 2008). The statistics indicate a high prevalence of CSA which is suggestive of the fact that there is poor enforcement of human rights with regard to children in South Africa. It is widely held that the prevalence of CSA experiences follow much the same trends of under reporting as do rape statistics (Loeb et al., 2002). What this means is that the number of reported cases of CSA, as with rape, are only a fraction of the number of total cases. Due to the fact that the prevalence of CSA, and other forms of child abuse, is so significant, it would stand to reason that the assumed deleterious impact of CSA would impact a large portion of the population. It is not only victim-survivors that are impacted as CSA has further far-reaching consequences for family members and society which then multiplies the number of affected individuals. Exploring possible effects on adult sexual functioning is a pertinent health concern because many widespread physical and psychological 11 Psychotherapists? Perceptions of CSA problems could potentially arise as a result of CSA (Meston et al., 2006; Randolph & Reddy, 2006a; Randolph & Reddy, 2006b). There is a large body of literature on the impact of CSA on adult intimate relationships (Colman et al., 2004; Heiman et al., 2004; Loeb et al., 2002). The perceived relationship between CSA and adult intimate relationships is of importance to psychology because the ability to be intimate with another is an important aspect of human relating and connecting to others. Intimate relationships have been reported to play a role in affecting an individual?s psychological functioning, one aspect of which is self-esteem. There is a significant correlation between an individual?s self-esteem and their perceived sexual functioning, where sexual functioning can be seen as a part of relational intimacy (Rehbein-Varvaez, Garcia-Vasquez & Madson, 2006). If it is the case that CSA affects adult intimate relationships, then it is further possible that the dysfunction in such relationships could lead to further psychological problems and related self-esteem problems. According to Ong and Bergeman (2008), self-esteem is one of the key components for maintaining psychological health. This study explored the perceptions of a sample of psychotherapists in order to give voice to their experiences in practice with victim-survivors of CSA in a way that resulted in a layered and multifarious body of description. Female victim-survivors who were abused by male perpetrators is the most common survivor-perpetrator gender dynamic and consequently the questions in the interview schedule had been specifically designed for female patients. Following this introductory chapter there are 4 subsequent chapters. Chapter 2 is the literature review in which contemporary and relevant literature on childhood sexual abuse is delineated. This research is both global as well as South African in origin. Chapter 3 explicates the thematic content analysis as used in this research. The method as well as a rationale for the particular paradigm ? interpretavist ? is explained in detail in this chapter. The following chapter, Chapter 4 is the results and discussion chapter. Particular exemplars were taken from interview transcripts from participants and 12 Psychotherapists? Perceptions of CSA discussed in relation to applicable theory. This chapter was separated along dominant themes, namely: Context comprising sub-themes of Definition and Impact (When is Abuse, Abuse?), Contact Specificity, Family and Social and Cultural Considerations in the Definition of Childhood Sexual Abuse; Betrayal which had the following sub- themes, Boundaries and Trust, Disclosure, and Body Betrayal/Arousal; Sex which was made up of sub-themes of Intimacy, Sex Work and Sexual Dysfunction; and lastly The Spectra of Damage which comprised sub-themes entitled Physical Manifestation, Psychological Manifestations, Self-Schema and Relational Dynamic. Chapter 5 is the last chapter in this research report and is predominantly a summary of he salient findings in this research. Limitations to the study are briefly discussed in this chapter in order to highlight the areas which are problematic in this study. Following the reference list are all the appendices which are the official documents used in the process of conducting this research. 13 Psychotherapists? Perceptions of CSA Chapter 2: Literature Review 2.1 Introduction This chapter addresses the consequences of CSA, researched and reported in a body of literature, expounded under the relevant headings below. The impact of CSA has been argued to manifest in a number of areas of functioning for the victim-survivor, such as psychological, physical and relational, specifically, for the purpose of this study, in the area of adult intimate relationships. A critical approach is considered with regard to CSA research as well as the possible impact that CSA may exert on a victim-survivor's adult intimate relationships. There are a number of contentious issues which arise in CSA research such as the lack of a universal definition for CSA as well as whether or not spectra of damage can be argued for. These issues will be discussed below. 2.2 Definition of Childhood Sexual Abuse There is no universal definition of childhood sexual abuse which results in individuals redefining the phenomenon consistently in the literature (Noll et al., 2003; Levett, 2004; Guma et al., 2004). This is further compounded by the fact that in the case of intrafamilial abuse, or where the perpetrator is a family member, this relationship is constructed according to cultural norms and practices (Pierce & Bozalek, 2004). It is unlikely to come to a precise definition of CSA as there is a discrepancy both in the professional understanding of the term as well as the lay understanding of what it is (Bornstein, Kaplan & Perry, 2007). The definition of what CSA is remains important for the inquiry into the impact of this phenomenon as an impact cannot be ascertained without an understanding of what it is. The United Nations Secretary General?s Study on Violence Against Children (2005) defines violence as any physical or mental injury and abuse or neglect, or negligent treatment, maltreatment or exploitation, including sexual abuse. They conducted a study where over 24,000 women were interviewed across 10 countries. According to the results 14 Psychotherapists? Perceptions of CSA of this study, an estimated 150 million children across the world have been sexually assaulted. There is unfortunately no clear indication in the report as to whether this figure is for cases reported in 2005 or if this is the total number of people in the world who are estimated to be currently living as victim-survivors of CSA. Kacker, Varadan and Kumar (2007), define childhood sexual abuse in the Study on Child Abuse: India, as any inappropriate sexual behaviour with a child including fondling, incest, rape, sodomy, exhibitionism, and sexual exploitation. The perpetrator needs to be older than the child and known to the child. It is not made explicit if a child can perpetrate abuse on another child and having this still constitutes CSA. If the perpetrator is unknown to the child, then this is termed sexual assault according to this report which implies than an experience can only be deemed ?abusive? if the child is familiar with the perpetrator. As understandings and experiences of CSA differ from person to person, it may not be useful to dictate when an act is abusive or not as this may be reliant on the interpretation of the potential victim- survivor. Likewise, the potential victim-survivor?s interpretation of the experience as either abusive or not may result in their own subjective manifestation of effects. It is argued above that an individual?s interpretation of an event is imperative for their own understanding; however it is equally as important to have legislation on something like CSA in an attempt to protect the rights of children. The rights of children have been legislated in South Africa, however, the difficulty in defining what constitutes CSA begins with the discrepant notion of how old an individual needs to be in order to be considered a child. The South African Constitution and the Children?s Act define a child to be anyone under the age of 18 years. However, the legal age for consensual sexual relations according to the Sexual Offences act is 16 years for heterosexual relations and 18 for homosexual relations. It is also stipulated that in the case of child abduction, a child is anyone under the age of 21 years (as cited in Richter & Dawes, 2008). The concern with the differing notions of how old an individual is in order to be considered a child is that without a universal notion of what it is to be a child, there is a problem with regards to identifying what it is to experience childhood abuse. To illustrate this point, if an individual is raped at the age of 15, considering that consensual (heterosexual) sexual relations are legal at 16, is this individual considered to have experienced childhood 15 Psychotherapists? Perceptions of CSA abuse, or rape? This has implications for the perpetrator as ?child abuser? or ?rapist? as well as the victim-survivor. The cognitive-behavioural and existential modalities in psychology, for example, view self-talk and the meaning that an individual gives to an experience as being key features in the process of healing (Corey, 2005). It is possible that confusion in naming an experience may lead to further distress for the victim- survivor. A further issue in formulating a definition for CSA is the variation in cross-cultural understandings of what constitutes abuse, which would include collective, or community beliefs, ideas and moral values encompassing norms and standard moral behaviour (Guma et al., 2004). The notion of what does or does not constitute child abuse depends on many factors such as cultural perspective, socio-economic and political circumstances in the country, to name a few. A further issue discussed by Guma et al. (2004) in the context of CSA research is that if definitions rely on culturally informed interpretations they will never be homogenous. They further note that more children suffer abuse in the name of culture than is evident in official records. 2.2.1 Context of the abuse The definitions of CSA are contentious in the literature, nonetheless the conventional and contemporary studies in the area define CSA as a coerced ?unwanted and inappropriate solicitation of, or exposure to, a child by an older person (non-contact abuse), genital touching or fondling (contact abuse), and penetration in terms of oral, anal, or vaginal intercourse or attempted intercourse (intercourse)? (Andrews et al., 2004, p. 1853). Following from the above definition of CSA, there are a number of factors that are considered relevant and unique to a victim-survivor?s experience and subsequent psychological, physical and relational manifestations. Some of these factors include: the age at which the abuse occurred; the duration of the abuse; the proximity of the victim- survivor?s to the perpetrator; the extent or severity of the abuse and the victim-survivor?s predisposition towards particular pathology. Poorer adjustment has been noted in victim- 16 Psychotherapists? Perceptions of CSA survivor?s who report more severe and prolonged forms of sexual abuse (Feiring, Taska & Lewis, 1999). There are various factors which need to be taken into consideration when deciding whether or not a particular behaviour or act can be termed sexual abuse. These include: the nature of the behaviour; the context in which the behaviour occurred; the intent with which the behaviour was perpetrated; the developmental level of the individuals involved; and whether force, coercion or manipulation was involved (Gordon & Schroeder, 1995). There are further factors important for the consideration of CSA and these include factors seen to be possible causes or predicators of CSA. These are cultural factors; psychological factors on the part of the parents; the pregnancy and postnatal period; and the functionality or level of dysfunction of the family (Le Roux, 2000). 2.2.2 Theoretical understandings of childhood sexual abuse There are a number of theoretical frameworks which attempt to explain the complexities involved in CSA. Psychology as a discipline contains within it these different frameworks resulting in there being different kinds of practicing therapists who utilise different theories in order to understand a problem. Some common theories that will be discussed here include attachment theory, object relations, existential and cognitive-behavioural theories. Childhood sexual abuse will be briefly delineated according to each of these theories. Looking at the impact of CSA on an individual?s relational style and ability requires a brief look at attachment theory and what has been theorised around attachment in victim-survivors of CSA. Insecure and anxious attachment styles have been found to correlate with histories of CSA (Schilling, Aseltine, & Gore, 2007). Insecure and anxious attachment has been associated with difficulties in relating with and to others (Schilling et al., 2007). This struggle in attachment and relating is associated with both intimate and non-intimate relationships. The struggle in relating has thought to be associated with both relational and emotional problems as well as problems with the self (Schilling et al., 2007). Crudely put, attachment theory argues that an individual?s ability to attach to external people in early childhood is a predictor of later attachment style (Shapiro & 17 Psychotherapists? Perceptions of CSA Levendosky, 1999). What this means for the victim-survivor of CSA is that, according to Shapiro and Levebdosky (1999), a victim-survivor with secure attachment prior to the abuse is more likely to be able to develop healthy intimate relationships in adulthood than a victim-survivor with insecure or poor attachment prior to the abuse. Attachment theory is seen to stand as a theory in its own right, however it is considered a part of psychoanalytic object relations theory (ORT) (Kernhof, Kaufhold & Grabhorn, 2008). ORT according to Kernhof et al. (2008) provides a model to explain how an individual?s early experiences are internalised and projected onto future relationships. What this means for the victim-survivor is that an early abusive experience is argued to be internalised and subsequent relationships are then perceived as dangerous. This may result in relationship problems if not managed sufficiently. Furthermore, it is argued to be useful in understanding relationship disorders, including intimate relationship discord, in victim-survivor?s adult relationships (Kernhof et al., 2008). An early abusive sexual experience, according to ORT may result in a projection of the idea that intimacy is dangerous and harmful onto future relationships. This may impact on a victim-survivor's capacity to be in an intimate relationship in adulthood as a result of this mistrust. Existential or spiritual well-being has been identified as an important part of a victim- survivor?s healing after the abuse (Feinhauer, Middleton & Hilton, 2003). Developing the ability to perceive the abusive experience as a fault of someone else (the perpetrator) was argued to allow for an element of self-blame, evident in many victim-survivors, to be resolved. Existential theory argues that in shifting the blame away from the self, healing can occur. This is imperative for the victim-survivor in that it is argued that by being able let go of the guilt and self-blame, s/he becomes more empowered and develops inner strength and determination (Feinhauer et al., 2003). In being able to develop a healthy relationship with the self, existential theory posits that an individual will then be more capable of developing a trusting and intimate relationship with others as argued by Feinhauer et al. (2003). 18 Psychotherapists? Perceptions of CSA It was argued by Bornstein et al. (2007) that a therapist?s perception of the extent of the abuse perpetrated, influenced their response to the victim-survivor as well as the treatment plan that was implemented. It becomes evident how a therapist?s perception of the abuse, based on the contact specific factors listed above as well as their theoretical orientation, becomes relevant in the case of victim-survivors of CSA. The last orientation to be briefly discussed is that of cognitive-behavioural therapy. Cognitive-behavioural therapy approaches CSA in terms of the current problematic behaviours or affects that are occurring. It is a collaborative process and much of the recovery is explicitly placed in the hands of the victim-survivor (Bass, 1996). Distorted cognitions can be focused on, regardless of the perceived etiology of these cognitions and in that way, this modality does not focus on the abuse history, but on the dysfunction in the here-and-now (Bass, 1996). 2.3 Global Considerations The prevalence of CSA is variable in the literature and this is argued by Pereda, Guilera, Forns and Gomez-Benito (2009) to be as a result of issues around the definition of CSA as well as due to the varied methodology used. With regards to definition, Pereda et al. (2009) found variations between ?the age difference between the perpetrator and the victim, the age used to define childhood or the type of sexual abuse? (p. 332). In conjunction with the issues around definition, further problems arose regarding the methodology used in order to collect data as it was found that face to face interviews often yielded higher disclosure rates than in self-report questionnaires (Pereda et al., 2009). The implications of discrepant prevalence rates are not vital to this study because of the fact that prevalence is not a factor and because psychotherapists are being interviewed and not survivors and so disclosure of CSA is not a requirement. It is possible to argue for contextual differences between low and high income countries, especially regarding the problems that people may face. However, due to the fact that prevalence rates do not differ greatly between different countries, these differences do not appear to have direct bearing on the rates of CSA. Lachman (2004) argues that the issues 19 Psychotherapists? Perceptions of CSA facing children are similar around the world, although these issues may vary in degree and prevalence. These issues include ?poverty, war, family disruption, family violence, abandonment, and HIV/AIDS, with the denial of their basic rights under the UN Convention of the Rights of the Child? (Lachman, 2004, p. 813). The prevalence of these issues is higher outside of Western Europe, North America and Australasia, although they are not exclusive to developing countries (Lachman, 2004). CSA is a global public health problem which has potential consequences for societies around the world. Despite the global appearance of children being sexually abused, two countries were found to report little or no occurrences of CSA: Portugal and China (Pereda et al., 2009). Impact studies of CSA are hence important ? because of the national as well as international prevalence - in order to ascertain what the impact of CSA is on the individual and society, as well as to bring attention to the issue. Childhood sexual abuse is noted to occur at all socio-economic levels, which implies that socio-economic status of perpetrators or victim-survivors is unlikely to be a definitive etiological contribution to occurrence. On the other hand, some studies have found prevalence rates to be higher in low to middle income countries than in high income countries (Kacker et al., 2007). Given this finding, it may be useful to consider socio- economic status as an aggravating factor in CSA. It may be more important to look at South Africa set apart from international research, in order to ascertain first what the similarities and differences are in comparison to international research. 2.4 Childhood Sexual Abuse in South Africa Incidence of neglect and ill-treatment of children in South Africa has increased by 55.1% from 2001-2008 according to the South African Police Service Crime Statistics for 2008 (SAPS, 2008). Although these statistics are not specific to incidence of CSA in South Africa, they do indicate at the very least that there has been an increase in the reporting of crimes against children since 2001. By looking at the incidence of reported child abuse in the country, it can either be inferred that more people are either reporting incidents of abuse, or that there are more cases occurring, including those that are left unreported. 