**3. The salutogenic paradigm: Growth from the ashes**

#### *"The world breaks everyone, and afterward some are strong at the broken places"* Hemmingway

In a move from the more traditional focus on pathological outcomes of trauma, and the understanding of what makes a difference in terms of reducing severity and duration of negative outcomes, research is now opening up to the broader scope of human experience and has begun to investigate factors related to more positive outcomes after trauma or severe stress. Concepts such as hardiness (Kobasa, 1979) and resilience (e.g., Bonanno, 2004; Rutter, 1987) have arisen as important determinants implicated in maintaining a person's base-line well-being in the face of traumatic or aversive life events. What these investigations have shown is that despite enduring personal traumas, some people, due to things such as favourable environmental conditions (e.g., support) and personality elements, are able to continue to function well, or are able to 'bounce back', with more ease and speed from these stressors than others. Walsh (2002) conceptualises resilience as "bouncing forward", suggesting that trauma changes a person's life and therefore "back" is not possible, and may not be desirable. Resilience and hardiness however, do not encapsulate the wide variety of ways of coping after stressors and traumas, and to this end, other investigations into how people cope with adversity and suffering have emerged in the literature.

The Salutogenic paradigm (Antonovsky, 1979) is one such reference theory that is interested in exploring the question of "What is it that keeps people well?", not only enduring personal traumas, but also within the bounds of more ordinary experiences of life stress, personal hardships, and setbacks. It was through his work with menopausal women, a sub-group of who had survived the holocaust, that medical sociologist Aaron Antonovsky began to wonder this very question. Studying these women who had endured unimaginable horrors, he discovered, to his surprise, that within the sub-group of menopausal holocaust survivors, nearly one third of the women were not only maintaining a good level of health, but were also managing to lead a fulfilling life, despite the trauma of their experiences. It was this discovery that led Antonovsky to depart from the more traditional, reductionist focus of pathology into a new paradigm of human capacity for health and wellness. Antonovsky's focus shifted to an attention on how people use their resources to remain well, even in the wake of very difficult circumstances. What he found was that the people who were able to remain relatively healthy after adversity had a certain way of looking at the world and their life, and he also noted differences in the way they coped with their life stressors. He suggested such people had a "sense of coherence".

Antonovsky's (1979) salutogenic theoretical approach views well-being as a multidimensional continuum, with health/ease on one end of the continuum, and dis-ease at the other, with fluid movement between the ends of these two poles being the normative experience. This way of thinking takes into account the very real fact that life is in and of itself inherently stressful, and that heterostasis, illness, and senescence are part of the human condition. This is a sentiment echoed by an ancient philosopher over 2 ½ thousand years ago, in the words of Buddha, "*Life is suffering".* From this perspective, the focus is on coping resources that contribute to movement towards the healthy end of the wellbeing continuum, or at the very least, which assists in the maintenance of one's position. In this way, salutogenesis is an investigation of the total story of a person, discovering how one successfully resolves tension in their lives and maintains or enhances their position on the well-being continuum despite, or perhaps because of, their difficulties.

At the core of the salutogenic paradigm is the theory behind the perceptual differences Antonovsky discovered in individuals who were able to maintain wellness despite their previous or current circumstances, what Antonovsky coined the sense of coherence (SOC). The SOC comprises three main components across cognitive, behavioural, and emotional domains, being comprehensibility, manageability, and meaningfulness. Comprehensibility is the extent to which an individual views stressors as understandable, clear and ordered. Manageability is the extent that resources are perceived to be available to the individual, and that these resources are adequate to meet the challenges a person might face. Meaningfulness is the extent to which an individual believes their emotional life makes sense, and the emotional demands they face are worth investing energy into. Therefore, healthy coping, according to Antonovsky, is when one is able to make sense of their situation, believe they have the abilities to cope with what is in front of them, and believe that the emotional struggle to deal with their difficulties is of importance and worthy of investment (Antonovsky, 1987).

