Psychology
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trumaprocessing.pdf
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Trauma Processing Reconsidered: Using Account-Making in Quantitative
Research With Male Survivors of Child Sexual Abuse
SCOTT D. EASTON Graduate School of Social Work, Boston College, Chestnut Hill,
Massachusetts, USA
Account-making is a sociopsychological model that describes the recovery process after a traumatic event. This study examined the theory’s utility in quantitative research using data from a large sample of men with histories of child sexual abuse ( N = 487). The three aims of the study were (a) to describe how account-making concepts can be operationalized, (b) to explore the relationship between account-making and mental health, and (c) to suggest revisions to the theoretical structure of the model. Results suggest that account-making is a useful framework for research with trauma survivors and may be related to mental health. Suggestions for future research are provided.
KEYWORDS trauma processing, account-making, accounts, child sexual abuse, male survivors
The study of how survivors process loss and trauma is a difficult task due, in part, to the broad range of traumatic events. A recent volume of this journal, for example, included articles that focused on stressors as diverse as
Received 22 March 2012; accepted 26 April 2012. This study received financial support from the John A. Hartford Foundation (Geriatric
Social Work Initiative) and support during recruitment from the following organizations: the Survivors Network of those Abused by Priests, MaleSurvivor, 1in6.org, and Dr. Jim Hopper. The author is grateful for the generosity and courage of the men who participated in this study.
Address correspondence to Scott D. Easton, Graduate School of Social Work, Boston College, McGuinn Hall, Room 207, 140 Commonwealth Avenue, Chestnut Hill, MA 02467, USA. E-mail: [email protected]
Journal of Loss and Trauma, 18:342–361, 2013 Copyright © Taylor & Francis Group, LLC ISSN: 1532-5024 print/1532-5032 online DOI: 10.1080/15325024.2012.701124
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pregnancy loss, bereavement, natural disasters, cancer, military service, and war. Despite differences in specific events, theories attempt to integrate common characteristics of the recovery process for survivors and describe how survivors process, interpret, create meaning, and adjust after a traumatic experience. One sociopsychological theory of trauma processing, account- making (Harvey, Orbuch, & Weber, 1990), posits that survivors progress through a series of stages in developing a narrative or account of the event. The purpose of this article is to assess the viability and utility of account- making theory in explaining trauma recovery using data from a large sample of men with histories of child sexual abuse (CSA).
LITERATURE REVIEW
Historical Roots of Account-Making
Account-making is a social-psychological model that describes the adjust- ment process of people who have encountered a severe stressor, a traumatic event, or a significant personal loss (Harvey et al., 1990). Traumatic events such as bereavement, natural disasters, or violent crimes often shatter commonly held assumptions of normalcy ( Janoff-Bulman & Berger, 2000) and increase the risk for psychological illnesses (Updegraff & Taylor, 2001) for survivors, including depression, anxiety, and posttraumatic stress disor- der. A core assumption of the account-making model is that people who have experienced potentially traumatic events can benefit by developing accounts to describe, interpret, and create meaning from the event. Researchers have defined accounts as “story-like constructions of events that include explanations, descriptions … and affective reaction” (Harvey, Orbuch, Chwalisz, & Garwood, 1991, p. 516).
The concept of accounts spans several academic disciplines (e.g., cognitive psychology, communication studies, linguistics) but originated in the research of sociologists Scott and Lyman. These scholars conceptualized accounts as linguistic tools used by individuals to justify or excuse actions associated with negative events (Lyman & Scott, 1970; Scott & Lyman, 1968). In the mid-1970s, Weiss (1975) applied the concept of accounts to the study of individuals undergoing marital separation and found that they have the potential to help individuals organize their lives in the aftermath of relation- ship loss. To understand how individuals manage blame, responsibility, and causality during relationship dissolution, other scholars incorporated attribution theory in the formation of accounts (Harvey, Wells, & Alvarez, 1978; Orvis, Kelly, & Butler, 1976). More than a decade later, social psychologists expanded the definition of accounts beyond a set of attributions following a divorce. Harvey et al. (1990) stated, “In more recent writings, we have continued to define accounts as people’s explanations presented in story-like form for
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past actions and events that include characterizations of self and key others in plots … thus accounts represent more than simply collections of disparate attributions” (p. 192).