20 Psychotherapists? Perceptions of CSA Richter and Dawes (2008) is one of the few emic studies conducted in South Africa. There are particular contextual elements which need to be considered when comparing studies done in other countries. One of these is the political and social position of South Africa as a country. For example, post-apartheid legislation has resulted in South Africa having highly advanced human rights legislation, however as previously stated, there is current failure in enforcing it. There is furthermore still much disparity regarding access to resources between people of diverse income groups. There is a lack of specific legislation in customary law regarding the rights of the child to freedom from abuse, the only related stipulation being that a man is required to pay reparations to the family of a woman that he has raped and if a child is born from this assault then the child will become the responsibility of the paternal household (Levett, 2003). Moreover, it is interesting to note that customary law in South Africa contains no stipulations regarding abuse or neglect of children or the sexual assault of women or children (Levett, 2003). The point being made in the above arguments is that there is little protection for children in South Africa despite the advanced human rights legislation in place. 2.4.1 Cultural Considerations When considering CSA in South Africa, it is imperative to consider cultural perceptions and ideologies around the different discourses related to CSA. Cultural perceptions are important to consider because of the relative cultural complexity implied by the fact that South Africa is a multi-cultural society. On the other hand, it is important to note that culture is not homogenous and static but is rather heterogeneous and dynamic and often conceptions of one culture may differ from member to member (Korbin, 2002). This then implies that although cultural understandings are important, they are not universal to all members. This section will briefly cover the nature of culture, cultural or social constructions of the family and finally, the cultural context that exists in South Africa. These areas are important contextual considerations when considering CSA because in 21 Psychotherapists? Perceptions of CSA order to understand an individual's experience of CSA it is important to locate them in their own context. Although victim-survivors themselves were not interviewed in this study, it was seen as important to understand the dominant cultural ideology in the country in order to contextualise the problem. Richter and Dawes (2008) delineate the ideological and cultural constructions of the family which they argue is perpetuated by socialisation. It is hence socialisation, which they argue, creates the conditions within a family. This, they explain, influences how men and women behave towards one another and how they behave towards their children. Many South African cultures are patriarchal and this is argued to influence family construction as well as to possibly play a role in the understanding of why instances CSA are so high in the country. This will be explained in more detail below. It stands to reason that if a family structure is patriarchal, then it is likely that gender power dynamics exist in many intimate relationships. So it can be seen how patriarchy and gender power dynamics could be argued to be present in both CSA as well as adult intimate relationships. South African society is seen as a predominantly patriarchal society, dictated by cultural ideology. Levett (2003) addresses the issue of patriarchy and discusses how two factors may contribute to the occurrence of CSA: the social production and proliferation of male authority; and the normative view of male promiscuity and hostile masculinity. Levett (2003) argues that patriarchal traditions that exist in South African families serve to facilitate the objectification of women and girls. Although it is argued that patriarchy is not theorised to be a main component of CSA, it is present in any incident of sexual exploitation, one of which is CSA (Baima & Feldhousen, 2007). It would seem that some argue for a causal relationship between patriarchy and victimization of females and this can be argued in some sense to epitomise CSA in cases where the victim-survivor is female and the perpetrator is male (Baima & Feldhousen, 2007; Levett, 2003; Soloman, 1992). 22 Psychotherapists? Perceptions of CSA Ken Hardy (2005) as cited in Baima and Feldhousen (2007) argues that any form of oppression contains within it an experience of trauma, and patriarchy is seen as a form of gender oppression. Possible subservience and unquestioning obedience expected of a child in a patriarchal context tends to prevent resistance to the abuser (Richter & Dawes, 2008; Vermeulen & Fouche, 2006). Thus many cases may fail to be reported or prevented and reporting is often discouraged by family members. Richter and Dawes (2008) argue that some victim-survivors felt that it would be ?wrong? to report abuse because of the subsequent impact it may have on the family (Richter & Dawes, 2008; Vermeulen & Fouche, 2006). A possible explanation for the refusal to report sexual abuse is that patriarchal oppression is pervasive and profoundly impacts an individual in making them feel degraded and less than human (Baima & Feldhousen, 2007). Many of these conceptualisations of CSA and stigma around reporting it are related to supposed cultural ideologies which exist in the country (Pierce & Bozalek, 2004). Richter and Dawes (2008), as discussed above, draw distinctions from information about cultural and ethnic groups in order to give a context for child abuse in South Africa. For the purposes of this study, a cultural explanation was only used insofar as the participants felt this context was relevant to them and their experience with their patients. The following quote clearly explains why a cultural perspective should be used with caution: ??classifying people on the basis of group membership only gives us the illusion that we are being culturally sensitive, when, in fact, we are failing to look beyond easy characterisations for particular and specific ways that this person is understanding, feeling, and acting.? (Connolly, 2003, p. 105). Considering that South Africa is a multi-cultural society, it is important to briefly address what impact cultural beliefs about health and illness might be. Lynam, Browne, Kirkham, and Anderson (2007) found in their research that often the meaning of health and illness can differ even within a particular cultural group. For example, while some individuals in a cultural group may find comfort in traditional understandings and treatments of illness and disease, there may be others in the group that do not. This an important consideration because of the fact that the demographics of private psychotherapists, as was used for this 23 Psychotherapists? Perceptions of CSA study, may not be representative of the South African sample. As private psychotherapy is costly, it is likely that the vast majority of South Africans would not be able to afford it. The consequence of the cost of psychotherapy as well as the cultural conceptions of health may result in a patient base that is relatively homogenous across cultural and socio-economic bounds. 2.5 Family It is argued that children who have CSA histories are often found to have grown up in adverse conditions, regardless of whether the perpetrator was intra- or extra-familial (Martsolf & Draucker, 2008). One possible reason for this is because it has been found that poorer families are more likely to report abuse to the authorities (Baumrind, 1994). Considering that South Africa is a country in which many families live in adverse conditions, this is relevant to the country, however, many individuals in private psychotherapy are likely to come from wealthier families and backgrounds. Bornstein et al. (2007) argue that the way in which the family reacts to the disclosure of abuse from a victim-survivor is instrumental in how the victim-survivor interacts with others later in life as well as how adjusted they become. Disclosure as well as other factors in the family such as punishment are sub-culturally mediated and so often in order for an action to be considered abuse, it will have to fall under a particular body of norms and ideas based in that particular culture or family (Baumrind, 1994). It has been argued that the mother of the abused child is the most heavily impacted member of the family and often the abused child will feel intense feelings of anger towards the mother post-abuse (Hiebert-Murphy, 1998). Greater mental health, coping and improvement has been found in cases where mothers respond in a protective and supportive manner (Lovett, 2004; Vermeulen & Fouche, 2006). 24 Psychotherapists? Perceptions of CSA 2.6 Influence of Childhood Sexual Abuse The three areas of physical, psychological and relational health, specifically within adult intimate relationships, are inherently connected and cannot be separated in abused or non- abused individuals. This inherent connection can be seen in the fact that many of the psychological effects of CSA also have an impact on sexual functioning. To illustrate, depression is sometimes associated with abuse histories, but it is also a common factor affecting sexual functioning. So, sexual dysfunction may be argued to be as a result of psychological distress and not directly related to the CSA (Meston et al., 2006). Depression can affect self-esteem which is also implicated in sexual functioning, this is explicated in the following quotation. ?Depression may decrease sexual interest, one?s sense of self-worth, communication, and positive experiencing (leading to) more relationship discord and unhappiness? (Heiman et al., 2004, p. 36). There is some debate about the causal chain, or etiology of sexual problems or dysfunction, insofar as it is unclear whether the sexual problem or dysfunction arises as a result of the CSA or the pathology. Furthermore, physical symptoms such as chronic pelvic pain, which will be discussed under the CSA and physical health subsection, may also affect one?s willingness to engage in a sexual act such as coitus that may result in pain or discomfort (Heiman, et al., 2004; Randolph et al., 2006a; Randolph et al., 2006b). The salient point here is that some researchers view sexual problems as being the result of physical ailment or pathology, but it could be argued that the pathology in question arose as a result of the sexual abuse and that in certain cases CSA is the essential reason underlying the sexual problem. Reduced libido and sexual satisfaction have been found to be associated with depression and anxiety, however it will be argued below that as depression is often seen as a consequence of CSA, it could hence be argued that the sexual problems are in fact as a result of the CSA (Ahmad, 2006). 25 Psychotherapists? Perceptions of CSA 2.6.1 Adult Intimate Relationships Intimacy is seen as the ability to develop closeness with another person in which there is adequate communication and commitment (Weinberger, Hofstein & Whitborne, 2008). Colman and Widom (2004) discuss intimacy with regards to dissatisfaction in an adult relationship involving a partner or marital disruption. They also address the overall quality of intimate relationships and the functioning of these relationships. It is argued that experiences of relationships and sexual functioning are relevant attributes to consider when exploring the area of the perceived impact of CSA on adult intimate relationships (Feinhauer, 1989; Liem, O-Toole & James, 1996). Victim-survivors are noted to associate intimacy in a relationship with fear and shame and there is often a preoccupation with submission and dominance in a sexual encounter (Feiring, Simon & Cleland, 2009). Furthermore, victim-survivors often equate love and intimacy with abuse, which ultimately impacts on their idea of what boundaries are and ought to be (Harper & Steadman, 2003). Testa, VanZile and Livingston (2005) found that victim-survivors of CSA were found to report lower levels of satisfaction in relationships and also reported more problems concerning attachment than their non-abused counterparts. It has been found that intimate relationship problems for victim-survivors are not solely related to sexual problems or difficulties, but that they are intricately linked with issues of trust (Oz, 2001). Trust is often associated with intimacy as one cannot be intimate without trust (Weinberger et al., 2008). 2.6.2 Sexual dysfunction The concept of sexual dysfunction is characterised in terms of various symptoms that may be experienced during a sexual encounter. These symptoms include a lack of interest in sex, lack of orgasm, displeasure during the experience, painful intercourse and anxiety about sexual performance (Najman, Dunne, Purdie, Boyle & Coxeter, 2005). Loeb et al. (2002) specify sexual desire disorder and inhibited female orgasm in their definition of sexual dysfunction. There is some debate as to whether or not a failure to engage in sex, 26 Psychotherapists? Perceptions of CSA or enjoy sex, constitutes a sexual dysfunction (Najman et al., 2005). It is therefore vital to include an examination of the context and etiology of these symptoms in order to acquire more in-depth information regarding the effect of CSA on sexuality and functioning as discussed by Loeb et al. (2002). Although sexual dysfunction is a major factor in this study, it is also necessary to engage with the literature surrounding over- and under-sexualization as this is far more dominant in discussions of the effect of CSA. This can be seen in Najman et al. (2005) amongst others. Noll et al. (2003) use the terms sexual ambivalence and heightened sexual preoccupation to refer to the concepts of over- and under-sexualization whereas Merrill et al. (2003) use the similar terms avoidance of sex and sexual compulsivity. So it can be seen that different terms are utilised in the current body of research giving rise to some confusion. For the purpose of this study, the terms sexual ambivalence and sexual preoccupation will be utilised in order to standardise the language throughout. These terms have been chosen because they do not immediately imply any pathology, which serves to reinforce the researcher in maintaining a non-judgmental frame of view throughout the research. Merrill et al. (2003) argue that sexually abused women are more likely than non-abused women to develop negative attitudes towards sex. They further argue that women who have experienced CSA are more likely than their non-abused counterparts to engage in dysfunctional sexual behaviour which they define as self-defeating or maladaptive sexual behaviour. Such sexual behaviour includes having sex with strangers, using sex to gain affection, to cope with distress or to feel powerful, or having secret sex. Noll et al. (2003) specify acts such as compulsive sexual behaviours, sexual risk-taking, and prostitution to name a few. Although these two authors present differing nomenclature, both sets of behaviour could arguably fall under the category mentioned above, namely, heightened sexuality or sexual preoccupation. Furthermore, Zurbriggen and Freyd (2004) similarly found a connection between CSA and sexual compulsivity in acts such as indiscriminate sex, which is similar to sex with strangers as mentioned by Merrill et al. (2003), a high 27 Psychotherapists? Perceptions of CSA number of sex partners which could be argued to be sexual risk-taking behaviour, as mentioned by Noll et al. (2003), and prostitution as also mentioned by Noll et al. (2003). Although different authors may vary in rhetoric and nomenclature, there is some resemblance or parallel in the idea or concept discussed under what has been termed ?heightened sexual preoccupation?. The second category for the effect of CSA on the sexual development trajectory as outlined by Noll et al. (2003) is the antithesis of sexual preoccupation, namely, sexual aversion. Again, it is important to note that although some authors may present this categorisation using a different terminology, the inclusion of authors who may seem to differ in nomenclature is important to draw attention to similar features. Sexual aversion includes problems with desire, sexual arousal and orgasm (Meston et al., 2006), sexual dissatisfaction (Heiman et al., 2004) and what Zurbriggen and Freyd, (2004) term sexual guilt. Meston et al. (2006) also discusses a decreased presence of romance and passion among CSA survivors as opposed to their non-abused counterparts. According to Noll et al. (2003) there is more than one developmental trajectory describing the effect of CSA on adult sexuality; heightened sexuality or sexual preoccupation, which includes excessive masturbation, sexual aversion or avoidance and a trajectory where both preoccupation and avoidance are present simultaneously and an individual believes that sex is undesirable but he/she possesses a compulsion to engage in sexual activity. Often definitions are limited to promiscuity or aversion only. 2.6.3 The Influence of Childhood Sexual Abuse on Adult Psychological Health There is a large body of literature correlating CSA and problems in adulthood, although there is contention among some authors as to whether or not we can attribute these problems solely to CSA (Merrill, Guimond, Thomsen & Milner, 2003; Noll et al., 2003; Zurbriggen & Freyd, 2004). 28 Psychotherapists? Perceptions of CSA Levett (1989) argues that the idea of ?trauma? is used as if the term is self-evident however the complexity of this term, especially in relation to CSA, has not been sufficiently explored. The term ?psychological trauma? insinuates the presence of a normative, value-laden baseline upon which one can judge that something unusual, or bad has happened to the psychological functioning. She further argues that there needs to be more research done on instances of CSA where no harmful effects have occurred. As argued above, one cannot adequately study the effect of CSA on adult sexuality, functioning, sexualisation and attitudes without including an aspect of psychological well-being or suffering. A variety of psychological effects have been researched and represented in the literature. The main categories of problems that occur can be grouped into mood disorders, self-image and self-worth problems, personality disorders and stress disorders. However, as discussed above, it is very difficult to separate sequelae of CSA into distinct categories (psychological, physical, relational) because of the interrelation between these categories. Mood effects include depression and anxiety, (Heiman et al., 2004; Meston et al., 2006) as well as suicidality (Merrill et al., 2003; Vigil, Geary & Byrd-Craven, 2005) and other self-destructive behaviour such as substance abuse and eating disorders (Heiman et al., 2004; Merrill et al., 2003; Zurbriggen & Freyd, 2004). Problems with self-image and self-worth include disturbances in self such as negative affect schemas about safety, others and self (Meston et al., 2006), decreased appraisals of self-worth, depreciation of body image and a decrease in overall physical, social (Heiman et al., 2004) and emotional well-being (Vigil, et al., 2005). Included in this would also be a marked low self-esteem (Heiman et al., 2004; Merrill et al., 2006; Vigil, et al., 2005; Zurbriggen & Freyd, 2004). Personality disorders include borderline personality disorder (Heiman et al., 2004; Vigil et al., 2005) and in rare circumstances dissociative identity disorder. And lastly stress disorders will include but are not be limited to the appearance of post-traumatic stress disorder symptoms (Heiman et al., 2004; Zurbriggen & Freyd, 2004). 29 Psychotherapists? Perceptions of CSA Some authors argue that at best CSA has an indirect effect on functioning. That is, the psychological distress resulting from CSA causes sexual dysfunction and not the CSA itself. Instead of seeing the aforementioned problem as A (CSA) leads to B (psychological distress) which in turn leads to C (sexual dysfunction), it ought to be seen as A (CSA) can cause B1 (depression), B2 (borderline personality disorder), B3 (PTSD), B4 (sexual dysfunction) and so on. It is important to view the argument in this fashion because it is argued that the effect of CSA on an individual should not be trivialised by failing to recognise it as a cause of problems that develop before or during adulthood. Furthermore, the impact of CSA on any aspect of a person?s functioning should not be seen as linear but as a part of a complex network of potential effects. Two people may have similar abuse experiences and yet this may manifest different issues in each individual. This is indicative of the multiple ways in which CSA may impact upon a person. 2.6.4 Self-schema This view predominantly sees CSA as having damaging and negative consequences for individuals as a consequence of the sexual abuse (Levett, 2003). Levett (2003) notes that the prevalence of CSA is exceptionally high and that given this prevalence, she considers it difficult to see CSA as something out of the ordinary as so many women have a history of CSA. She further argues that considering how many women have been sexually abused, CSA has become ?normalised?, but people are reluctant to see it as such because of the perceived moral turpitude involved in accepting this conception of CSA. Yet, accepting the normalisation of CSA is as much a difficult task in a society in which the entire discourse of CSA is laden with terms such as ?survivor?, ?victim? and ?damage? which pre-empts CSA victim-survivors in causing them to be viewed as such (Levett, 1992). However, in using Levett?s reasoning, even using the term ?survivor? implies that a sufficiently deleterious event happened to the individual so that they can indeed be seen as ?survivors? (Levett, 1989). Hence the conscious use of the term victim-survivor in this report. 