**A Salutogenic Approach to Healing Following Child Sexual Assault**

Sheryle Vilenica and Jane Shakespeare-Finch

*School of Psychology and Counselling, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia* 

### **1. Introduction**

32 Sexual Abuse – Breaking the Silence

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Decades of research has now produced a rich description of the destruction child sexual assault (CSA) can cause in an individual's life. Post-Traumatic Stress Disorder (PTSD), Dissociative Identity Disorder, Borderline Personality Disorder, depression, anxiety, Panic Disorder, intimacy issues, substance abuse, self-harm, and suicidal ideation and attempts, are some of the negative outcomes that have been attributed to this type of traumatic experience. Psychology's tendency to dwell within a pathological paradigm, along with popular media who espouse a similar rhetoric, would lead to the belief that once exposed to CSA, an individual is forever at the mercy of dealing with a massive array of accompanying negative effects. While the possibility of these outcomes in those who have experienced CSA is not at all denied, it is also timely to consider an alternative paradigm that up until now has received a paucity of attention in the sexual assault literature. That is to say, not only do people have the ability to work through the painful and personal impacts of CSA, but for some people the process of recovery may provide a catalyst for positive life changes that have been termed post-traumatic growth (Tedeschi & Calhoun, 1995).

To begin with in this chapter, the negative sequale' of childhood sexual assault it discussed. Inherent to this discussion are questions of measurement and definitions of sexual assault. The chapter highlights ways in which the term CSA has been defined and hence operationalised in research, and the myriad problems, confusions, and inconclusive findings that have plagued the sexual assault literature. Following this is a review of the sparse literature that has conceptualised CSA from a more salutogenic (Antonovsky, 1979) theoretical orientation. It is argued that a salutogenic approach to intervention and to research in this area, provides a more useful way of promoting healing and the gaining of wisdom, but importantly does not negate the very real distress that may accompany growth. This chapter will then present a case study to elucidate the theoretical and empirical literature discussed using the words of a survivor. Finally, the chapter concludes with implications for therapeutic practice, which includes some practical ways in which to promote adaptation to life within the context of having survived this insidious crime.

#### **1.1 The impact of child sexual abuse: An overview of the pathological paradigm**

For those who work therapeutically with individuals who have a history of child sexual abuse (CSA) there is no difficulty in understanding just how impactful this particular type

A Salutogenic Approach to Healing Following Child Sexual Assault 35

amongst sufferers of other tragedies and traumas, those who have experienced CSA show higher levels of impairment (Shakespeare-Finch & Armstrong, 2010), a testament to the highly invasive, personal, and damaging nature of the experience of sexual abuse in

The intrapersonal impact of CSA is perhaps the most pronounced and enduring of all the potential outcomes that can stem from a history of sexual abuse. Pervasive feelings of shame, guilt, and responsibility plague many of those who have endured this experience (Coffey et al., 1996). These particular effects show enduring consistency in those who have experienced repeated abuse over many years, through to those who have experienced one intrusive contact abuse act (Isley et al., 2008; Molner et al., 2002). Feelings of shame and responsibility permeate to the core of how an individual feels about themselves, not only as a person, but as a person within the abuse dyad. For a great many abuse survivors, a feeling of complicity exists, particularly if the offender is older, stronger, and in a position of authority over the child, and the abuse was not overtly challenged by the child. Survivors then take on the responsibility of the abuse, either in part or in full, believing had they said something, done something different, or been in some way different, this would not have happened to them. Through this process, core beliefs are formed about the self that often reflect worthlessness, hopelessness, or inherent 'badness'. Unfortunately, even therapeutic intervention has done little to create a shift in the global, negative way that individuals *feel* about who they are, as well as what they are worth as a person (Lev-Wiesel, 2000). From the vantage point of holding such a negative self-image, it is not difficult to understand how the

interpersonal and social difficulties that can stem from CSA are encountered.