#### **3.1 Post-traumatic growth**

40 Sexual Abuse – Breaking the Silence

beginning to emerge; one that seeks to add a new body of information on CSA; a complimentary, innovative way in which we both understand and work with survivors of

*"The world breaks everyone, and afterward some are strong at the broken places"* Hemmingway

In a move from the more traditional focus on pathological outcomes of trauma, and the understanding of what makes a difference in terms of reducing severity and duration of negative outcomes, research is now opening up to the broader scope of human experience and has begun to investigate factors related to more positive outcomes after trauma or severe stress. Concepts such as hardiness (Kobasa, 1979) and resilience (e.g., Bonanno, 2004; Rutter, 1987) have arisen as important determinants implicated in maintaining a person's base-line well-being in the face of traumatic or aversive life events. What these investigations have shown is that despite enduring personal traumas, some people, due to things such as favourable environmental conditions (e.g., support) and personality elements, are able to continue to function well, or are able to 'bounce back', with more ease and speed from these stressors than others. Walsh (2002) conceptualises resilience as "bouncing forward", suggesting that trauma changes a person's life and therefore "back" is not possible, and may not be desirable. Resilience and hardiness however, do not encapsulate the wide variety of ways of coping after stressors and traumas, and to this end, other investigations into how people cope with adversity and suffering have emerged in the

The Salutogenic paradigm (Antonovsky, 1979) is one such reference theory that is interested in exploring the question of "What is it that keeps people well?", not only enduring personal traumas, but also within the bounds of more ordinary experiences of life stress, personal hardships, and setbacks. It was through his work with menopausal women, a sub-group of who had survived the holocaust, that medical sociologist Aaron Antonovsky began to wonder this very question. Studying these women who had endured unimaginable horrors, he discovered, to his surprise, that within the sub-group of menopausal holocaust survivors, nearly one third of the women were not only maintaining a good level of health, but were also managing to lead a fulfilling life, despite the trauma of their experiences. It was this discovery that led Antonovsky to depart from the more traditional, reductionist focus of pathology into a new paradigm of human capacity for health and wellness. Antonovsky's focus shifted to an attention on how people use their resources to remain well, even in the wake of very difficult circumstances. What he found was that the people who were able to remain relatively healthy after adversity had a certain way of looking at the world and their life, and he also noted differences in the way they coped with their life stressors. He

Antonovsky's (1979) salutogenic theoretical approach views well-being as a multidimensional continuum, with health/ease on one end of the continuum, and dis-ease at the other, with fluid movement between the ends of these two poles being the normative experience. This way of thinking takes into account the very real fact that life is in and of itself inherently stressful, and that heterostasis, illness, and senescence are part of the human condition. This is a sentiment echoed by an ancient philosopher over 2 ½ thousand years

**3. The salutogenic paradigm: Growth from the ashes** 

suggested such people had a "sense of coherence".

this particular trauma.

literature.

The overall outlook of the salutogenic orientation is to offer a theoretical perspective of successful coping. Inherent in this theory is the notion that human wellness is more than an absence of pathology, and takes into consideration the human ability to flourish and experience positive change after the experience of a major disruption or trauma. Positive changes that arise from the struggle to cope with a traumatic event have been termed *posttraumatic growth* (PTG) (Calhoun & Tedeschi, 2006; Tedeschi & Calhoun, 1996). The notion of PTG is a burgeoning field of research that takes the notion of resilience and resistance to stress to a new level. Consequently, the past 15 years of inquiry has provided research demonstrating positive post-trauma changes in individuals who have struggled with many types of trauma (Janoff-Bulman, 2006; Tedeschi & Calhoun, 1995).

One theoretical process model of the pathways to PTG asserts that the experience of trauma is so powerful that it shakes the very foundations on which we view ourselves, our world, and our place in it (Janoff-Bulman, 2006). Fundamental cognitive assumptions held about the self and one's environments, assumptions that serve to make life predictable, logical, and intelligible, and which are based on concepts such as safety, benevolence, and good things happening to good people, and bad things happening to someone else, are believed to be in dissonance with reality after a perceived traumatic event, due to the profound loss of safety, protection and certainty the experience of trauma often brings (Janoff-Bulman, 2006; Calhoun & Tedeschi, 2006). The internal disruption of one's inner world through the experience of loss of safety and security is believed to overwhelm ordinary defences, leaving one with a sense of threat, helplessness, and vulnerability. Coping, then, becomes a process of reworking internal fundamental assumptions, moving from overgeneralisation of danger and helplessness, to a place that incorporates both the new reality of the uncertainty of the