30 Psychotherapists? Perceptions of CSA 2.6.5 Influence of Childhood Sexual Abuse on Physical Health As has been discussed above, sexual abuse in childhood affects many facets of the victim-survivor?s development into adulthood including physical health. Consequences of CSA include pelvic pain (Heiman et al., 2004; Randolph et al., 2006a; Randolph et al., 2006b), somatization, chronic pain, gastrointestinal problems, premenstrual symptoms and increased pelvic symptoms such as vaginal discharge and chronic abdominal pain (Heiman et al., 2004). The complaints included headaches which developed into migraines, vomiting, experiences of feeling as if the victim-survivor is choking, and nervous coughing (Loewenstein, 2004). With regards to effect on sexual functioning, the same issue applies as does in psychological consequences in that it is difficult to ascertain whether the sexual functioning is being affected by physical discomfort or directly impacted by the CSA. Although the physical symptoms may be as a result of CSA, it is difficult to make a direct connection from CSA to sexual functioning in the form of physical discomfort, although it will be argued here that this ought to be seen as a direct connection. Leeners, Stiller, Block, Gorres, Imthurn, and Rath (2007) found that women who reported a history of CSA tended to seek more medical attention and use more sick days than women without CSA histories. Furthermore, CSA victim-survivors have more physical complaints and they tend to rate their health lower than non-abused women (Leeners et al., 2007). The following complaints were found to be most common: pelvic pain; premenstrual dysmorphic disorder; dysmenorrhea; menorrhagia; bladder dysfunction; sexual dysfunction; sexually transmitted diseases and pelvic inflammatory diseases (Leeners et al., 2007). Chronic pelvic pain is commonly associated with psychosocial stressors, one of which is commonly physical or sexual abuse (Knight, Green & Hinson, 1997). 31 Psychotherapists? Perceptions of CSA Chapter 3: Method 3.1 Research Approach Embedded in an interpretavist paradigm, this study made use of semi-structured interviews which were transcribed and analysed using thematic content analysis. For the purposes of this study, the paradigm for analysing the data was interpretavist. The interpretavist paradigm was useful in a study such as this because this paradigm is committed to understanding human experience through the actual lived experience of the participants (Rossman & Rallis, 2003). Furthermore, this paradigm seeks to understand subjective experiences in the world in which the participant is located. Ultimately the participants are seen as agents of their own social worlds and as having their own perceptions as a result of their subjectivity (Mattila & Aaltio, 2006). Furthermore, both the subjectivity of both the participants and the researcher are recognised (Morrow, 2007). Qualitative research methods are seen as useful in exploring the depth and complexity in human experience (Morrow, 2007). Qualitative studies can often be used to explore a participant?s perspectives and understanding of an event (Ziebland & McPherson, 2006). But there is an inherent responsibility on the part of the researcher to accurately hear what participants are saying, what meaning they are giving to their experiences and to adequately construct an interpretation of this data (Larkin, Watts & Clifton, 2006). Qualitative research involves addressing alternative conceptions of social knowledge, meaning, reality and truth that might not be possible in quantitative inquiry, which aims to identify and collect objective quantifiable data (Kvale, 1996). Furthermore, quantitative research can only provide a certain broad understanding of a phenomenon (Morrow, 2007). In addition as this study was novel in the South African context, a more in depth methodology satisfied the aims of the study. 32 Psychotherapists? Perceptions of CSA 3.2 Participant Selection Participants were gathered using purposive sampling and accessed using internet sources for psychotherapists in Johannesburg, as well as through snowballing techniques. Purposive sampling is frequently used to acquire a sample group of participants who will be best suited to take part in a study of the required nature. In qualitative analysis, through a process of careful sampling, a rich and in-depth analysis can be performed on a relatively small number of participants (Ziebland & McPherson, 2006). For the purposes of this study, 8 participants were selected in order to provide adequate data to answer the research questions. The data gathered from 8 participants was thereby sufficient to reach data saturation. All participants are therapists currently residing in and working in Johannesburg, who have some experience in working with clients reporting a history of CSA. All participants are proficient in English. Although there did not appear to be major cultural differences between the researcher and the participants, the cultural aspects discussed above regarding CSA were discussed in the interviews with regards to the therapist?s patient base. Lastly, all participants volunteered to take part in the study of their own volition. This is to protect first and foremost the participant, secondly the researcher and thirdly the University. In order to maintain the principles of beneficence and non-maleficence inherent in the ethical code for the practice of psychology, it was seen as of central importance to protect the participants from any harm that may be avoided while conducting this research. 3.3 Procedure After ethics clearance from the University was obtained, psychotherapists were contacted telephonically and they were requested to take part in this study. A meeting was set up with those that agreed and the interviews were conducted at each therapist?s place of work in order to make the experience more comfortable for them as well as for their own convenience. 33 Psychotherapists? Perceptions of CSA The interview tapes and recorded transcripts were kept in a locked cupboard and only the researcher and supervisor had access to this material. The participants were informed of this as well as what will happen to the data upon completion of the study. They were also informed of how this data will be disseminated and that a summary of the results will be made available to them upon completion of the study. See Participant Information Sheet (Appendix D). 3.4 Data Collection Instrument This research utilised a semi-structured interview schedule or interview guide. Each participant was asked to take part in an interview lasting approximately 1 hour in length, depending on the nature and quality of the data being collected. Interviews are a stated way to obtain knowledge of the social world from the participants? own perspectives (Kvale, 1996). The purpose of a qualitative research interview is to attempt to understand the participants? world through their own eyes and to uncover the meaning that the participants? attach to the events that take place in their own world (Kvale, 1996). For the purposes of this study, a semi-structured interview structure approach was used in order to obtain in-depth accounts of the experiences and perceptions of the psychotherapists while still allowing for some flexibility in the interview schedule. This interview structure was useful in allowing the interviewees to present their views about their lives in their own words, and to evaluate individual?s responses (Taylor & Bogden, 1998). There are a number of obvious benefits and shortcomings in the use of interviews. The interview as a research tool can renew, broaden, and enrich the existing data on a subject (Kvale, 1996). Participants answer questions in the interview but they also formulate and express their own conceptions of the world in which they live (Kvale, 1996). On the other hand, interviews can be problematic in that they can lack a definitive procedure which needs to be followed when conducting an interview and so much is left up to the creative impulse of the researcher him/herself (Kvale, 1996). Advantages of interviewing include the widely held notion that there is no other method which can provide the depth of 34 Psychotherapists? Perceptions of CSA understanding that is achieved by listening to people talk (Taylor & Bogden, 1998). A limitation to interviewing is that the interviewer cannot assume that what a person says or does in an interview is necessarily how they would perceive or react consistently in every situation while secondly, if you are not observing a participant in their everyday lives, it might be difficult to adequately contextualise what they share in the interview (Taylor & Bogden, 1998). Furthermore, recording interviews can be problematic in the sense that interview participants may indeed feel self-conscious about what they are saying which could affect the data collected (Taylor & Bogden, 1998). The questions that were asked (Appendix A) were sufficiently open-ended so as to allow the participants to define and make meaning of CSA, adult intimate relationships and possible mental and physical effects that they perceive to experience as a result of the abuse experienced in childhood. 3.5 Data Analysis Thematic content analysis involves identifying recurring themes in literature or data (Dixon-Woods, Agarwal, Jones, Young, & Sutton, 2005). Thematic analysis is an ideal method for identifying, analysing and reporting themes found in individual interviews as well as across interviews. Not only does this method result in a rich body of information, but also allows for interpretations to be made by the researcher. The themes in the data were identified and studied at a semantic or explicit level. The analysis process involved a steady progression from description of patterns to a theoretical interpretation of the significance of these patterns. This allowed for broader meanings and implications to arise. The other method of analysing themes is at the latent level which intends to analyse the underlying meanings and ideologies which have shaped semantic content. This analysis was chosen because of the fact that the area this study aimed to investigate is not well-researched and so it was thought best to first understand the semantic content in this area before trying to understand underlying meanings (Braun & Clarke, 2006). 35 Psychotherapists? Perceptions of CSA Thematic content analysis was outlined by Braun and Clarke (2006) who identified 6 steps that need to take place in the actual analysis. The first step involved becoming familiar with the data by reading and re-reading the transcripts many times. The researcher in this study collected and transcribed the data personally and so some familiarity had already been achieved with the data at the commencement of analysis. However, it was vital to become further familiarised with the data by reading and re- reading interview transcripts to identify meanings, patterns and themes. At this stage of the analysis, some ideas about coding were noted but the formal coding of the data process had not begun as yet. The second phase in the analysis was to assign initial codes to the data, but this was only done once the researcher was particularly familiar with the data (Braun & Clarke, 2006). Coding allows for the researcher to meaningfully organise his/her data into groups. The coding depended on whether the data was theory or data driven and in the case of this study, there was be an emphasis placed on data driven coding. The entire data set was sufficiently coded and as many potential themes or patterns as possible were identified, while still retaining the context. The third phase in analysis was the focus on themes as opposed to codes in the previous step (Braun & Clarke, 2006). The different codes identified were considered under an over-arching theme, which had been identified. The researcher at this point started to consider the relationships between codes, themes and different levels of themes which could be either main themes or sub-themes. The fourth phase in analysis involved reviewing and refining themes identified in the previous phase (Braun & Clarke, 2006). Firstly the researcher reviewed the themes at the level of the coded data. Once this data was reworked and made coherent, the same work was done but in relation to the entire data set. It was possible that new themes could have been identified at this point and some might have been considered to no longer fit. The fifth phase involved defining and naming identified themes (Braun & Clarke, 2006). 36 Psychotherapists? Perceptions of CSA Once the themes had been sufficiently refined, the researcher began to define and name the themes. A detailed analysis was performed on every theme and on the themes in relation to each other. Sub-themes were identified and found to be useful in structuring a large and complex theme. The sixth and final step in thematic content analysis according to Braun & Clarke (2006) was the production of a report involving the final analysis and write-up. The main function of this stage was to tell the ?story? of the data within and across themes. The analytic narrative was aimed at going beyond simply descriptive elements and presents an interpretation and an argument that directly relates to the research question. Thematic content analysis is a flexible analysis which could be used for theory building (Dixon- Woods, 2005). 3.6 Issues of Self-Reflexivity and Representation Trustworthiness is a concern of ?good practice? which involves the researcher acknowledging their particular orientation, which could be social or cultural contexts, and discerning how this might affect the outcome of the data collected (Merrick, 1999). The approach, collection, analysis, interpretation and reporting of findings was pivotal to good practice in this study. The goal of trustworthiness is understood to be aware of the self-as-researcher whilst engaged in the research process (Merrick, 1999). Thus, self- reflexivity was an important aspect of this study. Self-Reflexivity is an inherent concern in qualitative research (Merrick, 1999). Reflexivity is the acknowledgment of the context and culture of the researcher being central in the construction of knowledge in the research process. Wilkinson (1988) identified three types of reflexivity: personal, functional, and disciplinary. Personal reflexivity is an acknowledgment of whether or not the researcher as an individual brings personal interests and values into conducting a particular piece of research. Functional reflexivity is an examination of the process of the research in order to reveal its assumptions, values and biases. And disciplinary reflexivity involves reflecting on larger 37 Psychotherapists? Perceptions of CSA issues at hand such as the methodology used and even being critical of psychology as a field itself. The process of reflexivity involves the researcher?s social, cultural and socio- economic position in relation to the participants and seeing the participants through a lens that was innately affected by the researcher?s particular orientation or context (Morrow, 2007). And lastly, representation includes the researcher disclosing personal material about him/herself and the research process as a way to evaluate the research (Merrick, 1999). With regards to this research, the researcher acknowledges the fact that being a young white female may have impacted on certain aspects of the data collection process where the psychotherapists being interviewed were older, possibly part of different cultures, language groups and socio-economic statuses. However, this was not seen as a problem in gathering the data in that it was taken as a matter of course that volunteers in this study were by volunteering, willing to talk about the topic in a relatively open manner regardless of who may have been asking the questions. Nonetheless, cultural sensitivity and the respect for each individual participant was carefully maintained at all times. 3.7 Ethical Considerations The research only commenced upon receiving ethical clearance from the ethics committee at Wits University. Once ethical clearance had been received, the relevant individuals were contacted regarding the study and a meeting was be set up with the psychotherapists in order to conduct interviews. Before commencement of the interviews the psychotherapists received a participant letter (Appendix B) and the researcher explicitly explained their rights in being interviewed. They were informed that their participation was voluntary and they have the right to stop at any point in the interview and to refuse to answer questions without any personal consequences. The participants fully understood their role and rights in the interview process before commencement of the interviews. 38 Psychotherapists? Perceptions of CSA The limits to confidentiality and anonymity were explained. Due to the fact that the researcher was conducting the interviews, anonymity could not be ensured, however the researcher was the only person who knew the identity of the volunteers. No identifying details were included in the dissemination of the results, which protects the identity of the volunteers. All audio recordings and transcripts were locked in an appropriate cupboard in the researcher?s office and are to be destroyed after receiving the final assessment for the research report at the end of 2009 or after all possible journal articles based on this research have been written. The participants were informed of this and it was made clear to them that only the researcher and the research supervisor did at any time have access to these recordings and documents, that they were safely locked away and that their names did not appear on any of the material Informed consent was obtained in writing from every volunteer involved, in order to protect their rights (see Appendix C). Furthermore, consent to record was obtained in writing in order to ethically allow for the interviews to be recorded (see Appendix D). Once informed consent had been obtained, the volunteer psychotherapists became participant psychotherapists in this study. Informed consent allowed the researcher to be explicit about the purpose of the study so that participants were provided information on the process of the research as well as what the research was for and about (Seidman, 1998). A problem with obtaining informed consent is identified by Seidman (1998) that participants may feel uncomfortable or suspicious and that informed consent may even contribute to the establishment of a power dynamic in the interview relationship. Nonetheless, the benefits of informed consent were seen to outweigh the potential drawbacks for this study. 39 Psychotherapists? Perceptions of CSA Chapter 4: Results and Discussion 4.1 Introduction This chapter presents the findings of this study and includes a theoretical discussion of each. Four main themes were identified in the analysis: context; betrayal; sex and the spectra of damage. Each theme was further divided into relevant sub-themes and discussed in conjunction with relevant research on the topic. The context theme was divided into definition, contact specificity, family and social and cultural considerations in definitions of childhood sexual abuse. Betrayal was found to be a dominant theme in the analysis and this contains the sub-themes boundaries and trust, disclosure and body betrayal/arousal. As the title of this research suggests, intimacy was an overarching theme for this research which led to the sex sub-theme of which intimacy, sex work and sexual dysfunction were seen to be a part. The last theme in this chapter is the spectra of damage where physical manifestations, psychological manifestations, self-schema and relational dynamic were described and discussed. 4.2 Context 4.2.1 Definition and impact (when is abuse, abuse?) The definition of childhood sexual abuse varies not only across different countries and cultures but across individuals working and researching in the field of childhood sexual abuse (Andrews et al., 2004; Meston et al., 2006; Richter & Dawes, 2008). This theme is important in this study because in order to explore what the psychotherapists being interviewed perceived with regards to CSA, it was necessary to first ascertain what subjective understanding of this phenomenon exists. Kinnear (2007) concurs with the variation of definitions for childhood sexual abuse but she argues that there are a few factors which occur across most definitions viz exploitation; coercion; and gratification on the part of the abuser. These three factors appeared to be present in many of the participant understandings of the nature of CSA but what was quite clear was that the definitions depended on the degree of contact involved in the abuse, which not only 40 Psychotherapists? Perceptions of CSA impacted on the definition of CSA but also on the impact, or degree of such an impact, perceived by the participants. It was apparent that the definition of CSA, as well as the impact of the experience, was seen by the participants to be contingent on the context of the abuse, including factors such as contact specificity, family context as well as social context. These will each be discussed below. 