In the search for understanding the sources of difficulty and distress in survivors of CSA, the pathological paradigm has provided a rich description of the vast spectrum of potential negative outcomes that often follow sexual abuse. Adding to the understanding of pathology are an array of established mediating and moderating variables known to increase the risk of harm and suffering after experiencing CSA. Abuse-specific variables of a longer duration (Reyes, 2008), a familial offender (Zinzow et al., 2010), more intrusive abuse (Nelson et al., 2002), and subjective distress at time of abuse (Briere & Elliott, 2003) have all been shown to cause more distress and impairment. When an individual discloses their abuse, as well as how it is responded to, makes a difference to psychological outcomes. Often it is found that children who's abuse is disclosed or discovered in childhood fare much worse than those who choose to wait until adulthood (O'Leary et al., 2010), although the reverse has also been found (Ullman, 2007). If disclosure is met with silence, or worse, with condemnation of the victim, poorer outcomes are likely to follow (Del Castillo & O'Dougherty, 2009). Attachment has been shown to be an important variable in outcomes, as children who report having one non-offending parent who provides them with belief and support fare better than those who do not report such a relationship (Bolen & Lamb, 2007). In adulthood, support appears to be just as important; women with CSA histories have reported the often transformative act of being believed and accepted by another through the process of disclosure, if the disclosure is met with acceptance and validation (Del Castillo & O'Dougherty, 2009), while the damaging effects of stigma and judgement after disclosure has been reported as an area of further distress and isolation (Jonzon & Lindblad, 2004).

With what is already known through exploration using the pathological paradigm it can be said definitively and conclusively that CSA causes harm, and that a direct link exists

childhood.

of trauma can be on a person. The elements that CSA consist of in the context of traumatic events are remarkably unique. With few exceptions, such as war, persecution, and slavery, most traumatic events are just that, single episode events that occur unexpectedly and are unpredictable. With CSA however, the 'event' is something that often, though not always, occurs over and over again, with a certain amount of predictability. Furthermore, the person responsible for committing CSA acts is resoundingly more often someone the child knows, loves, and often depends on for survival (Fanslow et al., 2007; Kouyoumdjian et al., 2009). That is to say, more frequently than not, offenders are either related to the child directly or are closely involved with the child's family; trusted, influential, and deeply imbedded within the child's support network. The betrayal of trust, abuse of the child's love for, and devotion to, the offender, and confusion caused by being both hurt and loved by a trusted adult is in and of itself damaging to the child's emerging sense of self and their intrinsic worth. This in turn greatly influences the child's working models of relationships and their place within these relationships. A further unique aspect of CSA is the secrecy that surrounds this issue. With other traumatic events often the event is well known to others, and support is available to the aggrieved party. However, when a child is sexually assaulted, more often than not the child suffers in silence, feeling alone and isolated (Isely et al., 2008). In addition to the emotional isolation is fact that CSA is an offence that happens *within* the child's body. Even acts of physical violence occur *to* an individual; with CSA the violation physically crosses the line from outside to within, and there is nowhere to escape. All this can happen at a time when the child has limited resources, or recourses, open to them, due to developmental stages associated with childhood (e.g., cognitive development, dependence). It is little wonder that so many individuals who have experienced this particular interpersonal trauma are often left with deep psychological scars that resound through so many domains within their lives (Nelson et al., 2002).

The field of psychological enquiry has long been aware of the devastating effects CSA leaves in its wake. In the three decades since CSA was first brought openly into the light of scientific investigation much has been learned not only in relation to the myriad negative impacts that follow CSA, but also regarding the array of mediating and moderating factors found to contribute to the increase or decrease of the subjective impact felt. Overwhelmingly, the focus of psychological investigation has been through the lens of a pathological paradigm. The focus of the pathological paradigm is on the origins of ill-health in the form of diagnosable psychological disorders, in the process of seeking to understand what contributes to worse outcomes so that one can identify and alleviate distressing symptoms. The overarching intention is to identify ways to alleviate suffering. With this framework of investigation, the field of psychological research has provided a rich description of the pathology that often occurs as a result of a child being sexually assaulted.

Of all areas studied pertaining to CSA, the area given most attention has been that of the negative outcomes experienced by victims of this crime. Consistently, research has continued to show the direct link between CSA exposure and negative outcomes (e.g. Molnar et al., 2001; Nelson et al., 2002; O'Leary et al., 2010). Of the diagnosable disorders, major depressive disorder (Nelson et al., 2002), anxiety disorders (Calam et al., 1998), suicide attempts (Belik et al., 2009), sexual dysfunction (Gold et al., 1999), post-traumatic stress disorder (PTSD) (Shakespeare-Finch & De Dassel, 2009), and other psychopathology (Molnar et al., 2001) are commonly studied, demonstrating that those who have experienced CSA are at a significantly greater risk of developing these impairments. Even