Social psychologists also advanced the account-making model by examining how people construct accounts after facing a wide variety of traumatic and stressful events: Vietnam veterans returning from combat (Harvey, Agostinelli, & Weber, 1989), older adults coping with the death of a spouse (Weber, Harvey, & Stanley, 1987), and adults who experienced sexual assaults (Harvey et al., 1991; Orbuch, Harvey, Davis, & Merbach, 1994). Although some people begin developing accounts shortly after the event occurs, many people delay account construction until long after the event. Regardless of when account construction begins, the cognitive and affective process of refining an account often takes years to complete. As a framework to understand how individuals create meaning from traumatic events, accounts share common traits with other frameworks such as narra- tives (Gergen & Gergen, 1988), stories (Coles, 1989), and life schemas (Thompson & Janigian, 1988). As a process to create meaning from a trau- matic event, account-making shares similarities with clinical interventions such as narrative therapy (Sommers-Flanagan & Sommers-Flanagan, 2004), logotherapy (Frankl, 1984), and structured, written emotional expression (Butcher & Buckwalter, 2002).
Stages of the Model
In an attempt to explain how people cope with traumatic events or severe stressors, the pioneering research of Horowitz (1986a) led to the develop- ment of one of the first stress-processing models. A few years later, Harvey et al. (1990) adapted Horowitz’s original model to fit within the emerging theory of account-making. The result was a structured account-making model that consisted of six stages that follow a traumatic event (see Figure 1).
In the immediate aftermath of a traumatic event (i.e., outcry stage), the survivor often feels shocked, overwhelmed, or numb as the event may severely disrupt the sense of normalcy. Horowitz (1986b) explained that “the person quickly processes the crude implications of the event, has an alarm reaction that interrupts ordinary activities, and expresses warning signals” (p. 241), a normal response to a shocking event. During the next stage (i.e., denial), the survivor may experience a cluster of cognitive, affective, and behavioral symptoms. Because of the intensity of the emotions surrounding the event, the survivor “ignores implications of threats or losses, forgets important problems, and experiences emotional numbing, withdrawal of interest in life, and behavioral constriction” (Horowitz, 1986b, p. 242). Although some denial symptoms might be adaptive in the short term, abnormal denial is characterized by extreme avoidance and countermeasures such as excessive use of drugs or thrill-seeking (Horowitz, 1986b).
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After the denial stage, the survivor may acknowledge that the event occurred and realize that it disrupted his or her sense of safety, normalcy, and continuity. In the intrusion stage of the account-making process, the survivor may attempt to restore a sense of equilibrium by trying to interpret and understand the event (i.e., initial account-making). However, he or she may become overpowered by the emotions associated with recalling the event and experience repetitive, intrusive thoughts; hypervigilance; somatic complaints; and difficulties with concentration. Despite attempts to make sense of the stressful event, the survivor may become stuck and dwell on the event without reaching new insights or understanding (i.e., obsessive review).
During the working through stage of account-making, the survivor intensifies processing efforts at both the cognitive and the affective levels. Account-making efforts can range from informal activities consisting of private reflection (e.g., journal keeping) to more formal account-making that involves interpersonal exchanges (e.g., self-help groups). Survivors may attempt to share the account with other people (e.g., family members, partners, close friends). Harvey et al. (1991) introduced the term productive confiding and defined it as an “interaction with other(s) that involves [others’] empathic and helpful response and in turn one’s own sense of greater relief, acceptance, clarification and direction for further coping” (p. 520). Realizing that productive confiding does not always occur, Harvey later added a confiding component to the account-making model with bidirectional outcomes that reflect whether the response to confiding was helpful or not.
FIGURE 1 Original account-making model.
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After the working through stage, a survivor then progresses to the completion stage. At this point, he or she has fully developed a story to explain the cause and impact of the precipitating traumatic event. The account has been revised several times and now provides the survivor with an enhanced feeling of control and validation and a heightened understand- ing of the self, others, and the world. During the completion stages, the survivor has integrated the traumatic event into his or her life story and can discuss it without experiencing distress, thereby increasing a sense of mastery over his or her past.
The final stage of the model is identity change. While a survivor recog- nizes losses associated with the event, he or she has developed adequate coping skills, regained a sense of personal control, and attained a sense of self-efficacy. Successful completion of account-making can lead to improved mental and physical health. Alternatively, if a survivor is unable to engage in the account-making process (or stops in the early or middle stages), he or she may develop maladaptive coping patterns (e.g., substance use), psycho- somatic problems (e.g., stress, hypertension), or psychological problems (e.g., chronic grief, anxiety, depression).