4.2.2 Contact Specificity As stated, an overarching theme in the interviews regarding both the definition as well as the impact of childhood sexual abuse was that the context of the abuse itself is a central consideration. Some contextual points that were discussed were the age at which the abuse occurred, the duration of the abuse, the identity of/relationship to the perpetrator, what happened to the perpetrator after the abuse and the severity of the abuse. Some participants argued that penetrative sexual abuse over a prolonged period of time was seen to yield more deleterious effects for the victim-survivor in later life than contact abuse, which would include fondling, or non-contact abuse which includes inappropriate comments or suggestions. Prolonged abuse has been noted to have more harmful effects than a once-off event as argued by Herman (1992). Further contextual considerations include relationships both prior and subsequent to the abuse. The participants generally acknowledged that sexual abuse can be both physically as well as emotionally perpetrated and falls on a continuum that extends from verbal suggestions or comments or fondling to sexual penetration. One of the definitive elements in the definition of CSA is that it is non-consensual. Furthermore, a child is generally understood to be a minor below the age of 18 and in order for the sexual assault to constitute sexual abuse, the perpetrator is understood to be an adult. Gordon and Schroeder (1995) list 5 factors which should be taken into consideration when deciding whether or not something ought to be considered sexual abuse: the exact behaviour which is being reported as sexual abuse; the specific context in which this reported behaviour occurred; the intent of the perpetrator; the developmental level of the individuals involved in the behaviour; and whether coercion, force or manipulation was used. These 5 factors were expressed in a variety of ways by the participants involved in this study. 41 Psychotherapists? Perceptions of CSA ?Well, I think childhood sexual abuse is anything physical, physical or emotional that leaves a person feeling that that their sexual boundaries have been ?penetrated? without their consent.? (Participant 1) ?Well it ranges from moderate to severe so there are quite a few definitions. Sexual abuse means any intimate contact by an adult with a child (a minor) and that contact can take various forms from touching to penetration, on a continuum, which then constitutes sexual abuse.? (Participant 2) ?The definition of childhood abuse in my experience is that a child is touched, or ?more than touched? sexually, [in] sexual areas, whether that?s a boy or a girl. And ?childhood?, well I think childhood is under a certain age, I think it?s 18.? (Participant 5) It is further argued that societal perceptions of what constitutes sexual abuse will impact on the way in which clinicians perceive abusive and non-abusive interactions. In South Africa, as mentioned above and described earlier, the Child Act describes and defines what kind of context and interaction constitutes the sexual abuse of a child. This legislation seems to have either directly or indirectly informed the participant?s perceptions based on the fact that their collective understanding of sexual abuse is in line with this legislation. Although the contention with regard to the definition of CSA is recognised, if there is no clear legislation around what is and what is not abuse, then this definition purported by Gordon et al. (1995) leaves much room open for interpretation around what it means to be abused. The exemplar from Participant 4 below is an illustration of how a psychotherapist?s perception of childhood sexual abuse can be influenced by the Child Act. ??obviously, you have the child act that defines it as inappropriate touching, fondling, rape, incest, inappropriate sexual behaviour towards a minor. I think it is not necessarily rape and indecent assault or fingering - the child will know that that is inappropriate. But I am [referring to] the more subtle ?sexy language? and maybe a hand - holding hands more often than they should be. That sort behaviour might not be perceived from the child?s point of view as some sort of sexual behaviour.? (Participant 4) 42 Psychotherapists? Perceptions of CSA Contextual factors were seen to include those that occurred both before as well as after the abuse took place. For some psychologists, specifically more psychodynamic therapists, the development of early object relationships were seen to heavily moderate the extent to which the abuse impacted on the individual. Many of the manifestations which arose were perceived to be somewhat dependent on these early developmental experiences. ??all of those things will have been informed by the abuse. But all of those things will also be informed by the way that they came into the world, and their upbringing and their experiences. There will be a spectrum of damage depending on the personality organisation and on how well-established other things, other boundaries and ?relatedness? was at the time.? (Participant 1) ??the reaction of the abused person is going to be determined by their early object-relatedness and the age at which the abuse occurs obviously is then going to be significant. And, Oedipal [complex] - pre-oedipal, post-oedipal, where the abuse happens is going to influence that as well.? (Participant 1) The two exemplars above illustrate the complexity underlying the reasons why one individual may react differently to an abusive experience than another. There are factors at play in the way an individual reacts which are not wholly reliant on the abuse itself. Participant 1 identifies these factors to be the environment in which a child was raised and the parenting style of the child?s parents, the personality organisation of the child which may be formed before the abuse as well as some theory regarding early childhood development from a psychoanalytic as well as an object-relations perspective. An abusive experience is often not seen as being a single event in a person?s life but a part of a greater context which ultimately impacts on that individual?s development. The reaction that an individual will have as a result of some kind of trauma is related to the ability of the child?s ego to cope (Steele, 1990). This is in line with the comments made by Participant 1 regarding the impact of early childhood development. Contrary to a psychodynamic understanding of contextual factors the psychotherapist who located himself within a cognitive-behavioural framework did not discuss any of 43 Psychotherapists? Perceptions of CSA these factors in the interview. He found the impact of CSA, regardless of contextual factors, to be minimal. This suggests that there may be diverse psychotherapist interpretations of CSA depending on the lens through which they see their patients. The varying ways in which different theoretical modalities construct a view CSA and its impact would necessarily alter the type of treatment and possibly the duration of treatment. The various factors of the abuse discussed above were found to have an impact on the subsequent manifestations that develop in the individual. Steele (1990) argues that the experience that the child has during the abuse will impact on their later behaviour and psychic developments. These factors include the age at which the abuse occurs as well as the type of abuse. ?Type? of abuse here refers to the range of abusive experiences explicated above such as duration, severity, single or multiple perpetrators of the abuse and so on. Furthermore, Gordon et al. (1995) found a lack of family support to be a pivotal factor in the development of coping skills and pathology. They found that the age at which the abuse occurred and the duration of the abuse to be compounding factors in the seriousness of the individual?s reaction to the abuse. Participant 1 emphasised the significance of the abuse factors in understanding an individual's experience of CSA. As she related to her clients through a psychodynamic approach, the abuse factors would play a role in the client's manifestations, as well as prior developmental factors as discussed above. ?Again, it will depend on the age at which the abuse has occurred, for how long it has occurred, who they?ve told, what that person?s reaction is, what was done subsequently, [the question of whether there] was on-going exposure to the abuser?? (Participant 1) According to Rowan (2006), a variety of contextual factors may influence the impact that the abuse has on an individual. These include those mentioned above, namely: the age at which the abuse occurred; and the severity of the abuse as well as the defenses and coping strategies that the child has already developed. He further explains that prolonged, sadistic abuse, the relationship to the perpetrator as well as having multiple abusers 44 Psychotherapists? Perceptions of CSA greatly increases the chance of a severe impact resulting from the abuse experience/s. Exemplars from Participant 6 and Participant 7 indicate their perceptions of this impact. They considered the impact of prolonged CSA to result in more severely deleterious effects and they perceived a definite impact on the victim-survivor as a result of the abuse. Participant 6 identified herself predominantly as an existentialist whereas Participant 7 identified herself predominantly as a psychodynamic psychotherapist. However, both of these participants stated that they used other modalities in conjunction with their primary theoretical orientation. ?I think that there is a difference ? and I?m not really sure what that difference is ? but I think that there is a difference between people who have been molested [contact abuse] versus people who have been raped [penetrative abuse]. Which is still of course very violating for a girl to have to go through that, even for an older girl to have to go through that. But I think to be raped just crosses a different boundary. And to be repeatedly raped, whether it is gang rape, or on-going rape by a step-father over a period of years for example, it?s just so damaging - it is so damaging.? (Participant 6) ?Well I guess in my own experience it has either been a once off event or it has been a chronic event. This is not diminishing the effect of a once off sexual abuse incident, but I think that chronic sexual abuse has very long lasting effects.? (Participant 7) 4.2.3. Family There is an added element of complexity in CSA if the perpetrator is a member of the family which is perceived by participants to often be the case. The perpetrator was often described as being a member of the family or a family friend and it was not seen as common that the perpetrator be a stranger. ?I think it?s almost easier if it?s a stranger, and it inevitably isn?t, or often isn?t. But it?s somehow easier, I think, to work through if it?s a stranger. When it?s somebody close, when it?s a parent or a relative, that is hard. And when it?s a grandfather then often the grandfather has also abused the mother and then the child and then there is that whole dynamic that comes into play.? (Participant 1) 45 Psychotherapists? Perceptions of CSA It is assumed that as an individual is often a part of a family unit, the abuse will likely impact on the functioning of the unit if the abuse is known about or has been disclosed. There are a variety of scenarios which could be played out in a family where there is CSA. The perpetrator may be a family member and there will therefore be consequences regarding potential retribution, there may be denial of the CSA because of the impact that the acceptance of such an occurrence might mean for the family or the perpetrator and by proxy, the family unit. A few ways in which this may manifest include if the perpetrator is the main bread winner in the family - the impact of reporting the abuse, if the perpetrator is the father or step-father - the possible implications for the parent?s marriage and the consequences of these for the victim-survivor. There may be further feelings of guilt or remorse or the victim-survivor may not disclose the abuse for fear of retribution or for fear of breaking up the family unit thereby enduring the abuse for an extended period of time. ?With parents who don?t separate that experience is also very, very hard. Because either they going to have the experience of a divorce and whatever goes with that ? whether they blame themselves or not for that ? what is their ongoing relationship with that father figure, if it?s a father? Or there is the other extreme of the parents who don?t separate and so, the mother who then almost chooses the father above the daughter. In the case where there?s a divorce the child then has to experience a divorce as well, and being instrumental in the divorce, if they blame themselves. Or the case where the mother stays in the marriage or the child stays with these parents ? it is almost then as if the mother is condoning it.? (Participant 1) The sad reality of the situation regarding CSA in South Africa is that it is not only the justice system which can bee seen to have failed children but also professionals working in the area, families and others. The context in which CSA occurs in South Africa is perceived to be heavily weighted in low socio-economic groups in which firstly, people do not have ready access to services; secondly, cultural aspects such as patriarchy may play a role; and thirdly, families are in no financial position to be losing the main breadwinner of the family to the criminal justice system. This may result in victim- survivors in lower socio-economic positions being somewhat more vulnerable, especially to repeated and prolonged childhood trauma, although it is acknowledged that CSA occurs at every socio-economic level. Furthermore, it may be the case that regardless of 46 Psychotherapists? Perceptions of CSA socio-economic status, the situation regarding CSA is still precarious and complex and wholly reliant on a host of contextual factors discussed in this research report. Nonetheless, the exemplar from Participant 4 below is an illustration of the complexity involved in this regard. ?We are taught as professionals that we must always believe the child. Realistically you can do so but in South Africa we also give in to financial difficulty and if that person [ the perpetrator] is the financial provider and you [ the child] are going to be out on the streets, yes you [the psychotherapist] may believe the child but [the result of] your actions [is] not going to show the child that you believe them. They [the child] are going to be undermined. Then again that also creates a difficulty with them growing up later in life - that their word really doesn?t hold any meaning because something severe happened to them and they were not listened to.? (Participant 4) Potgieter (2001) reports that sometimes a child may disclose the abuse to the mother where the mother requests the child to continue enduring the abuse so as not to lose the father and main breadwinner. Furthermore, it could be argued that this compliance and perhaps collusion of the mother is another form of abuse which the victim-survivor is forced to endure. ?The other part that I haven?t mentioned that comes to mind, which I think is quite important, is the rage of the mother. Often there is the terrible sense in the child that the mother knew and failed to protect her (the child) from the act, or was actually complicit or actually very active - not just complicit, very active. There is tremendous abuse also by mothers.? (Participant 3) Psychodynamically speaking the infant forms its first relationship with that of the mother or primary care-giver and in an instance where this relationship is not one which is protecting and nurturing, the infant will continue to see the world as dangerous. If this infant grows into a child and then gets abused, this would serve to further complicate matters in this relationship. The three exemplars from Participant 6 below are indicative of the different ways in which mother-daughter relationships can be affected by CSA. 47 Psychotherapists? Perceptions of CSA ?It seems that?and I don?t know if it?s just the clients that I see, but it is a lot of clients. Regardless of age, whether it?s older teens or adults way into their thirties or forties. I find that there is just this very - I don?t know what the word is - but this strange dynamic between mother and daughter. Usually it?s girls, and there?s a strange mother-daughter dynamic that seems to play out. It seems [to be there] regardless of whether the mother knows or not, or knew or not, about the abuse. So whether the mother could step in or not, whether she could do anything about it or not, whether she knew, it seems somehow that there is just this antagonistic relationship.? (Participant 6) ?I just think often times when in these kind of situations whether a mother knew or not. I think moms often just don?t want to acknowledge it, or don?t acknowledge it enough, and that that always seems to be - it?s like it can never be acknowledged enough. That seems to be a pattern with different ages who are at different stages of dealing with the abuse.? (Participant 6) ?I mean I had one client who?s mother just remained in denial regardless of all the stuff that had happened to her daughter, but her father was able to really acknowledge what had happened and he was the one who brought her to therapy and he was the one who really stepped in and did everything right. And yet it was never enough - she needed her mom?s acknowledgment and it was just not there. (Participant 6)? 