Adult Child Sexual Abuse Survivors

Contributors:
Rachel M. Hoffman, Meridian Community Care and Chelsey Zoldan, Youngstown State University

Sexual assault of children can include fondling, masturbation, intercourse, oral or anal sex, prostitution, pornography, and any other sexual conduct that is harmful to a child’s mental, emotional, or physical welfare Incest is considered a subtype of childhood sexual abuse

Resource:
United States Department of Veteran’s Affairs

Prevalence
Prevalence estimates of childhood sexual assault are difficult to estimate, as many of these crimes may go unreported. According to the U.S. Department of Health and Human Services’ Children’s Bureau report Child Maltreatment 2011, they estimated that about 9% of victimized children were sexually assaulted. Additionally, it is estimated that approximately 20% of females and 5%-10% of males reported a childhood sexual abuse or victimization incident (Finkelhor, 2008).

Resource:
U.S. Department of Health and Human Services’ Children’s Bureau Report on Child Maltreatment 2011

Identification Assessment Strategies

When working with people who have been sexually abused, it is important to identify the impacts the abuse experiences have had on the their psychological and behavioral functioning. Assessment instruments can be helpful in identifying these impacts, and in suggesting a course of treatment which best addresses the identified problems.

Trauma Symptom Inventory (TSI; Briere, 1995)
The Trauma Symptom Inventory (TSI; Briere, 1995) is a 100-item self-report measure developed for use in adults to assess a wide range of trauma-related symptoms. The TSI is composed of 10 clinical scales and 3 validity scales. Five clinical scales (i.e., Anxious Arousal, Depression, Anger/Irritability, Intrusive Experiences, and Defensive Avoidance) measure symptoms associated with the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) diagnosis of posttraumatic stress disorder (PTSD; American Psychiatric Association, 2000). The other five clinical scales (i.e., Dissociation, Sexual Concerns, Dysfunctional Sexual Behavior, Impaired Self-Reference, and Tension-Reduction Behavior) measure additional symptoms often seen in trauma survivors, especially survivors of childhood trauma.

The TSI is designed to be administered by counselors who hold a minimum of a master’s degree. It is appropriate for use in adults between the ages of 18-88 years old. Administration typically takes approximately 20 minutes. The TSI is available for purchase from Psychological Assessment Resources (PAR).

Resource: Review of the TSI measure:
Briere, J. (1995). Trauma Symptom Inventory professional manual. Odessa, FL: Psychological Assessment Resources.

Posttraumatic Diagnostic Scale (PDS; Foa, Cashman, Jaycox, & Perry, 1997)
The PDS is a 49-item self-report measure which measures the severity of PTSD symptoms related to a single identified traumatic event. The PDS assesses all of the DSM-IV criteria for PTSD (i.e., Criteria A–F) and inquires about symptoms during the past month. The PDS will reflect the severity and the frequency for which the respondent is experiencing the 17 symptoms of PTSD. It is appropriate for use in adults between the ages of 18-65 years old. Administration takes about 15 minutes.

Resource: Review of PDS
Foa, E. B., Cashman, L., Jaycox, L., & Perry, K. (1997). The validation of a self-report measure of posttraumatic stress disorder: The Posttraumatic Diagnostic Scale. Psychological Assessment, 9, 445-451.

Intervention Strategies

“There is little question that trauma symptomatology is prevalent in adult survivors of childhood sexual abuse and that treatment needs to address these symptoms” (Classen, Koopman, Nevill-Manning, & Spiegel, 2001, p. 267). Despite the importance of effective interventions for use with adult child sexual abuse (CSA) victims, the challenges involved in treating survivors of CSA are multifaceted (Gold, 1997). Effective training is essential for counselors to be prepared to meet the needs of clients who were sexually abused in childhood (Gold, 1997). A meta-analysis of therapeutic approaches for adult survivors demonstrated that abuse-focused psychotherapy (i.e., a counseling approach that addresses the past abuse) is generally beneficial for adult survivors of CSA (Martsolf & Draucker, 2005)

A meta-analysis of interventions for CSA survivors did not demonstrate any one therapeutic approach (e.g., cognitive-behavioral, EDMR, eclectic) to be superior in the treatment of the issues adult CSA survivors experience (Martsolf & Draucker, 2005). Effective treatment of adult survivors included the following therapeutic dynamics: a) creating a therapeutic climate which increases the likelihood of a CSA disclosure (Mennen & Pearlmutter, 1993), and responding to disclosures appropriately; b) recognizing the indicators that could suggest a history of CSA and proceeding appropriately (Mennen, 1992); c) determining a focus on past trauma or present symptoms to ensure that treatment is suitable for clients who have had a history of CSA (Mennen & Pearlmutter, 1993; Spiegel, Classen, Thurston, & Butler, 2004); and d) utilizing an effective treatment modality for adult survivors (Busby, Glenn, Steggell, & Adamson, 1993). Although numerous modalities (e.g., CBT, DBT, Narrative therapies) may be helpful in the treatment of adult survivors of CSA, perhaps one of the most important dynamics is creating a therapeutic environment which will facilitate disclosure and thus effective resolution of CSA-related issues.