A Salutogenic Approach to Healing Following Child Sexual Assault 43

freedom of self-disclosure within personal relationships, a shift in their philosophy of life, such as greater appreciation of the 'little things', changed priorities, or changes in religious or existential beliefs (Calhoun & Tedeschi, 2006; Tedeschi & Calhoun, 1999). Calhoun and Tedeschi (2006) propose growth is both a process and an outcome, in that processes such as volition rumination, self-disclosure, and managing distress, lead to the three broad outcome domains. This is a sentiment echoed in existing theories of coping that assert the struggle to process negative events, through mechanisms such as meaning making, leads to growth outcomes of cognitive reappraisals of fundamental assumptions (Park & Folkman, 1997; Park, 2009). An example of this can be seen in Flynn's (2008) investigation of women sexually abused by members of their church clergy. Although PTG was not examined in this study, the qualitative reports reveal that the process of being believed and supported was influential in these women being able to shift their negative view of themselves to a more realistic and positive view. Further, the women in this study also reported that shifting their focus of spirituality from a hierarchical, patriarchal church structure to a more relational, spiritual connection, allowed for a deeper connection to self and inner transformation. Although the question of whether PTG is a process or an outcome is left to be answered, from a philosophical perspective, an outcome depends on only where you stand in time. There are others however, who suggest that the pathways *to* growth are not necessarily the same as the outcomes *of* growth, and that research would do well to explore further the pathways taken that result in positive post-trauma change (Janoff-Bulman, 2004; Woodward & Joseph, 2003). Within these above-mentioned complimentary perspectives of human wellness and growth, the recurrent themes of three major processes are apparent. Antonovsky's SOC concept of manageability is echoed in Janoff-Bulman psychological preparedness and Tedeschi and Calhoun's strengthening of relationships with others, as each of these have components of being able to utilise resources, both intrapersonally and interpersonally, as that which assist in the facilitation of adaptive coping. Similarly, comprehensibility, strength through suffering, and changes in the way one views themselves all resonate with the notion that an increased knowledge and understanding of the self is important for positive change and growth. Finally, meaningfulness, existential re-evaluation, and changes in one's philosophy of life have at their core the assumption that changes in one's connection and commitment to one's life is an important determinant of growth, healing, and wellness after adversity. Reflected in these perspectives are themes such as connection, deepening of relationships, the use of knowledge as power, gratitude, and appreciation. By opening up to the whole story of the person, rather than merely focussing on negative outcomes from trauma and distress, a fuller picture of the

human capacity to cope, survive, and thrive after adversity emerges.

The phenomenon of PTG has now been shown to occur after an array of traumatic events, from bereavement (Cadell, 2003) and motor vehicle accidents (Shakespeare-Finch & Armstrong, 2010), to acts of terrorism (Take et al., 2008). However, the external event in and of itself is not what 'creates' the conditions for PTG to occur, but instead, it is more the internal disruption the experience creates, the subjective experience of it, and, most importantly, the struggle engaged in to incorporate the event into life. This is demonstrated by the fact that not all witnesses or survivors of a potentially traumatic experience suffer long-term negative effects from their exposure. Indeed some people may perceive an experience to be traumatic whereas the same experience may not be perceived as traumatic by another. The majority of people exposed to any of the myriad of sudden, unexpected,

world and one's own vulnerability. In other words, there needs to be a cognitive shift from being a 'victim' to being a 'survivor', while also allowing for a more positive sense of self and the world to emerge; one that is aware of, but is not defined by, vulnerability. Janoff-Bulman (2004, 2006) postulates that the path to successful coping is achieved through three psychological process; strength through suffering, psychological preparedness, and existential re-evaluation. Strength through suffering allows for knowledge gained through the struggle of coping to open an individual to a deeper understanding of themselves. Psychological preparedness is the process of the strengthening of inner resources through coping, which also makes future traumas more easily dealt with, as with experience one is more prepared for future challenges. While existential re-evaluation is the process of more fully connecting to one's life, such as developing a new-found appreciation of one's existence in the world, or developing a greater appreciation of one's life, as well as encompassing changes to one's philosophy of life and how they engage with themselves, others, and their environment on a day-to-day basis.

Theoretically however, the notion of trauma shaking the foundations of one's assumptive worlds does not entirely fit for those who experience trauma as children. Childhood and adolescence is seen as a time when one is *building* assumptive worlds about the self, others, and the world (Erikson, 1980). Therefore, it can be postulated that instead of *shaking* one's internal assumptions, childhood traumas like CSA could be seen to actually *create*  assumptions about the self, as the trauma is co-occurring at a time when these attributions are being formulated. This can be seen in research findings where individuals who were abused at a later age of onset, or experienced abuse that continued into their adolescence, are found to attribute the blame for the abuse on themselves (Zinzow et al., 2010). Frequently, research and clinical practice reveals that individuals who experience CSA hold inherent perceptions of themselves based on concepts of wrongness, damagedness, and separateness (Isely et al., 2008; Zinzow et al., 2010). Perhaps growth then, for those who experience traumas at a time when they are constructing their internal assumptions, could be more of a process of uncovering the false perceptions of the self and connecting to their true nature, or the truth about who they really are. An example of this can be seen in Phanichrat and Townshend's (2010) study of men and women who regard themselves a healed from CSA. Sentiments echoed from these individuals show that the process of letting go of shame and truly accepting themselves, and shifting the way they viewed themselves in relation to the abuse, were fundamental avenues that lead to their healing. Other research has revealed that gaining an understanding of power differentials, hierarchical relationships, and personal boundaries helped women to shift their perspective of selfblame to a more realistic and healthy view that the offender was responsible for the abuse, and not them (Flynn, 2008). By these reports, shifts in self-perception are seen as important aspects that allow for an experience of inner transformation and contribute significantly to healing from CSA.