4.2.4. Social and Cultural Considerations in the Definition of CSA Le Roux (2000) identified 4 main contributing factors or risk factors for childhood sexual abuse: cultural factors; psychological factors on the part of the parents; the pregnancy and postnatal period; and a dysfunctional family. For the purposes of this sub-theme the cultural factors will be considered as this is an important element in the understanding of the perceptions of childhood sexual abuse in a multicultural society such as South Africa. Levett (2003) argues that patriarchy within the South African context may be a contributing factor in the objectification of women and girls and Solomon (1992) concurs with this point. In many cultures in South Africa, men are considered to have more power than women (Richter & Dawes, 2008). All the participants identified the fact that most abuse cases tend to be perpetrated by males and the victim-survivors tend to be females. Although it was made explicit that there are cases in which the perpetrators are male and the victim-survivors are female or where the perpetrators are female and the victim- 48 Psychotherapists? Perceptions of CSA survivors are either male or female. The case example given below is an example of one participant?s experience in this regard. Le Roux (2000) argues that socio-economic conditions such as poor housing and poor environmental conditions are situations which may contribute to child abuse. Participant 3 alludes to this but goes further to explain that it is not only socio-economic conditions but different sets of norms which individuals may hold about childhood sexual abuse which could lead to problems for the survivor. This is similar to an example given in Chapter 2 where individuals in a small Karoo town were shocked to hear that the sexual activities that they had participated in when they were children are commonly considered abuse (Levett, 2003). ?Also you know some families, some socio-economic groups ?fiddling? and sexual interference with family members is regarded as alright. There is nothing abnormal about it within that social context and a social psychological interpretation of it is fine. So as these people graduate out of their families and they move up the social ladder, suddenly they realise that something that happened is not ok. This is rather difficult to deal with ? ?If it was ok then why is it not ok now?? and we have that kind of problem so I think the therapist needs to know where this person is coming from and what this persons background is before turning it into an issue.? (Participant 3) The critical debate which emerges from the above exemplar is whether or not we can see CSA as an objectively deleterious event or if this perceived harmful impact is one which arises due to societal perceptions of the phenomenon. This became a point of consideration in this study as it became apparent that psychotherapists seemed to perceive the impact of childhood sexual abuse differently when they were from different theoretical orientations. Although most of the participants did perceive an impact, the psychotherapist who worked more in a cognitive-behavioural framework focused more on ?here-an-now? impacts on behaviour and less on the impact of childhood experiences. Fergusson and Mullen (1999) discuss the definition of childhood sexual abuse as being very complex because of the fact that it is reliant on norms that dictate what is acceptable and what is not acceptable. Katerndhal, Burge and Kellogg (2006) found that there are serious, pervasive and long-lasting psychological and emotional consequences for 49 Psychotherapists? Perceptions of CSA survivors of childhood sexual abuse, however, some individuals do not consider these early abuse experiences to be ?abuse?. Abuse was only identified by 27%-48% of abuse survivors and in order to identify an abuse history, interviewers had to ask questions targeting specific abuse behaviours as opposed to using the term ?abuse?. Katerndhal et al. (2006) did however find that individuals who had experienced abuse, either acknowledged or unacknowledged, showed more psychological and social adjustment problems than their non-abused counterparts. This possibly points to the deleterious impact that abuse may have on an individual, even if they do not frame their experience as abusive. This is however a contentious point and not agreed upon by all in the field. Kinnear (2007) considers it imperative to look at the social context in which activities which could constitute sexual abuse occur. For example, in some families kissing on the mouth is appropriate and not seen or experienced as invasive. However, in another culture or even in another family this sort of behaviour could be considered highly inappropriate. A further consideration is that children, especially young children, may not be aware of the more nuanced behaviours which constitute CSA. This potentially leaves them more open to abuse and likely to under-report the more nuanced sexual overtures. ?But from a child?s point of view, the ones that I?ve seen I think a lot of children don?t perceive a lot of the slightly less obvious things as sexual abuse, maybe pushing it a little too far but also [perceiving] that that may be appropriate behaviour from an adult to a child, if they?ve grown up with it.? (Participant 4) ?So when is it exploring their body with a friend and when is it sexual abuse or rape? Is it the age difference between the child and the other person?? (Participant 5) Participant 2 below draws attention to an aspect of childhood sexual abuse which may be dependent upon a particular social construction of the experience. He suggests that some children may be unaware of the abusive nature of their experience until such a point as someone, in this example a parent, reacts in a particular way to the experience. Gordon et al. (1995) describe how in some cases the sexual abuse is actually less stressful for the child than the family?s or community?s reaction to the abuse. They further argue that this 50 Psychotherapists? Perceptions of CSA is why it is important to use restraint in defining or describing exactly what it is that constitutes sexual abuse. ?I mean people are moderately disturbed for a while. In the instances of children some don?t even know it has happened until the parents become very hysterical about it.? (Participant 2) Gordon et al. (1995) argue that a contributing factor to whether or not a child perceives a situation as abusive is the cognitive developmental point they are at when abused. It may only happen that the individual can only understand the experience as abusive when they have the cognitive capacity with which to understand the implications of their experience. Although, regardless of whether or not a child recognises something as abusive or not, there is a very high likelihood that the child will grow up and one day realise the implications of these experiences. For example, a child may find fondling from an uncle acceptable behaviour until disclosing this to a friend who reacts in a particular way to call into question what the victim-survivor originally thought about the act. This is illustrated by way of an example of a child being exposed to pornography at a young age and sharing this with her friends. ?I had a little girl that came in and they had had a pajama party. She was new at the school and she had been moved schools because of a divorce [in her family]. She had brought a pornographic DVD that she had found to the pajama party. Now that caused huge amounts of discrimination - she was shunned by the school kids because they were not exposed to that. But to her it was a movie. It changes the way they see what is appropriate and what is not appropriate behaviour not in regards to what is right and wrong - because according to her that was right, but in regards to how she is going to fit into society I think it creates a lot of difficulties in just fitting in with society.? Participant 4 51 Psychotherapists? Perceptions of CSA 4.3.Betrayal 4.3.1. Boundaries and Trust According to Geanellos (2003), the experience of childhood sexual abuse results in fundamentally violated and disordered boundary formation. This may result in the need for the maintenance as well as development of appropriate boundaries because this experience in childhood results in the child developing an impaired capacity to protect their own boundaries (Geanellos, 2003). The terms ?violated? and ?disordered? when used in connection with boundaries that individuals develop are imprecise and vague terms that do not accurately describe the way in which different types of CSA may impact on boundary formation. Boundary violations and formations featured as prominent themes in the interviews and emerged in the interviews in the following ways: some participants perceived boundaries to be profoundly impacted in terms of the victim- survivor developing porous boundaries; to fail to protect the victim-survivor; to develop confused boundaries; and finally to develop very rigid boundaries in which the victim- survivors struggled to be able to trust others. Boundaries are seen to act as a demarcation of the internal versus the external world of an individual and they serve to protect an individual from deleterious consequences (Geanellos, 2003). This sub-theme serves to illustrate the varied perceptions around boundary development and the impact of CSA on boundaries for victim-survivors. Boundary violations in childhood can result in the individual feeling helpless and powerless because their own defensive boundaries are not protecting them from the abuse that they are experiencing (Geanellos, 2003). Essentially the developing self of the victim-survivor is thrown into chaos (Geanellos, 2003). Scott (1993) theorised a series of levels regarding the boundary development in victim-survivors of CSA. Level 1 of Scott?s (1993) depiction of personal space boundaries (as cited in Geanellos, 2003) concerns a failure of the boundaries to protect the victim-survivor. Level 2 is the forced silence of the victim-survivor which results in them becoming, what they might perceive to be, a collaborator of the abuse (Geanellos, 2003). These two boundary violations result 52 Psychotherapists? Perceptions of CSA in the victim-survivor not being able to regulate their personal space boundaries at all which has two consequences: firstly, the child will struggle to see themselves as separate individuals from the perpetrator; and secondly, this results in feelings of guilt and shame (Geanellos, 2003). This then results in the development of a confused sense of self which could impact on adult intimate relationships in that the victim-survivor may not present a consistent self to their partner and hence could cause problems in the relationship (Geanellos, 2003). Some participants in this study found that CSA often revolves around boundary violations. As the definition of CSA is almost always understood to involve coercion or abuse of power, the conceptualisation of boundaries is imperative to the understanding of CSA. It is interesting to note that Participant 6 below considered the impact of a boundary violation to be worse for a female victim-survivor. ?I would define childhood sexual abuse as anything that has transgressed a physical or emotional boundary sexually with a child and sometimes with teenagers that maybe wouldn?t really be considered minors but especially if it is girls you know where it seems like for them that boundary has been crossed and it is really uncomfortable.? (Participant 6) Boundaries in adult victim-survivors of childhood sexual abuse are seen by some to become either profoundly rigid, or permeable (Geanellos, 2003). Long-term psychological effects are postulated to be as a result of a boundary violation in which the victim-survivor no longer has a positive relationship with their own body as a result of the violation (Wenninger & Heiman, 1998). Boundary formation in childhood has been found to be particularly important to a child?s development of sense of self as well as psychological integrity (Wenninger & Heiman, 1998). Furthermore, in the case of a victim-survivor, the boundaries cannot and do not protect the individual from the ensuing abuse and so the boundary formation during the abuse becomes neither permeable nor flexible (Geanellos, 2003). Permeable and flexible boundaries are adaptable and allow responses from the individual which are protective and relational (Geanellos, 2003). Although permeable and flexible boundaries are found to be beneficial, the spectrum of boundaries ranging from rigid to flexible or permeable to impermeable is not clearly defined and lacks coherent operationalisation. It is difficult to identify where on the 53 Psychotherapists? Perceptions of CSA boundary continuum an individual may be identified and furthermore whether or not this is as a result of CSA. The following exemplar demonstrates how CSA often entails a double-edged sword of abuse due to the fact that the boundaries are profoundly impacted upon at the time of the abuse. Understanding the implications of this and understanding the experience as abusive when the victim-survivor gets older is tantamount to a second abusive experience. What this may mean is that the victim-survivor does not fully understand the extent of the abusive experiences, although they do recognise it as abusive, but later in life they may come to perceive the true extent of the abuse and the nature of the violation and in that way almost relive the abusive experience. ?The difficulty with it is that often the abuse will have happened at a time when their boundaries have not been clearly defined for themselves, so it becomes very difficult for them to understand at that time that it was abuse. And they may only later in life understand that it has been abusive, which for me makes it even more abusive. I think it happens at a time when they don?t even know what their own sexual boundaries [are] so they?re being penetrated, yes on that level too.? (Participant 1) There are often confusions around boundaries of behaviour that distinguish affection, sex and abuse (Kinnear, 2007). What this implies is that often victim-survivors are unable to distinguish between what is construed as abuse and what is construed as affection. However, this does not sufficiently explain whether or not the victim-survivors know that the behaviour is abusive and they tolerate it which is then seen by an observer as the victim-survivor not seeing the behaviour as abusive. Hence it is unclear if this is an actual boundary issue for the victim-survivor or if it is perceived to be a boundary violation by others. Participant 1 below describes boundary confusion, which she sees as a difficulty in understanding where one person ends and another begins, as being attributable to the disrespected boundaries during the abuse. ??if those very early boundaries are not respected by adults and often adults that they trust, then it makes it very difficult for them [the child] to ever understand where they end and others begin?? (Participant 1) 54 Psychotherapists? Perceptions of CSA Burland and Raskin (1990) claim that psychoanalytically speaking, if the abuse occurs before the age of around 3 years old, the individual may not complete the developmental stage of separation-individuation and as a result self-other boundaries may never become differentiated. An individual who has not completed the separation-individuation stage may experience a loss of body-boundaries which may blur the ability to distinguish self from object (Burland & Raskin, 1990). It is considered very important to aid the survivor in being able to develop boundaries in which they can see themselves as distinct from an other (Draucker & Martsolf, 2006). Participant 1 identified the issue regarding seeing oneself as separate from an other with particular reference to the victim-survivor being taken advantage of later in life. As Participant 1 located herself in a psychodynamic frame, her understanding could be that the victim-survivor splits off the good parts of themselves and projects these onto an other, after which they identify with these good parts, resulting in projective identification. However, this is an object relations understanding of this phenomenon which is highly contested by other modalities, especially cognitive-behavioural theory which sees any boundary issues as being the result of here-and-now cognitions. Many of the participants argued that individuals who were sexually abused as children tend to be mistrustful of others and often see the world as a dangerous place in which they are very vulnerable. Although this is highlighted as an emotional manifestation, it is important to understand the extremity and pervasiveness of the mistrust. Trust and mistrust are foundational elements in understanding the complicated relational dynamics that victim-survivors enter into, which plays out in a variety of different contexts in their lives. For the purposes of understanding emotional manifestations the psychological aspect of the mistrust will be discussed below. The participants noted that feelings of mistrust are pervasive and not only related to a mistrust of others, but are also a mistrust of themselves. Participant 7 describes the mistrust and vulnerability that a survivor may experience. ?Yes in the unconscious mind I think they are going to live with [a lot]. A whole lot of things start to happen, [they are] very mistrustful, the world becomes a very dangerous place, it becomes a place in which there?s a lot of risk. You [travel] 55 Psychotherapists? Perceptions of CSA with that through your life and later you can?t trust and [you feel that] you are vulnerable and [that] you [are] exposed to risk all the time.? (Participant 7) This mistrust can be seen as related to the vulnerability that a victim-survivor feels in the world. It could be that a sense of vulnerability results in the victim-survivor being mistrustful as a way to protect themselves from further harm. It does not seem as if the emotional impact of mistrust and vulnerability are mutually exclusive but nor is it necessary for them to co-exist. Participant 1 expresses a view in the exemplar below in which she claims a definitive impact of CSA on a victim-survivor's sense of vulnerability. Although she states a strong case for the perception that all victim-survivors of CSA will feel vulnerable, it needs to be considered that people react in different ways based on a variety of factors, suggesting that there is no universal reaction or manifestation stemming from CSA. ?They?re always going to be vulnerable. I think what I can say is that having had an experience of childhood sexual abuse would make you more vulnerable. I would also say that having an experience of a childhood sexual abuse makes you more vulnerable to decompensating and to developing other kinds of disorders of the self. Yes, vulnerability.? (Participant 1) 4.3.2. Disclosure The majority of victim-survivors have been found to not disclose sexual abuse in childhood and often only when they reach adulthood (Somer & Szwarcberg, 2001). It is often the case that early disclosure can lead to adverse consequences, especially if the perpetrator is a family member (Somer et al., 2001). Although disclosure has been hypothesised by Somer et al. (2001) to instigate a move from viewing oneself as a victim to viewing oneself as a survivor, it is possible that the context in which the abuse is disclosed can have the impact of something like a secondary traumatisation as mentioned by Participant 1 below. ?Did they tell somebody/ didn?t they? At which stage? Who did they tell? How did that person react? Because that then becomes also a secondary traumatisation. 56 Psychotherapists? Perceptions of CSA So the reaction of the person that they then trust may repair some of the damage, - or not - or make it worse, exacerbate the situation.? (Participant 1) The failure of the police and justice system in South Africa with regards to CSA has been noted to sometimes cause a secondary traumatisation to the victim-survivor (van Zyl & Sinclair, 2007). It was reported that often the police will not adhere to the right of an individual to have privacy when reporting a crime, especially one of a sensitive nature, and so this impacts on the level of disclosure (van Zyl et al., 2007). The Human Rights Commission?s report on sexual offenses against children found that disclosing the abuse or making a statement in front of others increases the likelihood that this would serve as a secondary traumatisation for the child (SAHRC, 2002). Participant 4 expressed great disappointment with the justice system in South Africa as it fails to protect children from abuse and it further perpetuates a sense of ongoing victimisation for the victim-survivor. ?If you go into the whole court system the child is being abused again. They call it the second abuse when they go and testify, because [the person] has to re-live the whole experience in court and many times it is several years [after the fact] they can?t carry on with their lives because they are still testifying in court. Two, three years or four years after the [incident] that they still then need to keep remembering what?s happened when they go [in] and testify.? (Participant 4) Disclosure of sexual abuse in the therapeutic relationship is something which all participants found to be a deeply difficult thing to deal with. It was hypothesised that often clients who disclose sexual abuse will expect a particular reaction from the therapist such as horror, shock or disbelief. Expressing any reaction to a client for any disclosure including sexual abuse proves a complicated aspect of conducting therapy. On one hand a practitioner may be mirroring the patient?s response and in this way may create a working rapport with the client. But on the other hand, reacting to the disclosure may very well alienate the patient and make them feel uncomfortable or irrevocably damaged in some way. The exemplar from Participant 8 below is indicative of his own difficulty in this regard. 