Disrupted Relationships And Couple Therapy: Treating Female Survivors Of Child Sexual Abuse And Their Partners
By Jill M. Serafin
NCP Clinical Quarterly 6(2): Spring 1996
As with other traumatic life experiences, child sexual abuse (CSA) has been associated with many serious diruptions in individual and interpersonal functioning. The long-term intrapersonal correlates of CSA have been well-documented, and include an increased risk of negative internal experiences such as depression, anxiety, intrusive memories, rage, and shame (1-2). Many survivors also report self-harming behavior patterns which may have emotional avoidance or tension reducing function (3-4). For example, binge eating, substance abuse, suicide attempts, and self-mutilation occur at higher rates among survivor populations (5-6). While the constellations of symptoms reported by CSA survivors differ widely between individuals, the pattern of psychological difficulties experienced often resembles that of populations diagnosed with posttraumatic stress disorder (PTSD; 7-9).
Although systematic research investigating the interpersonal sequelae of CSA has been limited, there is substantial evidence to suggest that CSA is often associated with disturbances in a variety of adult relationships, including those with partners, children, family, and friends (3,10-11). Many women who have a history of CSA describe their couple relationships as dissatisfying and turbulent (12). Survivors tend to experience more fear and distrust of others (13), and often have problems with assertiveness and effective communication (14-15). Several studies indicate that survivors experience a range of sexual problems, including decreased sexual satisfaction and desire, increased sexual dysfunction, and a tendency to engage in multiple, short-term sexual relationships (16-17). Moreover, women who have a history of CSA appear to be more vulnerable to physical and sexual revictimization in their adult relationships when compared to nonabused women (18-19).
Although this area is only beginning to be investigated with scientific rigor, recent attention has focused on understanding the difficulties that survivors experience in their adult relationships (20-23). Findings from several areas of research have converged to suggest that survivor couple relationships play a central role in successful treatments with this population. For instance, CSA occurs in an interpersonal context often characterized by both emotional and sexual intimacy, a combination which closely resembles traditional expectations for adult couple relationships. Consequently, it is not uncommon for survivors to experience intense ambivalence about forming close, trusting relationships in adulthood, or to have skills deficits which make it difficult for them to sustain intimate and fulfilling relationships (3). In fact, survivor couples may experience decreased emotional expressiveness within their relationships, and report more difficulties with emotional communication and feeling connected to each other (23).
Many strategies commonly used by female survivors to cope with the extraordinary conditions of CSA become obsolete and potentially problematic in adulthood (22). An extremely cautious or ambivalent approach to interpersonal vulnerability during childhood for example, may serve a protective function for survivors. However, a similar approach during more developmentally mature stages of life may exacerbate both individual and interpersonal difficulties. There is evidence to suggest that couples who display low levels of emotional engagement also tend to experience less long-term relationship satisfaction and are less responsive to couple interventions (24-25). Moreover, female survivors, like women in general who do not have satisfying primary relationships, are at risk for further psychological and physical health problems (26). The importance of addressing couple relationships during treatment is underscored by findings which indicate that the level of closeness experienced during couple relationships is a significant factor for predicting both individual well-being (27) and long-term relationship satisfaction (28).
Clearly, survivors of CSA experience a wide range of individual difficulties which may interfere with their ability to function in couple relationships. While this is a new area of inquiry with survivors, individual psychopathology and couple distress have been found to have a reciprocal relationship in a variety of populations. Couples who have a partner diagnosed with mental health problems, are also at higher risk for other difficulties, including: 1) relationship distress (29); 2) report of psychological troubles on the part of the "asymptomatic" partner (30); and 3) mutual avoidance of relationship issues, due to focusing on the identified patient’s personal difficulties rather than on shared interaction patterns (31). Just as the survivor’s level of psychological functioning has a considerable impact on the health and satisfaction of their significant others, the behavior of significant others in the survivors environment may play a key role in either mitigating or exacerbating the impact of past traumatic experiences (9).
Group therapy has often been indicated as the preferred mode of treatment for CSA survivors, precisely because of its concurrent emphasis on individual and interpersonal issues (32-33). However, there is some evidence to suggest that group therapy may not be advised for all CSA survivors. One treatment outcome study, for example, found that married survivors may not benefit as much from group therapy as do single participants (34). On the other hand, individual treatment strategies may have iatrogenic effects on the participant’s relationships with significant others in general (35). Progress made during individual interventions may not generalize to the intimate relationships between survivors and their partners (20). Given this information, experts in the field recommend that couple therapy approaches be used when relationship issues are of primary concern (20, 36).
Initiating Treatment
The long-term consequences of CSA impact a significant percentage of individuals seeking therapy, with prevalence estimates consistently ranging from 15% to 33% in general female populations (37) and averaging about 50% in female clinical samples (38). While relationship difficulties are one of the most frequently reported complaints for survivors who seek psychological services (13), this population presents for treatment in a variety of ways. It is not uncommon, for instance, for female survivors to request individual or group treatment despite their intention to address relationship difficulties. Although interpersonal goals may be more apparent when survivors’ begin therapy with their partners, a routine and thorough assessment should be completed at the onset of therapy in all cases to identify which treatment modalities best suit the current needs of the survivor and/or couple.
There are several reasons that female survivors commonly choose to explore their relationship issues in an individual therapy context. First, many survivors were raised in father-dominated family systems (39), and subsequently enter into couple relationships characterized by traditional gender roles. While many spouses are willing to tolerate their partner seeking help, survivors often report that their partners refuse to participate in therapy themselves. In these cases, it is important to ascertain whether relationship issues will be the primary focus of treatment, or merely among several potential areas to be addressed. In the event that relationship improvements are the survivor’s primary goal, it is appropriate to inform the client that progress made in individual therapy may not generalize to their couple relationship.