Account-Making and Male Survivors of CSA
In the immediate aftermath of sexual abuse during childhood (i.e., the outcry stage), the sexually abused boy may feel panic, hopelessness, or even despair, especially because CSA often co-occurs with other forms of abuse (Banyard, Williams, & Siegel, 2004; MacMillan et al., 2001; Molnar, Buka, & Kessler, 2001). Due to cultural norms, the boy may also feel shame from not being able to protect himself from the abuser or from being abused by another male (Hunter, 2006). Alternatively, because some boys do not label the experience as sexual abuse (Fondacaro, Holt, & Powell, 1999; Holmes & Slap, 1998) and are manipulated by the abuser through psychological groom- ing strategies (Craven, Brown, & Gilchrist, 2006), the outcry stage for some boys may involve feelings of confusion or ambivalence.
The next stage of the model—the denial stage—is consistent with the numbing theory of psychopathology for people who were sexually abused during childhood (Polusny & Follette, 1995). To protect himself against feelings of confusion or shame, a sexually abused boy may minimize the experience, dissociate from it, or even deny that it occurred (Holmes, Offen, & Waller, 1997). Avoidance coping is very common during childhood for sexually abused children (Sigmon, Green, Rohan, & Nichols, 1996). Furthermore, sexually abused boys face many obstacles to disclosure, often resulting in “silencing” that can last well into adulthood (O’Leary & Barber, 2008).
As denial wanes and awareness increases, “the horror of the abuse overpowers [CSA] survivors whose emotions had been de-centered and blunted to avoid the emotional pain” (Fater & Mullaney, 2000, p. 288). In the
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intrusion stage, male survivors may experience fear associated with remem- bering the abuse, dreams, and flashbacks. Lisak (1994) wrote: “Perhaps the most common experience of fear described by [male survivors of CSA] was of fear associated with intrusions. The intrusions might be images of events which then evoked fear reactions, or they might be purely affective intrusions—unbidden and sudden experiences of raw fear and panic” (p. 532). In addition to fear, the intrusions may evoke feelings of intense anger (Fater & Mullaney, 2000; Lisak, 1994), a possible source of depression, anxiety, or suicidality.
During the working through stage, male survivors attempt to under- stand and create meaning from the sexual abuse through various activities. Initially, a survivor might seek out resources and gather information on CSA in a confidential or private manner (e.g., self-help books, Internet sites, psychotherapy). Other resources include the growing number of national survivor organizations (e.g., Male Survivor, 1in6.org, and the Survivors Network of those Abused by Priests), support groups, and online discussion boards for male survivors. Use of these resources can help survivors develop and refine their account of the sexual abuse, create meaning from the experi- ence, and contain the negative effects of the trauma. These activities may also empower the survivor through an enhanced sense of control and lead to identity change (e.g., moving from victim to survivor) and account completion.
Empirical Support
To date there is modest empirical support for the benefits of the account-making model for mental health. A fundamental assumption of the account-making model is that emotional expression—an interpersonal process at both the affective and cognitive levels—is beneficial to the psychological well-being of the survivor who experiences a traumatic event. This assumption is supported by the influential work of Pennebaker (1985, 1989). Other studies have examined account-making with various populations (e.g., veterans; Harvey et al., 1989) and found that account-making can have beneficial effects for adjustment. Harvey et al. (1991) stated that “available evidence suggests that well-developed accounts play a salutary role in providing perspective, the will to carry on, hope about the future, and closure regard- ing such stressors” (emphasis added) (p. 517).
Few researchers have specifically evaluated the account-making model with adults who experienced CSA. In one cross-sectional study of 26 adults with histories of nonconsensual sex during childhood (25 females, 1 male), Harvey et al. (1991) examined how levels of account-making activities (i.e., the extent to which the respondent mentioned activities in narrative responses) and the timing of disclosure were related to adjustment. The researchers reported that higher levels of account-making activities (e.g., journal keeping,
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private reflection, formal therapy) were positively associated with success- ful coping and negatively associated with negative emotions about the sexual abuse experience. In a similar qualitative study of 28 adults with histories of CSA (21 females, 7 males), Orbuch et al. (1994) found that the extent of account-making activities (i.e., activities such as journal keeping, private reflection, and formal therapy) and the completeness of account- making (i.e., level of understanding of the sexual abuse) were related to coping, close relationships, and emotional state. Orbuch et al. (1994) concluded that account-making activities and confiding “may represent invaluable acts of meaning in the recovery process of survivors of trauma … and may be essential to the will to recover and to other behav- ioral steps toward recovery” (p. 263).