57 Psychotherapists? Perceptions of CSA ?They expect you to react in a way that is judgmental or surprised but very often because we?re not shocked and surprised? they?re somewhat dissatisfied with your reaction. ?What?s going on, why are you not shocked? You know I was sexually abused, for goodness sakes!??and you can say ?That?s a really terrible thing that happened to you, you know, I really empathise with you, and I can understand why you are feeling this way and why you are here today, but I?m not really shocked that it?s happened to you because I see people like that all the time, and that is what I work with: and maybe I should be more shocked, but if I?m shocked are you going to run away? Are you going to feel that I can?t handle your difficulty you know, that together we can?t work through this, because if I?m so shocked, there might be more things that you need to talk to me about that might be more shocking than that, and if I can?t handle that bit of information??? (Participant 8) 4.3.3. Body Betrayal/Arousal Children may be coerced or exploited for sexual gratification in return for gifts or to provide the child with attention that they may not be getting elsewhere. The exemplar from Participant 4 below points to the complexity involved regarding potential rewards or special status that may be given to a child being abused. This is not to say that this relationship becomes consensual because, as Kinnear (2007) points out, the abuser is often more knowledgeable, resourceful and physically stronger than the child and may also threaten the child if they disclose the abuse. This may result in a particularly confusing situation for the child which has been found to result in the child feeling ambivalent towards the perpetrator as well as to the experience. ??people might, clients might acknowledge sexual abuse with enormous difficulty and in my experience very seldom will they acknowledge pleasure that they might have had, because that just feels so overwhelmingly shameful or [makes them feel so] guilty and of course is so out of their control that they feel quite split off from their bodies. ?It wasn?t me that did that it was my body? or ?it wasn?t me that did that it was him?. They get very confused about that because they may have they may have enjoyed [it]. Sexual abuse is very complex, sometimes it is very much wrapped in attention rewards that come with it, special status and that gets very confusing for clients?? (Participant 4) Ambivalence is found to be a common characteristic in childhood sexual abuse, as alluded to above, for reward and status outcomes, however the experience may also cause 58 Psychotherapists? Perceptions of CSA ambivalence because of an apparent disconnection between the emotional distress that the abuse may cause bodily arousal (Kinnear, 2007). The children might be aware of the fact that the experience is wrong or abusive but the body reacting in a pleasured and aroused way could possibly lead to even more confusion and ambivalence. ?Because sometimes the body responds and the body betrays the person. Depending on the age obviously, but sometimes your body betrays what your mind and your emotions are saying, you know. So sometimes the body gets aroused?and I think that is a very big part of why it?s so difficult to find healing when you have been sexually abused as a child, because if you?re 13 or 11 you?re already an adolescent, your body will obviously respond and then you?re going to wonder.? (Participant 8) Some of the participants highlighted the added complicating factor of when the body essentially betrays the individual by seeming to respond in a pleasured way. The disconnection between body and emotion which is likely to arise from this situation could become manifested in pathological ways of relating, especially in later intimate relationships. The idea of pleasure becomes intricately linked with fear, mistrust, and vulnerability which may play itself out in later intimate relationships. However, there may be cases in which the individual experiences pleasure and none of the harmful experiences alluded to in which case the manifestation, if there is one, will present itself differently. Penelope Hollander, a victim-survivor of CSA disclosed that although she experienced great pleasure during the sexual abuse of her by her father, she knew that the experience was wrong because of the feelings of fear that she experienced simultaneously (Loewenstein, 2004). Victim-survivors of childhood sexual abuse are found to have a higher likelihood of revictimization than their non-abused counterparts (Macy, 2007; Reid and Sullivan, 2009; Gobin & Freyd, 2009; Campbell, Greeson, Bybee, & Raja, 2008; Banyard, Williams, & Siegel, 2002). This is a contested point however many of the participants reported perceiving a pattern of revictimization among victim-survivors of childhood sexual abuse as indicated by the exemplars below taken from Participant 1 and Participant 3. The 59 Psychotherapists? Perceptions of CSA revictimization is seen as an unconscious manifestation over which the victim-survivors have little control. ?Often they will be abused later in life, or abuse. Yes, I mean I suppose some of the relationships they get into are abusive relationships whereby they?ve learned, or they haven?t learned when to protect themselves - so they?re vulnerable to people who are going to hurt them. Or the other broad category of people then [are those] who abuse because they were abused. So the way that they retaliate is that ?Nobody?s going to do this to me again? so they either abuse or get abused in subsequent relationships, because it happens unconsciously. They don?t consciously get engaged in abusive relationships.? (Participant 1) ??a very high tolerance level for something before that is perceived as abuse. It?s almost as if they re-enact a victim scenario where either they become the victim, see themselves as exploited, see themselves as not sexually valued but they see themselves as quite objectified. Women who had been sexually abused [as children] were often in very abusive relationships as adults with this very muddled sense of what is abuse. I think people set, or re-enact certain scenarios. It is very unconscious. I mean it has often been noted, horrendously tragically, that children who have been raped find themselves later raped [almost as if] at first glance for no explicable reason and that?s always difficult to look at and there is always that thin line of [wondering] is it coincidental or whether it is environmental or is it in some way something that is acted out.? (Participant 3) ?Yes I think it?s definitely true. I mean with the clients that I?ve seen, you know I would say, I don?t know if it?s in the majority, but the few that I can think of that I?ve seen recently have been ? well revictimized in a way ? but become very promiscuous. So they?ve been taken advantage of, not necessarily raped, because it?s voluntary, but I mean is it voluntary? They become very promiscuous, they?ve had affairs with married men; they?ve gotten into situations that are actually dangerous, without protection; a lot of substance abuse that comes into it, things like that. They put themselves at risk - it?s serious revictimization yes.? (Participant 6) Participant 2 was opposed to the idea that revictimization occurs more frequently in individuals who are victim-survivors of childhood sexual abuse despite his acknowledgment that the literature does indicate this is a likelihood. Literature on the subject as mentioned above is overwhelmingly concurrent with the idea that revictimization is highly likely and sometimes predictable. There is research to the contrary, however the extent of this literature is scarcely comparable to that indicating a 60 Psychotherapists? Perceptions of CSA possible increase in the risk of revictimization. Two exemplars below are illustrative of Participant 2?s denial of possible revictimization. ?I have read about that sort of theory about women looking for partners where they could [in some way reenact] and then find some sort of closure, but I think that is sort of more of a fairytale than anything else quite frankly.? (Participant 2) ?Well I have [observed] it as being just an unfortunate choice of partner, but I don?t think there is any unconscious steering to deliberately find a pathological relationship specifically to deal with that kind of problem. I mean, can you imagine someone deliberately getting into an emotionally, sexually abusive relationship in order to solve a problem they had long ago? One would imagine them to steer clear of that completely, not to move into it, and if you talking about unconscious or sub-conscious motivation - well surely that is there to protect the person, not to steer them into danger. So I find that unless that person is pretty masochistic - and I don?t in my experience, no, very seldom can you actually put two and two together and say that this is linked up.? (Participant 2) This contention about the impact that CSA has on an individual being revictimized later in life is, again indicative of the highly contentious nature of CSA and research of CSA. As with revictimization, there is no clear pattern which can be found with regards to the impact of CSA on an individual?s emotional reaction or functioning post-abuse (Persinger, 2008). The lens through which researchers and psychotherapists view this phenomenon seems to heavily impact on the way in which they interpret and perceive the various facets involved. Participant 2 as explained earlier in this report, was the one study participant who considered himself to be a cognitive-behavioural therapist and he did not put much weight in psychodynamic understandings or treatments of any phenomena. However, his point of view is valuable, albeit contrary, because it illustrates the many ways in which individual professionals have come to view and understand CSA. 61 Psychotherapists? Perceptions of CSA 4.4 Sex 4.4.1. Intimacy A healthy intimate relationship is one that involves a mutual social and sexual reciprocity where both partners who are sensitive to each other and have concern for the others' well- being (Feiring et al., 2009). In victim-survivors, intimacy is often associated with fear and shame, with a focus on elements of submission and dominance (Feiring et al., 2009). Victim-survivors tend to report having more difficulties in their relationships in areas regarding attachment, lower levels of relationship satisfaction and higher levels of divorce (Testa, VanZile, & Livingston, 2005). Trust, emotional expressiveness and intimacy have been found to play a massive role in intimate partner relationships where the woman is a victim-survivor of childhood abuse (Oz, 2001). ??also later in their relationships, intimate relationships, it does [impact] a lot on trust issues - them finding the ability to be intimate with that person and sharing that person.? (Participant 3) ?I think in terms of an intimate relationship, when you have been violated everything about your world is violated, everything about your world is unsafe. I think it?s very hard to trust in intimate relationships where you can be safe or where you are not going to be vulnerable. I think it kind of goes without saying how their relationships with their partners, their most intimate partners would be [adversely] affected.? (Participant 7) The phenomenon of childhood sexual abuse carries the inherent connection to an individual or group of individuals abusing their power over another individual through violating personal boundaries (Koehn, 2007). Liem et al. (1996) found that women with a history of sexual abuse in childhood were more likely to tell stories which involved both a need for power and a fear than those of their non-abused counterparts. This is argued to be compensatory and as a result of the feelings of powerlessness and betrayal that are experienced during the abuse (Liem, O?Toole, & James, 1992; Liem et al., 1996). 62 Psychotherapists? Perceptions of CSA Interpersonal theory suggests that the way that we view ourselves currently is inherently linked to how we were treated by significant others as children (Liem et al., 1996). ?You?d probably get to see I have seen women and men who would not take any domination or intimidation from their partner, I mean even normal amounts of intimidation, because they have once felt out of control and pressurised there might be some residue of that, [for example] if [the partner] feels like sex then ?You shouldn?t pressurise or make an issue of it?, issues of control do come up but then they also come up in relationship problems over money so it is hard to distinguish [true causes].? (Participant 2) ?It?s not usually sexually related, funnily enough. It?s usually power related. ?He?s not letting me write the script for him? is a typical scenario and you can have a lot of generalisations, but there is a typical scenario, where the woman wants to talk more, and be more open emotionally, more vulnerable, more naked, and the man wants to??Work is work, and friends are friends and sport is sport?, and ?I am me and you share this part which is the relationship? - compartmentalise. So she will want more of him, and he will want her not to nag and he?ll feel she is controlling. But the reversed is experienced as well where it?s the man who?s insecure, maybe had some mistrusting relationships in childhood, and he?s more wanting to know her movements and control and so on. And she wants to be trusted and to be left alone.? (Participant 5) Central to an individual?s sexual or intimate relationship functioning is the inherent idea of sexuality. If it is correct as hypothesised in previous sections that CSA has the potential to impact on one?s sense of self as well as on relational functioning then it centrally also follows that the way in which an individual deals with their sexuality will further be impacted by CSA. ??their sense of themselves as sexual beings ? what has developed for them in terms of their experience of their own sexuality and their own experience?yes, what is their view of what type of a sexual being they are? All of those things will impact on their subsequent sexual relationships.? (Participant 1) Sexual abuse has been linked to all forms of interpersonal and intrapersonal sexuality variables, according to a study conducted by Meston, Heiman & Trapnll (1999). It was 63 Psychotherapists? Perceptions of CSA found that sexual abuse in childhood has an impact on adult sexual behaviour and often abuse victim-survivors show more liberal attitudes towards sexuality as well as more liberal behaviour. Liberal sexual attitudes and behaviours, as defined by Meston et al. (1999) include ?a higher frequency of intercourse and masturbation, a greater range of sexual experiences and fantasies, and a greater likelihood of engaging in unrestricted sexual behaviour? (p. 391). Balsam, Rothblum and Beauchaine (2005) conducted research in order to ascertain the prevalence rates of abuse in childhood amongst lesbian, gay and bisexual individuals. The results of this study indicate that there is a higher prevalence of childhood experiences of abuse among lesbian, gay and bisexual individuals than the control group which was made up of heterosexual individuals. However, it is important to note that Balsam et al. (2005) argue that there is a possibility that children who disclose their gay, lesbian, or bisexual status may be victimised as a result of this disclosure. Their study does not indicate whether the abuse occurred before or after the discovery and disclosure of their sexual orientation. None of the participants in this study considered there to be a particularly relevant link between childhood abuse and sexual orientation, but Participant 1 below explains how this would be possible. ?I suppose sometimes there?s homosexual relationships as a consequence of a heterosexual abusive relationship where: ?I can?t trust men so I?m going to be with women? or ?I can?t trust women, I need to be with men?. That I suppose brings with it all all its complications, because is this person engaging in homosexual sexual relationships because they are gay? Or because they?ve just had a [negative] early sexual experience? If it is primarily because of their early sexual experience, then we have a situation where they don?t want to be homosexual but they don?t know how to deal with having a ?normal? sexual ? a heterosexual relationship.? (Participant 1) In order for a successful intimate relationship to exist, there is an element of vulnerability which needs to be achieved by both parties. A lack of ability to be vulnerable in the presence of another could seriously compromise the ability to connect and relate in an intimate relationship. ??they battle with sexual intimacy, you know. So, that adds to the complication of your emotions in relation to yourself as a sexual being and in relation to your 64 Psychotherapists? Perceptions of CSA sexual experience with your partner or partners. So, depending on the dynamic of the situation, the relationships that they have in adulthood will be different to someone else?s dynamic. Very often, people who have been sexually abused are needy and they want to be loved because they don?t like themselves very much very often, you know.? (Participant 8) ?I think for relationships to be healthy or certainly to be functional, there needs to be an element of trust and an element of security - you need to be able to feel safe and you need to be vulnerable in those relationships and know that you are going to be safe in that.? (Participant 7) The trauma dialectic impacts on the victim-survivor of childhood sexual abuse in a variety of different contexts, one of which is the intimate relationship/s that the individual may enter into (Oz, 2001). This dialectic may play out in the individual alternating between behaving in a promiscuous manner to appearing quite frigid (Oz, 2001). This is a polarised behaviour manifestation which can be expressed in a variety of ways including an over-expression of anger and the inability to express anger at all (Oz, 2001). In a similarly relevant way, Participant 1 below describes a situation where an individual is averse to the idea of a sexual relationship and Participant 4 describes a situation in which the victim-survivor may become oversexualized. ?Yes. All of these things influence their sexual lives. But it?s not only sex that?s impacted on. Sometimes they don?t even get close enough to anybody to have sex. So?one doesn?t even know what?s then going to happen when they have to. Sometimes I suppose they?re so terrified of?they don?t allow a relationship to get there because they?re so terrified of it.? (Participant 1) ??they then become over-sexualized and you know display sexual behaviour that is highly inappropriate?they won?t have that awareness of the impact that their [over-sexualized] behaviour has on other people and how other people perceive their behaviour, unless it is pointed out to them by somebody that they are relatively close to - because their opinion will hold more weight?? (Participant 4) Feiring et al. (2009) found that individuals with high levels of self-blame were likely to exhibit submissive behaviour in relationships and believe that they deserve the hostile and aggressive acts perpetrated by their partners. This suggests that victim-survivors with 65 Psychotherapists? Perceptions of CSA high-levels of self-blame are likely to be taken advantage of in relationships as perceived by Participant 1 below. ?I suppose some of the relationships they get into are abusive relationships whereby they?ve learned, or they haven?t learned when to protect themselves so they?re vulnerable to people who are going to hurt them. They don?t know how to manage their relationships, often appropriately, so they give too much or they give too little, those kinds of things. Because if they?re giving too much then they?re going to be taken advantage of.? (Participant 1) Positive emotions associated with childhood sexual abuse include feeling cared for, special and enjoying the attention (Whealin, 2002). According to Finkelhor and Browne?s (1985) model of traumagenic dynamics (cited in Testa et al., 2005), children who experience sexual abuse are often rewarded with affection or attention which may lead to confusion in later intimate relationships. According to Testa et al. (2005), victim- survivors? relationships become sexual much faster than their non-abused counterparts and they may feel obligated to give their partner sex in order to maintain their affections. ??they struggle with a lot of confusion in relationships, they confuse sexuality with affection, they confuse sexuality with intimacy and attachment. They often find themselves in bargaining positions in relationships ? a sort of trade-off. Well for instance one way to manage it would be to use your sexuality as a kind of currency so in other words you accentuate sexuality or even, I was going to say, provoke sexuality as a way of gaining attachment or connection.? (Participant 3) ??you will probably find a lot of sexual dysfunction or avoidance in regards to them just performing it because they feel like they are obliged to do it, they not really enjoying the act, or are making excuses. So again, they?ve got headaches they working late, they not interested, they are too busy, they just don?t have a high sexual libido, all of those things then become an avoidance technique for them to try and deal with the situation?so this has a huge impact on relationships?? (Participant 4) Victim-survivors have been reported to engage in more risky behaviour than they non- abused counterparts and often have multiple sexual partners (Testa et al., 2005). 