A further theoretical postulation of PTG comes from Tedeschi and Calhoun (2004) who have found that through the process of actively dealing with the experience of trauma, people often report growth and change in three major domains; in ones' sense of self, their relationships with others, and in their philosophy in life. People report feeling a greater sense of personal strength, self-reliance and competence through successfully negotiating the struggle to cope with their traumatic experience, a strengthening in their relationships with others and greater

world and one's own vulnerability. In other words, there needs to be a cognitive shift from being a 'victim' to being a 'survivor', while also allowing for a more positive sense of self and the world to emerge; one that is aware of, but is not defined by, vulnerability. Janoff-Bulman (2004, 2006) postulates that the path to successful coping is achieved through three psychological process; strength through suffering, psychological preparedness, and existential re-evaluation. Strength through suffering allows for knowledge gained through the struggle of coping to open an individual to a deeper understanding of themselves. Psychological preparedness is the process of the strengthening of inner resources through coping, which also makes future traumas more easily dealt with, as with experience one is more prepared for future challenges. While existential re-evaluation is the process of more fully connecting to one's life, such as developing a new-found appreciation of one's existence in the world, or developing a greater appreciation of one's life, as well as encompassing changes to one's philosophy of life and how they engage with themselves,

Theoretically however, the notion of trauma shaking the foundations of one's assumptive worlds does not entirely fit for those who experience trauma as children. Childhood and adolescence is seen as a time when one is *building* assumptive worlds about the self, others, and the world (Erikson, 1980). Therefore, it can be postulated that instead of *shaking* one's internal assumptions, childhood traumas like CSA could be seen to actually *create*  assumptions about the self, as the trauma is co-occurring at a time when these attributions are being formulated. This can be seen in research findings where individuals who were abused at a later age of onset, or experienced abuse that continued into their adolescence, are found to attribute the blame for the abuse on themselves (Zinzow et al., 2010). Frequently, research and clinical practice reveals that individuals who experience CSA hold inherent perceptions of themselves based on concepts of wrongness, damagedness, and separateness (Isely et al., 2008; Zinzow et al., 2010). Perhaps growth then, for those who experience traumas at a time when they are constructing their internal assumptions, could be more of a process of uncovering the false perceptions of the self and connecting to their true nature, or the truth about who they really are. An example of this can be seen in Phanichrat and Townshend's (2010) study of men and women who regard themselves a healed from CSA. Sentiments echoed from these individuals show that the process of letting go of shame and truly accepting themselves, and shifting the way they viewed themselves in relation to the abuse, were fundamental avenues that lead to their healing. Other research has revealed that gaining an understanding of power differentials, hierarchical relationships, and personal boundaries helped women to shift their perspective of selfblame to a more realistic and healthy view that the offender was responsible for the abuse, and not them (Flynn, 2008). By these reports, shifts in self-perception are seen as important aspects that allow for an experience of inner transformation and contribute significantly to

A further theoretical postulation of PTG comes from Tedeschi and Calhoun (2004) who have found that through the process of actively dealing with the experience of trauma, people often report growth and change in three major domains; in ones' sense of self, their relationships with others, and in their philosophy in life. People report feeling a greater sense of personal strength, self-reliance and competence through successfully negotiating the struggle to cope with their traumatic experience, a strengthening in their relationships with others and greater

others, and their environment on a day-to-day basis.

healing from CSA.