By attempting to operationalize and measure components of the account-making model, these studies (Harvey et al., 1991; Orbuch et al., 1994) greatly advanced our understanding of account-making in general and, more specifically, its relevance to special populations such as adult survivors of CSA. Nonetheless, the researchers acknowledged several limita- tions of the studies, including small sample sizes, not controlling for gender, self-selection bias, and nonstandardized measures. The current study is the first study to apply account-making to a large, nonclinical sample of male survivors of CSA using standardized measures of mental health. The study had three specific aims: (a) to describe how measures of account-making can be operationalized in quantitative research, (b) to explore the relation- ship between account-making and mental health for men with histories of CSA, and (c) to suggest revisions to the structure of the account-making model. The results of the current study will provide directions for future research using account-making in understanding how survivors recover from traumatic events.
METHOD
This study used a cross-sectional survey design with purposive sampling from three national survivor organizations: the Survivors Network of those Abused by Priests (SNAP), MaleSurvivor, and 1in6.org. Each organization posted a Web site study announcement; SNAP also sent recruitment emails to its members. After reading the announcement, potential participants were directed to a survey Web site with a welcome message, consent letter, and eligibility screening questions. Participants were eligible if they were male, 18 years of age or older, and had been sexually abused before the age of 18. Interested, eligible participants completed an anonymous, Internet-based survey during an 8-week period in the summer of 2010.
The study received human subjects approval from the institutional review board at a midwestern university. Prior to implementation, the survey
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was pretested in three phases with input from national sexual abuse and trauma experts, clinicians, and graduate students in social work. The final survey consisted of 137 items, and the current study utilized a subset of items from the general survey.
Participants
The final sample consisted of 487 men with histories of CSA ranging in age from 19 to 84 years (M = 50.4 years). The level of education was measured on a Likert scale ranging from less than a high school diploma (1) to a doctorate or professional degree (8). The modal level of education was 6 (bachelor’s degree). Most participants were Caucasian (90.9%), living with a spouse/partner (69.9%), and members of a national survivor organization (81.8%). The mean level of total household income was $60,000–$69,000.
Measures
MENTAL DISTRESS
The measure for mental health problems was the General Mental Health Distress Scale (GMDS; Dennis, White, Titus, & Unsicker, 2007), a component of a comprehensive biopsychosocial assessment, the General Assessment of Individual Needs (GAIN; Dennis et al., 2007). The GMDS is a symptom count of internal sources of distress that were experienced in the past 12 months. For this study, the measure included 25 items related to internalizing disor- ders (depression, anxiety, somatization, and suicidality). Participants selected yes (1) or no (0) for each symptom. The measure was scored by adding the number of symptoms that each participant endorsed (range = 0–25), with higher scores indicating more psychological distress. The clinical cut-points were as follows: low (0–3), moderate (4–6), and high (7–25). The Cronbach’s alpha for the index was .904.
ACCOUNT-MAKING VARIABLES
The measures used for account stage, account development, and other account-making components will be described below.
Data Analysis
Data were cleaned and imported into a data file in SPSS 19.0. There were very little missing data in this study (generally < 3%), and data appeared to be missing at random. Diagnostic tests were conducted prior to inferential testing to examine potential problems such as influential outliers, nonlinear- ity, and multicollinearity. Unless otherwise noted, the results indicated that the assumptions were met for statistical tests. In addition to univariate
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analyses, bivariate tests (i.e., chi-square tests, t tests) and interitem correla- tions were conducted.
STAGING WITHIN ACCOUNT-MAKING
Development of Measure
To identify the stage of account-making for each participant, the researcher generated items that assessed characteristics of each stage as described in previous studies (Harvey et al., 1990). Each item was then customized to reflect the specific stressor of CSA. For example, one item that assessed the denial stage stated “Because the sexual abuse is hard to deal with emotion- ally, I try not to think about it.” During the process of item construction, the researcher consulted over a 2-year period (2008–2010) with experts who specialized in trauma processing models, account-making theory, child abuse and neglect, and clinical practice with men who were sexually abused during childhood (MSAC). These consultations evaluated face and content validity and reduced the original list of more than 20 items to six items (see the appendix): denial stage (Items 1, 2), intrusion stage (Items 3, 4), working through stage (Item 5), and end stage (Item 6). The initial outcry stage was not measured due to the composition of the sample (i.e., mean age of 50.4 years).