66 Psychotherapists? Perceptions of CSA ?And very often they are in relationships with people who are abusive or they themselves are abusive, very often there?s co-dependence - very often there are no relationships, or they are promiscuous, going from relationship to relationship, looking for love or looking for something to numb the pain in the form of multiple sexual partners, you know, wanting to be liked.? (Participant 8) 4.4.2. Sex Work Literature suggests that there is a high correlation between childhood experiences of sexual abuse and sex work (Abramovich, 2005; Steel & Herlitz, 2005). A further study indicated that victim-survivor?s of childhood sexual abuse were 1.5 times more likely to engage in sex work than their non-abused counterparts (Vaddiparti, Bogetto, Callahan, Abdallah, Spitznagel, & Cottler, 2006). The literature indicates that more than half of the sex workers interviewed for various studies reported a history of childhood sexual abuse (Abramovich, 2005). Risky sexual behaviours, including sex work, were identified by the participants as being an effect of childhood sexual abuse. Participant 6 below mentions prostitution as a perceived outcome, with special reference to the element of power that is involved in this type of work. ??female sex workers and their experiences and background, many of them have come from a background of sexual abuse and gone on to become sex workers and a lot of them say that this is part of an element of wanting to be in control of the situation. When they see a client, they charge for it, if there?s role-play they decide on it and they sort of, have some element of control. So they make a living from it.? (Participant 6) The exemplar from Participant 1 below illustrates the difficulty that she has perceived among female sex workers who may not necessarily want to continue in this line of work but feel that they cannot do anything else. ?Yes, obviously then you have the other extreme where you have prostitution, where their bodies continue to be used as the sexual object. And I?ve had clients like that as well, who don?t want to be prostitutes anymore. Yes, I guess these are the far-reaching consequences of that, so they?ve chosen their lifestyle, that?s all they?ve known. Now they?ve decided they don?t want to do it anymore, but what 67 Psychotherapists? Perceptions of CSA can they do now? Because that lifestyle has now also exacerbated their lack of self-worth and all of these kinds of things, and [they experience] embarrassment about what they do and ?this is all I can do? and so you?re dealing with all of that. Even when you help them to see why they chose that profession, that job, whatever you want to call it, now they?re stuck in it you know: ?What else can I do??? (Participant 1) Although there is a vast amount literature supporting the hypothesis that early experiences of childhood sexual abuse may result in risky sexual behaviour, there is disagreement as to how influential the abuse experience is and how much of the behaviour is more globally influenced or produced (Abromovich, 2005). This implies that risky sexual behaviour comes about as a result of a variety of influences such as family characteristics, socioeconomic status and education level to name a few (Abromovich, 2005). Participant 2 shares these sentiments and expresses the perception that we cannot know if there is a direct link or not to sex work per s?, but regardless of socioeconomic factors, anti-social behaviour has been found to correlate with childhood sexual abuse. Meston et al. (1999) argue that much of the literature on childhood sexual abuse focuses on aggressive and criminal behaviour, substance abuse and a variety of emotional problems. ??we don?t really know if it?s because of living conditions, overcrowded circumstances, poor parenting or that there is [a history of] sexual abuse itself but there is a link between childhood sexual abuse and criminal behavior in adulthood?there is a correlation between childhood sexual abuse and anti-social behavior later on - whether its from a low socioeconomic standard or a middle or upper.? (Participant 2) ?You know, like, ?my life means nothing anyway, so I might as well sleep around, and I don?t care if I get AIDS and die? or whatever, ?I don?t care if I?m drunk and driving around, it doesn?t matter, my life is crap anyway? you know. Because very often people who have been sexually abused, or have had any kind of abuse, they really want to excel and they really want to be noticed and want to make something of their lives because of what happened, almost like an ?I?ll show you? kind of mentality, you know, so that is actually very useful for people who have been sexually abused.? (Participant 8) 68 Psychotherapists? Perceptions of CSA 4.4.3. Sexual Dysfunction The perception of the physical impact of childhood sexual abuse has been reported by the participants to include many manifestations which are related to sexual functioning such as vaginusmus, anorgasmia, pain during sex, dryness during sex, low libido, gynaecologic problems such as painful periods, endometriosis symptoms, and other possible somatising complaints such as headaches and irritable bowel syndrome (IBS). The Diagnostic and Statistical Manual of Mental Disorders IV-TR (DSM-IV-TR) (APA, 2000) categorises sexual disorders into four main sections: Sexual Desire Disorders; Sexual Arousal Disorders; Orgasmic Disorders; and Sexual Pain Disorders. The aforementioned list of symptoms reported by the participants could fall into this category of sexual disorders as well as possibly meeting the criteria for a somatisation disorder. However the participants did not speak about these sexual disorders with specific reference to the DSM-IV-TR. Sexual dysfunctions have been found to have both a physiological as well as a psychological etiology (Arikan, 2006). ?The whole natural, physical experience of becoming tense at the interaction, and therefore then I suppose that their experience of that may be that it was painful, and they?re re-enacting that because of their body?s reaction. So if they?re going to get vaginusmus for example then it is painful and so they can?t relax sexually.? (Participant 1) ??sometimes they do, if there are libidinal differences or she?s off him or he?s off her or?pain, or some kind of sexual problem?where, where the traumatic event is so suppressed that the body speaks for the person in keeping a distance, the mistrust becomes a sexual [phenomenon]. Like low libido, or dryness, or no arousal or lack of interest. There?ll be a barrier around the person, particularly the sexual areas ? too tender, too soft, too something. Yes because we?re not our bodies actually, the bodies are genetics from our parents and chemicals and atoms and molecules and [matter] from the universe. So what we are actually is our emotions and our thoughts and our soul and our spirit, or whatever you believe we are. So it can?t just be physical ever. It comes from somewhere else.? (Participant 5) 69 Psychotherapists? Perceptions of CSA 4.5 The Spectra of Damage 4.5.1 Physical Manifestation The impact of childhood sexual abuse is seen to be pervasive and systemic with a deleterious effect on clinical populations. The complexity and multiple layers involved in understanding childhood sexual abuse results in the impact on psychological, physical and relational functioning respectively, to overlap. For example, would physical symptoms of subjective pain be considered a psychological manifestation due to the possible somatising presumed; would this be a physical manifestation because there is physical pain involved; or would it be considered a relational and intimate functioning problem because of the fact that it is ultimately the sexual functioning which is impacted? As a result of this complexity, the impact on sexuality and sexual relationships will be presented in both the physical impact sub-themes. The exemplar from Participant 7 below illustrates the point that the physical impact of childhood sexual abuse can be experienced physically (pain), caused psychologically (anxiety) and impact on intimate relations with a partner. ?I?ve had women in therapy who complain about pain during intimacy with husbands or intercourse with husbands which I think is linked to anxiety - that would be a physical thing. I think then what you are looking at is a level of anxiety that goes with the intercourse or with being intimate with this person or whatever the case may be; and that creates physical problems. But perhaps, I can?t say that I have really experienced someone having physical problems?that I think it is a psychosomatic thing. But if you are talking about physical, nothing medical as such, but I think that there certainly is a level of anxiety for some people around intimacy and that kind of thing - so that creates problems.? (Participant 7) Participant 6 in the exemplar below talks about victim-survivors of childhood sexual abuse reporting ?non-specific? illness. ?Non-specific? illnesses are here seen as physical complaints for which there is no corresponding physical evidence. ?Non-specific? illnesses are likely more diagnosed according to self-reporting by patients. Randolph et al. (2006) found chronic pelvic pain to play a role in sexual dysfunction for women. Chronic pelvic pain has been found to be related to numerous levels of functioning for 70 Psychotherapists? Perceptions of CSA women such as the psychological, physiological as well as social well-being (Randolph et al., 2006). This indicates that ?non-specific? illnesses may impact on an individual?s global functioning and there is evidence to suggest that there may be a multitude of causes for ?non-specific? illnesses. ?In other people, I think illness comes up a lot. Like just illness that?s non- specific, like chronic back pain and tummy aches and those kind of? IBS I think comes up a lot.? (Participant 6) 4.5.2 Psychological Manifestations Research suggests that a violation at the level of childhood sexual abuse can result in the individual developing feelings of ?(i) self-hate, worthlessness and guilt (perception of self as hateful, guilty and worthless); (ii) vulnerability, mistrust and fear (perception of self as vulnerable, the environment as dangerous and others as untrustworthy); (iii) anxiety, helplessness and powerlessness (perception of dis-ability and lack of choice and control); and (iv) anger, grief/despair and confusion/doubt (the primary emotions through which perception and choice are filtered)? (Geanellos, 2003, p. 189). Anger, betrayal, guilt and responsibility were key emotional consequences identified by participants in this study. These emotional manifestations were seen to play out in complicated and at times pathological ways for victim-survivors. There seemed to be a perception that victim-survivors took responsibility for the abuse which was often related to feelings of guilt. Although as discussed above, there is often an element of ambivalence that victim-survivors develop, so they may resort to anger for having to undergo the particular emotions associated with the abuse. The emotional impact of CSA is complex and intricate and can be related to how victim-survivors perceive their childhood abuse as well as having an impact on current and future global functioning. ?I think people carry with them ideas about sexual abuse. They?ve got their own issues around guilt and shame - so I think it?s very complex.? (Participant 7) 71 Psychotherapists? Perceptions of CSA An overarching emotion that seems to develop in survivors of childhood sexual abuse is one of guilt. Whether or not this guilt tends to arise in situations where the individual may be responsible for these feelings is unclear. What is clear though is that the participants viewed survivors as being predisposed towards guilt feelings in situations where they perceived the abuse as being their fault. The first exemplar below from Participant 3 illustrates guilt that survivors may feel about their own emotions as well as their sexuality. It is understood in this exemplar that individuals feel guilty about emotions that they may or may not experience. This can develop into a sense of shame about one?s feelings and possibly a shame about one?s own sexuality. ??enormous tendency to guilt, guilt if you feel something, guilt if you don?t feel something: a tremendous sense of shame about feelings or about their own sexuality. People might, clients might acknowledge sexual abuse with enormous difficulty and in my experience very seldom will they acknowledge pleasure that they might have had because that just feels so overwhelmingly shameful or guilty and of course is so out of their control that they feel quite split off from their bodies.? (Participant 3) The betrayal of the body in a sexually abusive encounter was mentioned above but there are emotional consequences of this arousal which may include feelings of guilt or shame. The result of individual?s feeling as if they are not in control of their own body can lead to a defensive splitting where the individual almost dissociates from their own body in order to reconcile the physical arousal that they may experience. A further element of guilt arises in feeling a sense of responsibility for what happened. Survivors may feel as if they could have avoided the situation or stopped it but they did not, which gives rise to a sense of responsibility for the abuse as seen below. ?Yes and then you get all the guilt and the ?I could have stopped it and I should have? and all of that.? (Participant 1) Childhood sexual abuse is seen to be an experience which elicits universal feelings of anger and fear in victim-survivors according to Whealin (2002). As previously mentioned, CSA is a complex and multifaceted phenomenon which is experienced and 72 Psychotherapists? Perceptions of CSA understood differently by each victim-survivor. Although anger is a commonly featuring manifestation which was perceived by participants in this study, it is precarious to make a claim of universality with regard to either experience or manifestation because of the fact that there is little consensus regarding this phenomenon. Nonetheless, the participants did perceive an inability to express as well as sit with feelings of anger in clients who had disclosed CSA. In a study conducted with 137 victim-survivors, feelings of victim- survivors included feelings of anger, disgust and feeling repulsed (Whealin, 2002). However, although anger is a common emotion felt by victim-survivors, it is reported to often be pushed into the unconscious at the time of the abuse (Painter & Howell, 1999). The result of this in adulthood is that often the anger is suppressed and if it is realised it frequently becomes rage (Painter & Howell, 1999). Furthermore, the expression of rage can be difficult in a patriarchal society which does not openly accept women expressing rage and in fact where women are taught to repress anger from a young age (Painter & Howell, 1999). This leads to a further difficulty in female victim-survivors expressing their anger or rage. This difficulty is alluded to in the exemplars below. ??a lot of difficulty around expressing anger, very conflicted feelings about that. I?ve known clients that have - like I say they have difficulty expressing anger and there is a great tendency to act it out and they might act it out?? (Participant 3) ??when they get to adolescence or adulthood and they haven?t denied it they may go back or be angry with the person later on, so the anger doesn?t necessarily have to be related at that specific time.? (Participant 4) Although anger is seen to be a common manifestation in victim-survivors, the multitude of contextual factors in both the contextual factors surrounding the abuse as well as psychosocial factors needs to be considered. South Africa is a patriarchal society with definite gender roles as well as gendered power dynamics. It could therefore be hypothesised, as suggested above, that this would play a role in a female victim- survivor?s ability to express anger in a society in which such significant gender roles exist. However, this is not sufficient to detract from a universal explanation of a manifestation of CSA that is, it is not possible to claim that all female victim-survivors of 73 Psychotherapists? Perceptions of CSA CSA will experience anger but some are not able to express this due to socially constructed norms and values. It was noted that PTSD was only mentioned by one of the participants in this study and borderline personality disorder was the dominant diagnosis given although this was qualified extensively. Borderline personality disorder is not only highly correlated with complex trauma as a co-morbid diagnosis but it is also a highly correlated differential diagnosis (Herman, 1992). Bearing in mind Herman (1992) and her theories regarding complex trauma which is often seen to have overlapping symptoms with borderline personality disorder, it is interesting that none of the participants mentioned complex trauma. Similarly, only 2 participants mentioned PTSD, and only in a cursory manner. According to a study conducted in The United States of America, 80% of individuals who report sexual abuse in childhood report at least one other type of childhood maltreatment or abuse and 50% report two or more (Lu et al., 2008). Bearing in mind that it has been hypothesised that in low to middle income countries the prevalence of childhood abuse is higher than high income countries, it is possible that these statistics are the same if not lower than those in low-middle income countries. 4.5.3 Self-Schema Children internalise (take in and process) the meaning of the external world by relating to the self and this is influenced by what they perceive the self to be as well as what they perceive the self to be in relation to others (Potgieter, 2000). What this means for a sexually abused child is that they internalise traumatic external experiences which will then impact on their behaviour as well as how they interact with and see the world as well as themselves (Potgieter, 2000). A child develops a concept of the self with regards to a consciousness of the body which will include the development of body boundaries (Potgieter, 2000). It is body boundaries which allows for the child to distinction between self and other (Potgieter, 2000). The impact on boundaries is discussed at length above, with regards to the impact of childhood sexual abuse on boundary formation. For the purposes of this sub-theme, boundary formation is important in how it impacts on an individual?s development of the self. 74 Psychotherapists? Perceptions of CSA Childhood sexual abuse has been found to impact on more than just boundary development, but it also profoundly impacts on the way an individual perceives themselves. The participants reported numerous impacts that could be broadly classified into self-schema or how the victim-survivors of childhood sexual abuse view themselves. There were reported feelings of guilt, shame, self-blame, responsibility for the victimization as well as self-loathing, a lack of self-esteem (implicates sexual functioning) and self-worth, and a poor sense of self. Self-blame is seen as the victim- survivor viewing characterological or behavioural aspects of the self as being to blame for the abuse (Feiring et al., 2009). Some victim-survivors were reported to almost objectify themselves in seeing themselves as sexual objects to fulfill another person?s sexual needs. The implication for this being that in their complicit behaviour in allowing others to use them as objects, this paradoxically further confirms their original belief that they are just objects that should serve to pleasure others. Participant 1 below highlights this fact which she has perceived amongst victim-survivors of CSA. ?Problems in perceptions of the self: because they are fragmented anyway, so their sense of self is very vulnerable?they do not necessarily develop a coherent or healthy or whole sense of self?they never build that sense of self?all of those kinds of things are going to determine [that]. How coherent that sense of self is -some people are more intact than others. The less intact they are, the more impact the abuse is going to have on them and the less resilient they are going to be. So they develop a poor, if they develop a poor sense of self then they often think of themselves as sexual objects and they think ?I?m bad so people can do whatever they like to me?. ?I?m only going to be loved if I if I engage in sexual interactions.? Because that was how the early object loved me - loved me for what my body could do.? (Participant 1) The development of self-blame was a prominent feature in the perceptions of the participants. The development of the sense of self-blame in victim-survivors is an important aspect in the study of CSA because of the implications this has for potential further victimization. As was explained, an individual who sees themselves as being an object may be further objectified and much in the same way, an individual that claims full responsibility for the sexual abuse that they endure may struggle to over come this abuse 75 Psychotherapists? Perceptions of CSA as they continue to perceive it as being ego-syntonic. The pre-operational stage of development (2-7 years) is a stage in which children are absent of logical thought and do not have a sense of cause and effect (Sadock & Sadock, 2007). It stands to reason that if an individual is sexually abused at this developmental stage, they may be easily manipulated into believing that it is their fault which may impact on disclosure of the abuse. Furthermore, this could activate feelings of self-blame, especially if disclosure of the abuse leads directly to the perpetrator being punished, which may have a significant impact on the family, if the perpetrator is a close friend or family member (Potgieter, 2000). The exemplars from Participant 1 and Participant 5 below indicate this intense confusion that perpetuates itself into the adult consciousness of a childhood victim- survivor. ?What your self worth, I think that I haven?t even mentioned that but, (I?ve talked on sense of self) but there is something - I think their self-worth