Resources:
Overview of counseling adult survivors of childhood sexual abuse. 
Sanderson, C. (2006). Counseling adult survivors of child sexual abuse. Philadelphia, PA: Jessica Kingsley Publishers.

U.S. Department of Health and Human Services (USDHHS), Substance Abuse and Mental Health Services Administration (SAMHSA), National Registry of Evidence-Based Programs and Practices (a search on sexual abuse provides information on treatment programs which address sexual abuse) 

Cognitive Behavioral Therapies (CBT)
The majority of empirically-supported interventions for adult survivors fall under the theoretical realm of cognitive behavioral therapy (Gore-Felton, Gill, Koopman, & Spiegel, 1999). While there are many different types of cognitive behavioral therapy approaches, a commonality of these therapies is the emphasis on helping clients change their cognitions and meanings related to the sexual abuse and assisting clients in identifying adaptive behaviors. McDonagh et al. (2005) noted that CBT was effective in decreasing the PTSD-related symptomology in adult female survivors of CSA. Other researchers (e.g., Putman, 2003) have suggested that CBT may be effective in the treatment of trauma symptoms in survivors of CSA.

Resource: Overview of Cognitive Behavioral Approaches 

Two types of CBT approaches include Anxiety Management Therapy (AMT) and Cognitive Restructuring. Anxiety management therapy (AMT) can be helpful for CSA survivors who are exhibiting symptoms consistent with PTSD (Foa & Rothbaum, 1998). Stress inoculation training (SIT; Meichenbaum, 1974), the most researched form of AMT, offers clients the opportunity to manage anxiety symptoms using a variety of cognitive and behavioral coping skills. Examples of coping skills that may help reduce anxiety are: covert modeling, positive thinking and self-talk, assertiveness training, guided imagery, and thought-stopping (Hensley, 2002).

Cognitive restructuring assists the client to name the assault, correct distortions that perpetuate self- blame, and find meaning in the experience (Burkhart & Fromuth, 1996). Cognitive restructuring is used to challenge client’s faulty beliefs as they arise in sessions. When these beliefs arise, the counselor can help the client replace the self-defeating and self-blaming beliefs with more logical self-statements that reflect the client’s strengths and sense of power (Kubany, 1998). For example, a counselor may help the client confront and dispute the faulty belief that she somehow caused the abuse to happen.

Mindfulness-Based Approaches
Mindfulness-based approaches (e.g., Acceptance and Commitment Therapy [ACT] Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Dialectical Behavioral Therapy [DBT] Linehan, 2000; Mindfulness-Based Stress Reduction [MBSR] Kabat-Zinn, 1982) may be effective in the treatment of adult CSA survivors. Although research on these approaches is still in its infancy, there have been several studies which have shown mind- fulness-based approaches as promising interventions for adult survivors of CSA. Kimbrough, Magyari, Langenberg, Chesney, and Berman (2010) found that an 8-week MSBR program decreased self-reported depressive and PTSD symptoms in adult survivors of CSA. Similarly, Steil, Dyer, Priebe, Kleindienst and Bohus (2011) found that DBT was helpful in reducing PTSD symptomology in adult survivors of CSA.

Resources:
Overview of DBT 
Overview of ACT 

Narrative Approaches
Counselors who work with adult survivors of CSA are tasked with finding a way to move the client from victim to survivor (Bogar & Hulse-Killacky, 2006; Kress & Hoffman, 2008). Narrative approaches to treatment (e.g., externalization of the abuse, letter writing) may be helpful in empowering the survivor to externalize the abuse event (Kress, Hoffman, & Thomas, 2008). It is important to note that language can be powerful element of effective treatment. In fact, adult CSA survivors have noted the importance of moving beyond the labels associated with the experience of CSA. Philips and Daniluk (2004) identified that letting go of the victim identity and embracing the survivor identity is a very powerful experience for women in treatment; however, eventually, clients note that letting go of the survivor label becomes an important goal as counseling proceeds.

Resources: Narrative approaches to working with survivors of CSA
Bogar, C. B., & Hulse-Killacky, D. (2006). Resiliency determinants and resiliency processes among female adult survivors of childhood sexual abuse. Journal of Counseling & Development, 84, 318-327. 

Kress, V. E., Hoffman, R. M., & Thomas, A. M. (2008). Letters from the future: The use of therapeutic letter writing in counseling sexual abuse survivors. Journal of Creativity in Mental Health, 3, 105-118.