Other survivors present for individual rather than couple therapy because they have not yet disclosed their abuse histories to their partners. While this type of secret may severely impact levels of intimacy in the relationship, survivors should seriously explore their individual expectations and hesitancies related to disclosing this information prior to making the choice to disclose (20). Furthermore, in this situation it is crucial to provide partners with educational materials about CSA and the impact this trauma may have on significant other relationships. In other cases, female survivors pursue individual treatment prior to presenting with their partners, or hope to alternate between individual and couple sessions. Many survivors report a need for an appropriate forum to sort out unpleasant and vivid details of their abuse histories which their partners may find overwhelming. Although some clinicians report success alternating between roles as an individual and a couple therapist (36), when intensive couple work is indicated it may be more appropriate to refer the couple to another therapist (22). Finally, survivors may present for individual therapy to address relationship difficulties so severe that it may not be advisable to include their partner. It is not uncommon for survivors to be involved in relationships characterized by physical, sexual, or emotional abuse, and these areas should be routinely assessed. Many women who have experienced a history of CSA have also learned to associate their intimate relationships with being dominated or even tortured. This learning history, in combination with the intense feelings of inadequacy often experienced by survivors, often leads this population to value relationships which would be described as intolerable by traditional standards.
Treatment Strategies
Behavioral couple therapy (BCT) is one treatment approach which may be useful for work with survivor couples, since it is both flexible and egalitarian (20). Although BCT is considered among the best available treatments for relationship problems, many couples do not experience significant changes in relationship satisfaction following completion of treatment (40, 25). Among the explanations for BCT's limitations are that this approach has been used without variation to treat many different populations, and it has focused almost entirely on current relationship functioning rather while ignoring individual and historical factors (41-42). Furthermore, while BCT’s emphasis has traditionally focused on changing client behaviors to alleviate relationship problems, such change strategies have proven to be difficult (43). As a reflection of current developments in behavioral theory, BCT has recently been updated to include a focus on issues of emotional acceptance (43). Contemporary BCT, or Integrative Couple Therapy, emphasizes the process of accepting both private events (e.g., our own thoughts and feelings), and the personal experience of relationship partners (43). Thus, behaviorally oriented approaches to couple therapy with survivor populations should include a combination of basic communication and problem-solving skills, an emphasis on acceptance and change strategies, and the flexibility to focus on both historical factors and current relationship problems.
While many survivors seek conjoint couple therapy with their partners, partners often view their role in therapy as merely facilitating individual growth on the part of the survivor. Although often well-meaning, partners who view the survivor as the identified patient in couple therapy, may also attribute primary responsibility for relationship difficulties to the survivor or their history of abuse (20). This pattern of "benevolent blame" may perpetuate feelings of shame and stigmatization already experienced by many survivors of CSA, and the issue of mutual responsibility should be addressed directly in therapy. Alternating the emphasis of treatment from one partner to the other and from historical issues to current relationship problems, may facilitate increasingly collaborative interactions among couples (21). Moreover, this strategy may assist the therapist by ensuring a position of neutrality during couple therapy.
Issues of intimacy and closeness are frequently identified as primary problems by survivors of CSA. Not surprisingly, many survivors report seeking out partners who are not likely to demand uncomfortable levels of intimacy in their relationships. However, over time, many couples report conflict between partners over the level of closeness desired in their primary relationships, and this discrepancy is often a presenting complaint for couple therapy (44). As issues around vulnerability and intimacy arise in treatment, it is important to acknowledge that many survivors experience apprehension about trusting both the therapist and the therapy process. It takes time to create an environment safe enough to successfully address these core difficulties. A careful functional analysis of the interaction patterns between partners will provide useful information about the context in which couples feel more and less intimate with each other. Videotaped couple interactions may also be useful tool for helping clients to understand their struggles around closeness in their relationships (45).
There is tremendous support for the common sense notion that CSA has a significant and aversive impact on later sexual adjustment (46). Many female survivors experience uncomfortable reminders of the abuse during sexual activity, including intrusive thoughts, memories, or flashbacks (17). Furthermore, it is not uncommon for CSA survivors to attempt to minimize these experiences by avoiding sexual activity directly, engaging in compulsive sexual behavior, or by dissociating during stressful sexual encounters. Survivor couples are more likely to experience sexual dysfunctions, including low sexual desire, inorgasmia, and impotence (17, 47), and often describe their sexual relationships as unfulfilling. Extensive assessment of sexual functioning should be standard practice with CSA clients. It is particularly important to focus on identifying the stimuli which might trigger unwanted flashbacks, and to systematically facilitate open communication about sexual issues.
In conclusion, clinical and empirical evidence suggest that CSA may be associated with a variety of long-term interpersonal difficulties. While survivors may experience problems across social roles, there are many reasons to believe that the most profound disruptions will be observed in survivor couple relationships. While many survivor couples experience relationship difficulties, there is no support for the notion that a particular syndrome characterizes this population. Careful and thorough assessment strategies are needed to understand the specific relationship issues experienced by any particular couple with an abuse history. While it is essential to maintain a balance between historical and current issues, an emphasis should be placed on facilitating change in a direction consistent with the goals outlined by each couple. Finally, although it is important to obtain a clear understanding of relationship problem areas, it is equally important to understand the strengths and coping strategies characteristic of couples who are challenged by the ongoing difficulties associated with CSA trauma.
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Jill M. Serafin is an advanced graduate student at the University of Nevada, Reno, working with Victoria Follette, Ph.D. in the Clinical Psychology Doctoral Program. She currently divides her time equally between direct service delivery and several research projects, including her dissertation entitled "Early Trauma, Psychopathology, and Couple Functioning."
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