freedom of self-disclosure within personal relationships, a shift in their philosophy of life, such as greater appreciation of the 'little things', changed priorities, or changes in religious or existential beliefs (Calhoun & Tedeschi, 2006; Tedeschi & Calhoun, 1999). Calhoun and Tedeschi (2006) propose growth is both a process and an outcome, in that processes such as volition rumination, self-disclosure, and managing distress, lead to the three broad outcome domains. This is a sentiment echoed in existing theories of coping that assert the struggle to process negative events, through mechanisms such as meaning making, leads to growth outcomes of cognitive reappraisals of fundamental assumptions (Park & Folkman, 1997; Park, 2009). An example of this can be seen in Flynn's (2008) investigation of women sexually abused by members of their church clergy. Although PTG was not examined in this study, the qualitative reports reveal that the process of being believed and supported was influential in these women being able to shift their negative view of themselves to a more realistic and positive view. Further, the women in this study also reported that shifting their focus of spirituality from a hierarchical, patriarchal church structure to a more relational, spiritual connection, allowed for a deeper connection to self and inner transformation. Although the question of whether PTG is a process or an outcome is left to be answered, from a philosophical perspective, an outcome depends on only where you stand in time. There are others however, who suggest that the pathways *to* growth are not necessarily the same as the outcomes *of* growth, and that research would do well to explore further the pathways taken that result in positive post-trauma change (Janoff-Bulman, 2004; Woodward & Joseph, 2003).

Within these above-mentioned complimentary perspectives of human wellness and growth, the recurrent themes of three major processes are apparent. Antonovsky's SOC concept of manageability is echoed in Janoff-Bulman psychological preparedness and Tedeschi and Calhoun's strengthening of relationships with others, as each of these have components of being able to utilise resources, both intrapersonally and interpersonally, as that which assist in the facilitation of adaptive coping. Similarly, comprehensibility, strength through suffering, and changes in the way one views themselves all resonate with the notion that an increased knowledge and understanding of the self is important for positive change and growth. Finally, meaningfulness, existential re-evaluation, and changes in one's philosophy of life have at their core the assumption that changes in one's connection and commitment to one's life is an important determinant of growth, healing, and wellness after adversity. Reflected in these perspectives are themes such as connection, deepening of relationships, the use of knowledge as power, gratitude, and appreciation. By opening up to the whole story of the person, rather than merely focussing on negative outcomes from trauma and distress, a fuller picture of the human capacity to cope, survive, and thrive after adversity emerges.

The phenomenon of PTG has now been shown to occur after an array of traumatic events, from bereavement (Cadell, 2003) and motor vehicle accidents (Shakespeare-Finch & Armstrong, 2010), to acts of terrorism (Take et al., 2008). However, the external event in and of itself is not what 'creates' the conditions for PTG to occur, but instead, it is more the internal disruption the experience creates, the subjective experience of it, and, most importantly, the struggle engaged in to incorporate the event into life. This is demonstrated by the fact that not all witnesses or survivors of a potentially traumatic experience suffer long-term negative effects from their exposure. Indeed some people may perceive an experience to be traumatic whereas the same experience may not be perceived as traumatic by another. The majority of people exposed to any of the myriad of sudden, unexpected,

A Salutogenic Approach to Healing Following Child Sexual Assault 45

Another finding from PTG research is that is that growth as a result of dealing with CSA and distress from CSA appear to be independent of each other. Lev-Wiesel and colleagues (2004) explored both PTSD and PTG in women who were abused by either a family member or a stranger. Their findings revealed a high positive relationship between PTG and PTSD. Further, those who experienced abuse at the hand of a relative were both more likely to have high levels of PTSD and were also more likely to report positive change and growth. A similar relationship between distress and growth can also be seen in the sample of women studied by O'Dougherty and colleagues (2007), although benefits reported from the struggle to cope with abuse resonated across intrapersonal, relational, and existential domains, these perceived benefits were not associated with lower depressive symptoms. What these findings suggest is that the relationship between growth and distress is not yet clear. As has been previously stated, the likelihood of growth occurring out of a traumatic experience is dependent upon both the trauma being severe enough to cause disruption to one's internal world, as well as one's active engagement in rebuilding one's self after such an experience. The process of actually facing the impact CSA has had one one's life and actively engaging in healing from this experience is in itself a process of turning *towards* the pain and working through it. With that in mind, it does make intuitive sense that growth and distress would

An interesting finding from research into positive change and growth after CSA is the role of coping in healing. Qualitative research into processes that lead to positive change and growth reveal the adaptive nature of avoidant coping and how individuals often choose avoidant strategies as a way of managing overwhelming distress until the time comes when they have adequate resources to actively deal with their trauma (Phanichrat & Townshend, 2010). Expressions of avoidant coping strategies being 'best-friends' or 'life-savers' show that these ways of coping, for a time, can be highly adaptive and can allow one to function in their lives until such time that they are able to move from avoidance to active engagement (Phanichrat & Townshend, 2010). Although avoidant coping has been reported as being adaptive during a point in time in ones healing journey, staying with this way of coping is not facilitative of growth, and in fact has been shown to negatively correlate with growth (Shakespeare-Finch & De Dassel, 2009). What has been shown is that the absence of avoidant coping, and thereby implied the presence of acceptance of what has actually occurred, or successful coping, assists in the positive resolution of CSA (O'Dougherty et al., 2007). But there is perhaps an optimum time for this transition from avoidant coping to