of trauma can be on a person. The elements that CSA consist of in the context of traumatic events are remarkably unique. With few exceptions, such as war, persecution, and slavery, most traumatic events are just that, single episode events that occur unexpectedly and are unpredictable. With CSA however, the 'event' is something that often, though not always, occurs over and over again, with a certain amount of predictability. Furthermore, the person responsible for committing CSA acts is resoundingly more often someone the child knows, loves, and often depends on for survival (Fanslow et al., 2007; Kouyoumdjian et al., 2009). That is to say, more frequently than not, offenders are either related to the child directly or are closely involved with the child's family; trusted, influential, and deeply imbedded within the child's support network. The betrayal of trust, abuse of the child's love for, and devotion to, the offender, and confusion caused by being both hurt and loved by a trusted adult is in and of itself damaging to the child's emerging sense of self and their intrinsic worth. This in turn greatly influences the child's working models of relationships and their place within these relationships. A further unique aspect of CSA is the secrecy that surrounds this issue. With other traumatic events often the event is well known to others, and support is available to the aggrieved party. However, when a child is sexually assaulted, more often than not the child suffers in silence, feeling alone and isolated (Isely et al., 2008). In addition to the emotional isolation is fact that CSA is an offence that happens *within* the child's body. Even acts of physical violence occur *to* an individual; with CSA the violation physically crosses the line from outside to within, and there is nowhere to escape. All this can happen at a time when the child has limited resources, or recourses, open to them, due to developmental stages associated with childhood (e.g., cognitive development, dependence). It is little wonder that so many individuals who have experienced this particular interpersonal trauma are often left with deep psychological scars that resound

The field of psychological enquiry has long been aware of the devastating effects CSA leaves in its wake. In the three decades since CSA was first brought openly into the light of scientific investigation much has been learned not only in relation to the myriad negative impacts that follow CSA, but also regarding the array of mediating and moderating factors found to contribute to the increase or decrease of the subjective impact felt. Overwhelmingly, the focus of psychological investigation has been through the lens of a pathological paradigm. The focus of the pathological paradigm is on the origins of ill-health in the form of diagnosable psychological disorders, in the process of seeking to understand what contributes to worse outcomes so that one can identify and alleviate distressing symptoms. The overarching intention is to identify ways to alleviate suffering. With this framework of investigation, the field of psychological research has provided a rich description of the pathology that often occurs as a result of a child being sexually assaulted. Of all areas studied pertaining to CSA, the area given most attention has been that of the negative outcomes experienced by victims of this crime. Consistently, research has continued to show the direct link between CSA exposure and negative outcomes (e.g. Molnar et al., 2001; Nelson et al., 2002; O'Leary et al., 2010). Of the diagnosable disorders, major depressive disorder (Nelson et al., 2002), anxiety disorders (Calam et al., 1998), suicide attempts (Belik et al., 2009), sexual dysfunction (Gold et al., 1999), post-traumatic stress disorder (PTSD) (Shakespeare-Finch & De Dassel, 2009), and other psychopathology (Molnar et al., 2001) are commonly studied, demonstrating that those who have experienced CSA are at a significantly greater risk of developing these impairments. Even

through so many domains within their lives (Nelson et al., 2002).

amongst sufferers of other tragedies and traumas, those who have experienced CSA show higher levels of impairment (Shakespeare-Finch & Armstrong, 2010), a testament to the highly invasive, personal, and damaging nature of the experience of sexual abuse in childhood.

The intrapersonal impact of CSA is perhaps the most pronounced and enduring of all the potential outcomes that can stem from a history of sexual abuse. Pervasive feelings of shame, guilt, and responsibility plague many of those who have endured this experience (Coffey et al., 1996). These particular effects show enduring consistency in those who have experienced repeated abuse over many years, through to those who have experienced one intrusive contact abuse act (Isley et al., 2008; Molner et al., 2002). Feelings of shame and responsibility permeate to the core of how an individual feels about themselves, not only as a person, but as a person within the abuse dyad. For a great many abuse survivors, a feeling of complicity exists, particularly if the offender is older, stronger, and in a position of authority over the child, and the abuse was not overtly challenged by the child. Survivors then take on the responsibility of the abuse, either in part or in full, believing had they said something, done something different, or been in some way different, this would not have happened to them. Through this process, core beliefs are formed about the self that often reflect worthlessness, hopelessness, or inherent 'badness'. Unfortunately, even therapeutic intervention has done little to create a shift in the global, negative way that individuals *feel* about who they are, as well as what they are worth as a person (Lev-Wiesel, 2000). From the vantage point of holding such a negative self-image, it is not difficult to understand how the interpersonal and social difficulties that can stem from CSA are encountered.