is just very damaged, and it?s very clouded around who?s to blame. ?Did I cause this to happen? So am I the perpetrator or the victim? Did I seek it out? Was it something I did? Was it something I said? Could I have stopped it? Who should I have told? When should I have told them?? So lots and lots of them struggle with that.? (Participant 1) ?They?re bad. Because it was wrong and they enjoyed it, so there must be something wrong with them. Maybe they?re mentally ill? Their self-esteem is? Look - either way, their self-esteem is damaged from the childhood sexual encounter, because they?re not ready. They haven?t formed any sense of self yet, and so what is the self? What is the self-esteem that is affected by the experience? But it?s either affected by it in that they feel that it shouldn?t have happened ? then, or that it shouldn?t have happened later. And then that affects their adult self-esteem. So it?s either affecting their self-worth as a child, or as an adult, or as both.? (Participant 5) 4.5.4 Relational Dynamic Sexual abuse in childhood has been found to impact on emotional functional and internal schemata of victim-survivors as well as to produce long-term sequelae which impact on relational functioning (Liem, O-Toole, & James, 1996). Victim-survivors were perceived amongst the participants to have problems relating to themselves, others as well as the world. The result of this sometimes led to unhealthy relationships or unhealthy 76 Psychotherapists? Perceptions of CSA behaviours in relationships. The way in which an individual relates impacts on their sense of self and like wise an individual?s sense self will impact the way that they relate. An early sexual abuse experience can impact on an individual in that they relate this early experience to affection or love so sexual behaviour becomes to them the way in which they seek out affection later in life. This was suggested by Participant 6 below. ?I think in many ways it becomes their currency. In a very, very twisted way it becomes what they?ve been valued as, and what they?ve been objectified as, what they?ve been good at or, what they?ve been taught. So it doesn?t necessarily bring them joy or peace, but it?s nevertheless what they seek out. Yes. It?s almost like confirmatory for their sense of self, that this is what they do. And I think for some of them, you know when there really is limited insight, they will interpret it as ?Because he likes me?. There?s a very childlike thing of ?well it must be he really loves me, it must be he really likes me? even though it?s clear, clear, clear [that the person is] just being used, you know it?s just? they?re being called up for sex.? (Participant 6) According to Feinhauer (1989), women who were sexually abused as children show problems with relating to both men and women. What this indicates is that there is a pervasive and systemic impact on relating and not necessarily just in terms of relating on a sexual level. Elements of trust and mistrust as well as self-schema seem to play an important role in the development of relational style for victim-survivors. ?Because, I think a lot of people who have been abused have a perception that the abuse will impact on their sexual relationship - they don?t often see that it?s actually pervasive and that it?s having an impact on relating per se. So yes I suppose the difficulty is that the impact on their sense of self is what then hinders also their ability to form healthy relationships.? (Participant 1) The exemplar from Participant 1 below corresponds to the perceived difficulty that victim-survivors have as a result of the complex and multitude of factors involved in the reaction to the phenomenon of CSA. ??but I find that the struggle is just in relationships generally because I suppose of issues of trust. I mean you can?t?it?s very difficult to have a normal, healthy relationship when there are trust issues. Because any close relationship is going to 77 Psychotherapists? Perceptions of CSA require a person to have adequate levels of trust, adequate levels of boundary- setting, adequate levels of understanding who to allow in and who not to.? (Participant 1) Childhood sexual abuse has been discussed as a complex phenomenon with various resultant impacts in a variety of areas in a victim-survivors life. The etiology of these impacts is difficult to ascertain for a number of reasons, one being that human subjectivity plays a role in both dealing with the experience at the time as well as particular victim-survivors' manifestations that occur. The difficulty enters in when an individual displays traits or borderline personality disorder, which is indicated by a chain of unstable relationships, and to extricate which behaviour is as a result of the abuse and which behaviour is due to a preexisting personality organisation is exceptionally difficult. ?I think there?s some kind of inconsistency. They seem very inconsistent in those relationships. So again; typical borderline traits of idealising and degrading ? that kind of thing. I think that happens a lot. I think they set people up for failure quite often. I think there?s a lot of inconsistencies in what they evoke from others, and in what they give out. I think they tend to be inconsistent in that they will expect something from a friend that they wouldn?t necessarily do for that friend. I think their friends probably don?t experience them as very emotionally stable, and consistent in terms of what, you know whether their behaviour is predictable or not.? (Participant 6) One participant discussed the link that she had perceived between substance abuse and relationships that were perceived to be unhealthy for the victim-survivor. She stated that she had observed many victim-survivors who would get into relationships with men who were either unavailable in the sense of being married or were unemployed and expected the victim-survivor to provide all the necessary financial capital. She further explained that these relationships would often be born out of mutual substance abuse experiences. What this suggests is that the addiction for some victim-survivors may be as a result of using substances to interact socially as well as for escapist or coping reasons. It would stand to reason that an individual who feels innately unsafe in the world, has intense dislike of themselves and struggles to connect with people on an intimate (not necessarily sexual) level, might would utilise substances as a way to feel different. In addition it may 78 Psychotherapists? Perceptions of CSA be a mechanism for this individual to have the confidence to interact socially while still maintaining the ability to maintain distance from others. 79 Psychotherapists? Perceptions of CSA Chapter 5: Conclusion 5.1 Introduction In concluding this research report it may be useful to emphasise again some of the difficulties inherent in the study of CSA. The main issue that arises in this field of inquiry is the lack of a universal definition for what specifically constitutes CSA. It has been argued in this report that CSA is a global phenomenon that impacts all levels of socio- economic status and yet there is no consensus regarding what context, behaviour or impact is attributable to CSA. The impacts of CSA, as well as the perpetration of CSA, were regarded in this report as deleterious social problems with consequences impacting heavily on the victim-survivor as well as their family and society. Although there is contention regarding the extent of the impact of CSA, it was found in this study that the majority of the sample of psychotherapists interviewed found that there were in fact very real and harmful consequences for the victim-survivor as a result of their abuse histories. 5.2 Summary of Research Findings In analysing the data collected for the purposes of this study it became apparent that the identified themes were in fact inextricably linked and not mutually exclusive. However, the themes were discussed separately in this report. The four main themes identified in the data analysis were context, betrayal, sex and the spectra of damage. Each main theme had a number of sub-themes in order to explore the information obtained during data collection. The theme of context delineated the core issue related to the problematics of defining CSA. Across the participants it was found that Kinnear?s (2007) definition where CSA must involve the following four elements: exploitation; coercion; and gratification on the part of the abuser, best summarised the participant?s understandings of CSA. The contact specificity sub-theme was concerned with the context of the actual abuse. Some factors considered here were the age of the victim-survivor when the abuse occurred; the 80 Psychotherapists? Perceptions of CSA duration of the abuse; the severity of the abuse; the relationship of the perpetrator to the victim-survivor; and the consequences for the perpetrator upon disclosure. The specificity of the contact was argued by the participants to be important to the definition of as well as the potential damage caused by the CSA. Related to this sub-theme was the family sub- theme which added further contextual information regarding the CSA, especially in the case where a family member perpetrated the abuse. Having argued at length for the importance of looking at cultural factors and social environments, social and cultural considerations in the definition of CSA covered some subjective areas regarding the participant?s perceptions of CSA. The main point in this sub-theme being that difficulty arises when a child is not aware of their experience as being abusive. Betrayal was a dominant point of discussion for the participants and they found this to be pivotal in much of the resultant manifestations expressed by victim-survivors in therapy. Boundaries and trust were argued to be implicit in adulthood, where some argued that boundaries became more porous and others found that boundaries became more rigid in the victim-survivor. It was found that many victim-survivors will only disclose CSA in adulthood as disclosure was often found to be very traumatic and exposing. A novel finding of this study was some of the participants discussing an element of body betrayal/arousal that victim-survivors experienced during the abuse. This was found to be linked to very strong feelings of guilt, confusion and ambivalence. A further point was noted that it is a common perception that victim-survivors of CSA are more likely to be revictimized later in life. The main area of inquiry in this study was the impact that a CSA history may have on an adult experience of intimacy. The participants interpreted intimacy to equate with sex and so this became a major theme, with intimacy as it?s sub-theme. Trust, emotional expressiveness and intimacy were found to be closely related and often implicated in adult relationships with a victim-survivor of CSA. Furthermore, it was argued that the exertion of power in the CSA experience ultimately contributed to the development of some of these problematic areas. An unexpected finding in this research was the link to sex work - identified by some of the participants, some of whose clients main source of 81 Psychotherapists? Perceptions of CSA income was sex work. Sexual dysfunction arose as a point of interest in the interviews, however it was not seen as a main point of manifestation for the participants. They did however note that they had experience with clients who had sexual problems or dysfunction along with CSA histories. The final theme in this report was the spectra of damage which encompassed four parts: physical manifestation; psychological manifestation; self-schema; and relational dynamic. Physical manifestations were often noted to be ?non-specific illnesses? such as chronic back pain and irritable bowel syndrome where a physical examination did not yield any empirical results and the diagnosis was made on patient reporting. The psychological manifestations were found to be vast and varied resulting from a variety of hypothetical possibilities including both predisposition as well as current situation. There was a profound impact on a victim-survivor?s self-schema noted by some of the participants and this was argued to have an influence on how an individual views both themselves, as well as the world. Lastly, the relational dynamic for the victim-survivor was found to be important for the victim-survivor in their relationships with non-intimate others and non-family members. Although a contention exists regarding the impact of CSA, the above summary suggests that the majority of the participants in this study perceived there to be a profoundly systemic impact on the victim-survivor and their lives. This impact affected the victim- survivor, their family as well as their social world in a deep and, at least in clinical samples, deleterious way. 5.3 Implications of the Findings This study argues that clinicians perceive there to be a profound and harmful impact of CSA on victim-survivors, their families, relationships and society. Although there were some contradictory findings in this study, on the whole the participants were in agreement regarding the fact that CSA leads to negative consequences. The implication 82 Psychotherapists? Perceptions of CSA for this is that this forms part of the body of research that argues for a negative impact of CSA seen in clinical populations. 5.4 Limitations of the Study Due to the fact that this study only involved one group of individuals working with victim-survivors of CSA and the fact that the participants are likely dealing with a clinical population, the results of this study cannot be applied to other populations. Although it was found that clinical populations have a particular perceived set of consequences, it cannot be argued from these results that a non-clinical group of victim- survivors also experience the same impacts. 5.5 Future Directions It may be useful to conduct a similar study on other professionals who work with victim- survivors of CSA such as hospital employees and police officers. This would serve to add to the literature on the subject and hopefully work towards a better understanding of the impact of CSA in community as well as clinical victim-survivors. As this is an area of inquiry that has non-exact prevalence rates and comparatively little research conducted compared to that of overseas publications, further research in the area of CSA will aid in building a body of literature in the South African context. 5.6 Concluding Comments Childhood sexual abuse is a prevalent social concern in South Africa that is not limited to those of any particular socio-economic status. There is a perception that there is little consequence for perpetrators, whereas the impact on victim-survivors is far-reaching. 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Pequegnat (Eds.), From child sexual abuse to adult sexual risk. Trauma, revictimization, and intervention (pp. 135-157). Washington DC: American Psychological Association 94 Psychotherapists? Perceptions of CSA Appendices APPENDIX A: Semi-structured Interview Schedule 1.) Broadly speaking, in your experience of dealing with individuals who experienced sexual abuse as children, how is it that you understand and define this phenomenon? 2.) What does an individual?s experience of childhood sexual abuse mean to you as a therapist? 3.) Based on your own perceptions and experience, what do you feel the impact of childhood sexual abuse is on an adult?s emotional functioning? a. What pathology have you been able to attribute at least in part to an individual?s experience of childhood sexual abuse? 4.) In your experience, what impact does childhood sexual abuse have on an individual?s intimate relationships in adulthood? 5.) What kinds of relationships, intimate or otherwise, do survivors of childhood sexual abuse tend to have? 6.) How successful are survivors? intimate relationships with others? 7.) Can you tell me a little bit about how survivors of childhood sexual abuse manage intimacy in their relationships? 8.) What kinds of physical effects have you seen in survivors of childhood sexual abuse that could be attributed to the abuse in childhood? 95 Psychotherapists? Perceptions of CSA APPENDIX B: Participant Information Sheet School of Human and Community Development Private Bag 3 Wits University 2050 Johannesburg Tel: (011) 717-4500 E-mail: casey.bradford@gmail.com The University of the Witwatersrand Department Of Psychology Ms. C. Bradford Supervisor: Dr. Brett Bowman Dear Sir/Madam, My name is Casey Bradford and I am currently completing my Master of Arts in Community-Based Counselling psychology at Wits University. I have to complete a research thesis for partial fulfilment of this degree. My research intends to explore the perceptions that therapists have of the impact of childhood sexual abuse on an individual?s emotional, physical and interpersonal well-being. I am particularly interested in the impact of childhood sexual abuse on adult intimate relationships. This letter serves as an invitation to take part in the aforementioned study with no obligation necessary. If you decide that you would like to participate, please find attached to this letter two consent forms; one is consent to be interviewed by the researcher, and the other is a consent form for the interview to be recorded. Participation is voluntary and you have the right to refuse to participate. If you decide to participate then you have the right to stop the interview at any point as well as to refuse to answer any questions that you do not feel comfortable with. The information cannot be guaranteed anonymity as I will be conducting the interviews and so will know who you are. However, the information is confidential and your identity will be protected by the use of a pseudonym in the final report. All identifying details will be removed from material used in the report. It might be the case that some direct quotes will be taken from my interview with you but these will be kept confidential. Your participation will entail one 1-hour interview which, with your permission, will be audio recorded. The recordings will be kept in a locked cupboard in my office and the only people who will have access to these recordings as well as the transcripts written up from the recordings will be my supervisor (details below) and me. Upon completion of 96 Psychotherapists? Perceptions of CSA the research report and once all possible articles have been written from the data, the interview recordings as well as the transcripts will be destroyed. Once the report is written up I will make a summary of my findings available to all participants. If you would be interested in receiving a copy of the summarised findings then this will be made available to you upon completion of the research report. Thank you for your considered participation in this study, your participation is greatly appreciated. Sincerely Yours, ________________________ Ms. Casey Bradford M.A Student in Community-Based Counselling Psychology Psychology Department University of the Witwatersrand Ms. Casey Bradford Dr. Brett Bowman Cell: 084 299 2641 Tel: (011) 7178335 Home: (011) 431 2144 E-mail: casey.bradford@gmail.com Ethics Committee: Professor Thornton Tel: (011) 717-2301 Tel: (011) 717-2301 97 Psychotherapists? Perceptions of CSA APPENDIX C: Consent from for participants I have read the information sheet and I am aware of the nature of this study. I hereby voluntarily consent to being interviewed by Casey Bradford for her study on the impact of childhood sexual abuse on adult intimate relationships. I understand that: Please tick Participation in this interview is completely voluntary. I may refuse to answer any questions I would prefer not to. I may withdraw from the study at any time. I understand that there are no direct risks or benefits to participating in the study. No information that may identify me will be included in the research report, and my responses will remain confidential. The researcher may use direct quotes taken from my interview, in the research report, provided no information that may identify me is included. I will receive a summary of the research results if requested. Signature: Date: 98 Psychotherapists? Perceptions of CSA APPENDIX D: Audio-recording and transcript consent form I, hereby voluntarily consent to my interview with Casey Bradford for her study on the perceptions of the impact of childhood sexual abuse on adult intimate relationships in a sample of women who have disclosed childhood sexual abuse in Johannesburg, being audio-tape recorded, and transcribed. I understand that: ? The tapes and transcripts will only be heard by the researcher and her research supervisor, and will only be processed by the researcher. ? All tape recordings and transcripts will be kept in a secure location, which only the researcher will have access to. ? All tape recordings will be destroyed after the research is completed and examined. ? No identifying information will be used in the transcripts or the research report. Signature: Date: 99