Beyond coping, Bogar and Hulse-Killacky (2006) found some similar processes of resilient women who had experienced CSA and who were actively engaged in their lives, and who rated their lives as meaningful. What these women revealed is that the processes of moving on from their old self-constructs, active participation in their healing, and achieving a sense of closure to their CSA experiences, is what made the difference to their healing. Traditionally, treatments for CSA have focussed on reducing post-traumatic symptoms in order to facilitate change and psychological improvement (Chambless & Hollan, 1998; Foa et al., 1999). As the majority of adult CSA survivors who seek therapy have experienced PTSD at some point in their lives (Rodridues et al., 1998), the most advocated approach to the treatment of PTSD in sexual trauma survivors has been through the use of cognitivebehavioural therapy (CBT), with particular emphasis on exposure and desensitisation (Foa et al., 1999). Clinical practice however, often reveals that it is precisely this focus on the

occur at the same time.

happen, which is likely to be highly individualised.

negative events that could be construed as a traumatic experience tend to show initial, shortlived posttraumatic symptoms (a normal response to such an experience) however, most people will not develop PTSD (Bonanno, 2004). Although this holds for the broader scope of traumatic events, sexual trauma is significantly different. Not only are those who experience CSA at a significantly high risk of developing PTSD at some stage than survivors of other sorts of trauma, they are also more likely to endure lifetime PTSD symptoms (Rodridues et al., 1998). Another difference found when contrasting CSA survivors with other trauma populations is the trend for them to show less growth as a group compared to those who have survived serious motor vehicle accidents or sudden bereavement (Shakespeare-Finch & Armstrong, 2010). These differences could be due to the fact that CSA is often a prolonged, intentional trauma, most commonly perpetrated by a loved and trusted abuser, rather than single incident trauma, such as a car accident. Recently it has been suggested that the domains of PTG may have different values to different trauma populations, and to this end it would be wise to explore different types of trauma separately (Shakespeare-Finch & de Dassel, 2009), or with very large and tightly defined groups permitting in-depth analysis of the dimensions of growth in relation to other variables, including depression, anxiety, and PTSD.

#### **3.2 Growth, healing, and wellness after CSA**

Currently the research exploring wellness and PTG processes and outcomes on the single population of adult survivors of CSA is still emerging and is relatively scarce (Lev-Wiesel et al., 2004; Shakespeare-Finch & de Dassel, 2009; Woodward & Joseph, 2003). What research has uncovered at this point in time however, is that growth and healing after sexual abuse in childhood is possible, that the relationship between growth and distress is currently unclear, and that the traditional ways of working therapeutically with CSA survivors may not be as facilitative of growth and change as other modalities.

Contrary to historical views of outcomes of CSA, research has shown that positive change and growth can and does occur in many individuals. O'Dougherty and colleagues (2007) explored the ways in which 60 women with children found ways of positively resolving their CSA histories. In this sample almost half of the women conveyed that they perceived they had gained great benefit as a result of working through their trauma, whereas only 7% felt nothing positive had come from their experience of CSA. Resonating with PTG theory, the women who felt they had gained something reported positive changes in areas of personal strength and knowledge, changes in their relations with others, including a positive influence in the way they parented their children, and changes in their spiritual or religious domains. Where women situated themselves on their healing journey was important in relation to the amount of growth felt, as those who reported greater meaning as a result of their struggle were also more likely to report their abuse as mostly resolved. Similarly, in a study investigating turning points in men and women's lives who had experienced CSA, Woodward and Joseph (2003) also found people reported positive changes in the way they saw themselves, in their relationships with others, and in their philosophy of life. Further, their findings revealed that it was more the process of gaining a sense of mastery and control over one's life, be that by taking the offender to court, developing a kinder intrapersonal connection, or investing in nurturing relationship with others, that was seen as an important factor for health and recovery in these individuals.