In the search for understanding the sources of difficulty and distress in survivors of CSA, the pathological paradigm has provided a rich description of the vast spectrum of potential negative outcomes that often follow sexual abuse. Adding to the understanding of pathology are an array of established mediating and moderating variables known to increase the risk of harm and suffering after experiencing CSA. Abuse-specific variables of a longer duration (Reyes, 2008), a familial offender (Zinzow et al., 2010), more intrusive abuse (Nelson et al., 2002), and subjective distress at time of abuse (Briere & Elliott, 2003) have all been shown to cause more distress and impairment. When an individual discloses their abuse, as well as how it is responded to, makes a difference to psychological outcomes. Often it is found that children who's abuse is disclosed or discovered in childhood fare much worse than those who choose to wait until adulthood (O'Leary et al., 2010), although the reverse has also been found (Ullman, 2007). If disclosure is met with silence, or worse, with condemnation of the victim, poorer outcomes are likely to follow (Del Castillo & O'Dougherty, 2009). Attachment has been shown to be an important variable in outcomes, as children who report having one non-offending parent who provides them with belief and support fare better than those who do not report such a relationship (Bolen & Lamb, 2007). In adulthood, support appears to be just as important; women with CSA histories have reported the often transformative act of being believed and accepted by another through the process of disclosure, if the disclosure is met with acceptance and validation (Del Castillo & O'Dougherty, 2009), while the damaging effects of stigma and judgement after disclosure has been reported as an area of further distress and isolation (Jonzon & Lindblad, 2004).

With what is already known through exploration using the pathological paradigm it can be said definitively and conclusively that CSA causes harm, and that a direct link exists

A Salutogenic Approach to Healing Following Child Sexual Assault 37

showed the severe and lasting effects of the impact of CSA, with high impairments found across a number of domains within these women. However, clinical populations do not provide a representative picture of the majority of those who have experienced CSA, as evidenced by the large number of people within the general community who report

The rise of university student samples has been a popular choice for researchers for some time now (see Finkelhor & Browne, 1986). The benefit of using university students as research populations is that it provides researchers with access to large numbers of easily accessible participants. Although ease of gathering information with the use of this population is enticing, there are also inherent problems with the use of university student samples. First, within university samples, CSA prevalence rates have been shown to be lower than what is found within the general community, and the types of offences reported show a disproportionately higher percentage of non-contact abuse (exposure, pornography), and single-episode, non-penetrative abuse (Ullman, 2007; Zinzow et al., 2010) than those found within the general public (McGregor et al., 2010). A further limitation in utilising university students is that they often consist of relatively young people, the majority of whom are in their late teens to early thirties, who most often are not married and have no children (Harding et al., 2010; Zinzow et al., 2010). What this means in practice is that the sample consists largely of individuals who would be considered high-functioning, as evidenced by the fact they have met requirements to enter tertiary education, and who are also yet to go through significant life stages of partnering, marriage, and child rearing; stages that often cause one to think about the impacts of their own childhood on the way in which one conducts themselves as a spouse, mother or father (O'Dougherty et al., 2007). Not surprisingly then, university populations have been found to show less impairment than that found when studying individuals within the general population (Molner et al., 2001;

In reality, neither of these sample bases can be considered truly representative to the scope of individuals affected by CSA. With estimates of one in four women and one in seven men experiencing some form of CSA in childhood (Finkelhor, 1994) we only need to look at our workplaces, the local community, and indeed our own families, to see that if we have a mother, sister, aunty, and grandmother, the likelihood exists that one of these women have been affected (not withstanding familial correlates of CSA incidents). Similarly, a company board meeting consisting of 25 men could mean three or more of these men have also experienced CSA. What this means for research is that in order for our results to be truly meaningful, and to encapsulate the spectrum of individuals affected by this experience, broadening the use of general population samples would provide a more representative

Other problematic issues within research lays both within the way CSA is defined and measured. As it stands, no universal definition exists as to what actually constitutes CSA. This alone is contentious, as an obvious question is then of how is it possible for contradictory findings *not* to emerge if there is yet to be an agreement on what CSA actually is. Definition and measurement discrepancies lay within the types of experiences classified as abuse, the age of the victim at time of the assault, and a lack of enquiry into the subjective

view of CSA and arguably, a reduction of null findings would also follow.

experiencing abuse.

Rojas & Kinder, 2009).

**2.2 Definitions and measurement** 

between CSA and risk for adverse outcomes (Molar et al., 2001; Nelson et al., 2002; Wiffen & MacIntosh, 2005). With this being said, due to the heterogeneity of CSA experiences, individual differences in coping strategies during and after abuse, the interplay of the various mediating and moderating variables, as well as a host of other factors, a simple cause and effect model cannot be created to account for the myriad adverse outcomes that co-occur with the often traumatic experience of CSA (Putnam, 2003). This disparity not only exists among the types of experiences or environmental conditions that make up the population of those exposed to CSA; discrepancy and contradictions exist within the CSA literature itself.