Kress, V. E., & Hoffman, R. M. (2008). A strength-based, solution-focused Ericksonian counseling group for sexually abused adolescents. Journal of Humanistic Counseling, Education, and Development, 47, 172 – 186.

Couples Counseling
Couples counseling may be another treatment option to help resolve present relational difficulties result- ing from CSA. Problems associated with CSA may have implications for adult intimate relationships and counselors should recognize the connection of present behavior with past CSA (Cobia, Sobansky, & In- gram, 2004). Cobia et al. (2004) described the following relationship difficulties that can occur as a result of past CSA: a) coercion with expressing love and acceptance, b) sexual difficulties, c) forming trusting relationships, and d) strained relational attachments. The goal of couples counseling is to work on these issues within the relational dyad.

Resources: Couples Counseling with CSA Survivors 
Cobia, D. C., Sobansky, R. R., & Ingram, M. (2004). Female survivors of childhood sexual abuse: Implications for couples’ therapists. The Family Journal: Counseling and Therapy for Couples and Families, 12, 312-318.

Special Populations
Women. Childhood sexual trauma is associated with problematic behaviors in adult females including the following: pervasive mental health issues (Noll, 2008), sexual promiscuity (Niehaus, Jackson, & Da- vies,2010), self-injury, eating disorders, dissociation, and antisocial behavior (Wise, Florio, Benz, & Geier, 2007). Counseling is useful in altering women’s perceptions of self from contaminated and self-blaming, shame-based, and invisibility to a positive, integrated, visible identity (Phillips & Daniluk, 2004).

Resources: Working with women who are survivors of CSA.
Philips, A., & Daniluk, J.C. (2004). Beyond “survivor”: How childhood sexual abuse informs the identity of adult women at the end of the therapeutic process. Journal of Counseling & Development, 84, 177-184.

Men. Until recently, male survivors of child sexual abuse have not been adequately represented in the re- search literature. However, recent researchers have discussed the importance of understanding the unique treatment needs of male survivors of CSA. Hovey, Stalker, Schachter, Teram, and Lasiuk (2011) pointed out  various considerations for male survivors, including the following: a) issues with seeing a counselor who is of the same gender of the perpetrator, b) experience of triggers during medical procedures which may result in untreated physical health concerns, and c) fear of making the initial disclosure of the abuse.

Resources: Considerations for working with male CSA survivors
Hovey, A., Stalker, C. A., Schachter, C. L., Teram, E., & Lasiuk, G. (2011). Practical ways psychotherapy can support physical healthcare experiences of male survivors of childhood sexual abuse. Journal of Child Sexual Abuse, 20, 37-57.

Revictimized clients. Childhood sexual abuse (CSA) is a factor associated with greater risk for adult sexual assault (Arata, 2002; Messman-Moore & Long, 2000, 2002; Noll, Horowitz, Bonanno,Trickett, & Putnam, 2003; Roodman & Clum, 2001), with estimates suggesting that CSA survivors are two to three times more likely to be sexually assaulted in adolescence and adulthood than the general population (e.g., Arata, 2002; Cloitre, Tardiff, Marduk, & Leon, 1996). Researchers (e.g.,Walsh, Blaustein, Knight, Spinazzola, & van der Kolk, 2007) have suggested that an internal locus of control and effective coping strategies may serve as a protective factor against sexual revictimization in adulthood. Thus, it is important for counselors to address these variables during the treatment process. Hodges and Myers (2010) proposed a wellness-based model for working with adult survivors that may increase self-efficacy, resiliency, and awareness of healthy coping skills.

Resource: Wellness-based approach to Adult Survivors of CSA
Hodges, E. A., & Myers, J. E. (2010). Counseling adult women survivors of childhood sexual abuse: Bene- fits of a wellness approach. Journal of Mental Health Counseling, 32, 139-154.

REFERENCES

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Busby, D. M., Glenn, E., Steggell, G. L., & Adamson, D. W. (1993). Treatment issues for survivors of physi- cal and sexual abuse. Journal of Marital and Family Therapy, 19, 377-391

Classen, C., Koopman, C., Nevill-Manning, K., & Spiegel, D. (2001). A preliminary report comparing trauma-focused and present-focused group therapy against a wait-listed condition among child- hood sexual abuse survivors with PTSD. Journal of Aggression, Maltreatment & Trauma, 4, 265-288.

Cloitre, M., Tardiff, K., Marduk, P. M., & Leon, A. C. (1996). Childhood abuse and subsequent sexual assault among female inpatients. Journal of Traumatic Stress, 9, 473-482.

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Gold, S. N. (1997). Training professional psychologists to treat survivors of childhood sexual abuse. Psychotherapy, 34, 365-374.

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Published: February 2024
Updated: August 2016