negative events that could be construed as a traumatic experience tend to show initial, shortlived posttraumatic symptoms (a normal response to such an experience) however, most people will not develop PTSD (Bonanno, 2004). Although this holds for the broader scope of traumatic events, sexual trauma is significantly different. Not only are those who experience CSA at a significantly high risk of developing PTSD at some stage than survivors of other sorts of trauma, they are also more likely to endure lifetime PTSD symptoms (Rodridues et al., 1998). Another difference found when contrasting CSA survivors with other trauma populations is the trend for them to show less growth as a group compared to those who have survived serious motor vehicle accidents or sudden bereavement (Shakespeare-Finch & Armstrong, 2010). These differences could be due to the fact that CSA is often a prolonged, intentional trauma, most commonly perpetrated by a loved and trusted abuser, rather than single incident trauma, such as a car accident. Recently it has been suggested that the domains of PTG may have different values to different trauma populations, and to this end it would be wise to explore different types of trauma separately (Shakespeare-Finch & de Dassel, 2009), or with very large and tightly defined groups permitting in-depth analysis of the dimensions of growth in relation to other variables, including depression,

Currently the research exploring wellness and PTG processes and outcomes on the single population of adult survivors of CSA is still emerging and is relatively scarce (Lev-Wiesel et al., 2004; Shakespeare-Finch & de Dassel, 2009; Woodward & Joseph, 2003). What research has uncovered at this point in time however, is that growth and healing after sexual abuse in childhood is possible, that the relationship between growth and distress is currently unclear, and that the traditional ways of working therapeutically with CSA survivors may not be as

Contrary to historical views of outcomes of CSA, research has shown that positive change and growth can and does occur in many individuals. O'Dougherty and colleagues (2007) explored the ways in which 60 women with children found ways of positively resolving their CSA histories. In this sample almost half of the women conveyed that they perceived they had gained great benefit as a result of working through their trauma, whereas only 7% felt nothing positive had come from their experience of CSA. Resonating with PTG theory, the women who felt they had gained something reported positive changes in areas of personal strength and knowledge, changes in their relations with others, including a positive influence in the way they parented their children, and changes in their spiritual or religious domains. Where women situated themselves on their healing journey was important in relation to the amount of growth felt, as those who reported greater meaning as a result of their struggle were also more likely to report their abuse as mostly resolved. Similarly, in a study investigating turning points in men and women's lives who had experienced CSA, Woodward and Joseph (2003) also found people reported positive changes in the way they saw themselves, in their relationships with others, and in their philosophy of life. Further, their findings revealed that it was more the process of gaining a sense of mastery and control over one's life, be that by taking the offender to court, developing a kinder intrapersonal connection, or investing in nurturing relationship with others, that was seen as an important factor for health and recovery in these individuals.

anxiety, and PTSD.

**3.2 Growth, healing, and wellness after CSA** 

facilitative of growth and change as other modalities.

Another finding from PTG research is that is that growth as a result of dealing with CSA and distress from CSA appear to be independent of each other. Lev-Wiesel and colleagues (2004) explored both PTSD and PTG in women who were abused by either a family member or a stranger. Their findings revealed a high positive relationship between PTG and PTSD. Further, those who experienced abuse at the hand of a relative were both more likely to have high levels of PTSD and were also more likely to report positive change and growth. A similar relationship between distress and growth can also be seen in the sample of women studied by O'Dougherty and colleagues (2007), although benefits reported from the struggle to cope with abuse resonated across intrapersonal, relational, and existential domains, these perceived benefits were not associated with lower depressive symptoms. What these findings suggest is that the relationship between growth and distress is not yet clear. As has been previously stated, the likelihood of growth occurring out of a traumatic experience is dependent upon both the trauma being severe enough to cause disruption to one's internal world, as well as one's active engagement in rebuilding one's self after such an experience. The process of actually facing the impact CSA has had one one's life and actively engaging in healing from this experience is in itself a process of turning *towards* the pain and working through it. With that in mind, it does make intuitive sense that growth and distress would occur at the same time.

An interesting finding from research into positive change and growth after CSA is the role of coping in healing. Qualitative research into processes that lead to positive change and growth reveal the adaptive nature of avoidant coping and how individuals often choose avoidant strategies as a way of managing overwhelming distress until the time comes when they have adequate resources to actively deal with their trauma (Phanichrat & Townshend, 2010). Expressions of avoidant coping strategies being 'best-friends' or 'life-savers' show that these ways of coping, for a time, can be highly adaptive and can allow one to function in their lives until such time that they are able to move from avoidance to active engagement (Phanichrat & Townshend, 2010). Although avoidant coping has been reported as being adaptive during a point in time in ones healing journey, staying with this way of coping is not facilitative of growth, and in fact has been shown to negatively correlate with growth (Shakespeare-Finch & De Dassel, 2009). What has been shown is that the absence of avoidant coping, and thereby implied the presence of acceptance of what has actually occurred, or successful coping, assists in the positive resolution of CSA (O'Dougherty et al., 2007). But there is perhaps an optimum time for this transition from avoidant coping to happen, which is likely to be highly individualised.

Beyond coping, Bogar and Hulse-Killacky (2006) found some similar processes of resilient women who had experienced CSA and who were actively engaged in their lives, and who rated their lives as meaningful. What these women revealed is that the processes of moving on from their old self-constructs, active participation in their healing, and achieving a sense of closure to their CSA experiences, is what made the difference to their healing. Traditionally, treatments for CSA have focussed on reducing post-traumatic symptoms in order to facilitate change and psychological improvement (Chambless & Hollan, 1998; Foa et al., 1999). As the majority of adult CSA survivors who seek therapy have experienced PTSD at some point in their lives (Rodridues et al., 1998), the most advocated approach to the treatment of PTSD in sexual trauma survivors has been through the use of cognitivebehavioural therapy (CBT), with particular emphasis on exposure and desensitisation (Foa et al., 1999). Clinical practice however, often reveals that it is precisely this focus on the

A Salutogenic Approach to Healing Following Child Sexual Assault 47

reacted to it (the abuse) too, it has a bearing on that. The first reaction (from my mother) was "No, it didn't happen", and she has said "well this is just the things that kids do". And whether it is just in my mind thinking that "your mum doesn't love you", I have learnt that

"The first time in my adult life that I ever had talked face to face with (the offender) he said, "It was nothing", and I said "It's not like nothing happened". That was the first time that I had acknowledged it in his company. And then, because I was having flashbacks and not sleeping after that phone call, I then rang the SA (sexual assault) unit and started the first real counselling that I had". Prior to this phone call, Kate had brief discussions with her husband about her abuse, but would minimise the impact it had on her, saying: "It wasn't much; I was one of the lucky ones. I think I allayed his (her husband) anxieties by saying I was one of the lucky ones, I am fine". After verbally acknowledging the abuse to her offender, this brought to the surface all the latent emotions that were still within her and

After a process of active engagement in her healing, these are some of the pathways Kate identified in her eventual resolution of the past and her new appreciation of herself and her

"There were times (after the disclosure) when I was feeling very vulnerable with two young children and all this going on and lots to carry once it had blown up, and I stood on my own. And it was all good, for me to prove that once I am in the firing line I was able to trust my own judgement, and that helped me get through too. Circumstances transpired that put me in situations to enable me to have a chance to prove to myself that I can cope". This quote indicates the perception of manageability and also of psychological preparedness for future life experiences that may threaten her sense of self, and being able to trust that she

When describing the turning points for her that were gained through a therapeutic process, Kate said: "Something in counselling that has really helped is that I am only responsible for myself, but I AM responsible for my stuff. That was very powerful, and it helped me release old feelings of responsibility for others and for the abuse. Overcoming the mind talk, that has been a wonderful gift. Just being able to know that I am not my mind, I am not my collection of thoughts, I am so much more. I have come a long way; I was so in my head and could not get out – knowing now that I am not my collection of thoughts. I read a lot about CSA and perpetrators and got all this knowledge. I think the knowledge helped too, once I saw that it wasn't just me and I read it is NEVER YOUR FAULT - that was a turning point, once I stopped blaming myself it was a real unblocking. Also, moving from the 'victim mode' (was important). I think the victim phase served me, it helped, because if I never felt like that I would not have been able to release all the stagnant energy and toxicity in me. I had to feel it to heal it, but I didn't know that yet. And victim is not a good place to be so I wasn't going to stay there". In this quote, Kate reveals her new-found capacity for comprehensibility of her experiences. She also demonstrates that she has found a new sense of personal strength through her suffering. This quote also highlights the importance of connecting to the pain of being a victim, and how it is described as a necessary place to be,

this has a BIG impact; it has had one on me".

started Kate on her path to healing.

life.

**Growth as a process** 

could cope.

**Acknowledgement of abuse started the healing process** 

constant revisiting of the trauma that causes people to terminate CBT interventions early, often with reports that range from dissatisfaction in the therapeutic process by not exploring the core issues relating to their inner experience, through to feeling more traumatised than before therapy due to the constant revisiting of the abusive acts via the process of desensitisation. Far from needing to talk about the specifics of their abuse and to de-sensitise to their traumatic memories, the well-functioning women in Bogar and Hulse-Killacky's (2006) study reveal that actively connecting to the impact the experience of CSA had on their lives and on their sense of self, and changing the way in which they viewed themselves, was the most important determinant of wellness and being able to move on.