For each item, participants were asked the extent to which they agreed with the statement. The response choices were based on a 6-point Likert scale ranging from strongly disagree (1) to strongly agree (6). The responses were then recoded into dichotomous variables for each of the four stages: denial, intrusion, working through, and end. Participants who agreed (5) or strongly agreed (6) with the original item were assigned a score of 1 (yes) for the stage (no = 0).
Further analysis, however, revealed that the stages were not mutually exclusive. Many participants provided responses that classified them into multiple stages. For example, 66.5% (n = 314) of the sample was classified as being in the working through stage, and 39.6% (n = 187) of the sample was classified as being in the end stage (see Table 1). A cross-tabulation found that of those who met the criteria for working through, 48.4% (n = 152) also met the criteria for the end stage. Thus, the items were not useful in defini- tively classifying participants into one of the stages of the account-making model.
Results for Mental Health
Although the stages were not mutually exclusive, they did measure charac- teristics of the recovery process that may be related to mental distress. Based
Trauma Processing Reconsidered 351
TABLE 1 Results for Account-Making Stages and Relation to Mental Distress (N = 487).
Stage % Mental distress
score (SD) Range
Denial Yes 44.9 13.69 (5.92)** 0–25 No 55.1 11.57 (6.43) Intrusion Yes 57.9 14.68 (5.49)** 0–25 No 42.1 9.53 (6.11) Working through Yes 66.7 12.98 (6.02)* 0–25 No 33.3 11.68 (6.73) End Yes 39.4 11.69 (6.41)* 0–25 No 60.6 13.05 (6.16)
*p < .05; **p < .001.
on account-making theory, it was expected that the early (denial) and middle stages (intrusion, working through) would be positively related to mental distress and that the end stage would be negatively related to mental distress. Independent samples t tests were conducted and found support for these relationships (see Table 1). For example, participants who met criteria for denial had a higher score on mental distress (M = 13.69, SD = 5.92) than par- ticipants who did not meet criteria for denial (M = 11.57, SD = 6.43), t(476) = −3.67, p < .001. Similarly, participants who met the criteria for the end stage had a lower score for mental distress (M = 11.69, SD = 6.41) than participants who were not in the end stage (M = 13.05, SD = 6.16), t(390) = 2.29, p < .05.
Implications
Although efforts to classify participants into a single stage of account-making with a scale were unsuccessful, the items that assessed characteristics associ- ated with each stage of account-making were useful. As expected, the early and middle stages of account-making were positively related to mental distress, and the end stage was negatively related to mental distress. The results of the current study are important because they provide support for the association between account-making stages and mental health using a standardized, validated measure of mental distress. Researchers can build on these findings by developing measures to more accurately identify the stage of account development for survivors at a particular point in time. Studies with probability samples from the general population would allow research- ers to measure the full range of stages. Future studies should also examine whether account-making varies depending on factors such as gender, race/ ethnicity, or socioeconomic background.
352 S. D. Easton
ACCOUNT DEVELOPMENT
Development of Measure
Another goal of this study was to develop a measure of account develop- ment and assess its relationship to mental distress among MSAC. Originally the researcher generated dozens of items based on dimensions of account development cited in previous research with sexual assault survivors (Harvey et al., 1991; Orbuch et al., 1994) and conversations with mental health practitioners who specialize in treating MSAC. Some of the dimensions that were identified included naming the experience as sexual abuse, assessing responsibility for the abuse, understanding the response to the abuse (by the survivor and his caregivers), and identifying the emotional and behavioral impact of the CSA for the survivor. The dimension of naming the experience as CSA was not included because it was one of the eligibility criteria for this study.
Through consultations with the panel of experts, the original list of items was reduced to six measuring three dimensions: assessing responsibil- ity (Items 1 and 2), understanding the response to the abuse (Items 3 and 4), and understanding the impact of CSA (Items 5 and 6; see the appendix). For example, one item measuring responsibility read “The person who sexually abused me is responsible for the abuse.” The response choices for each item ranged from strongly disagree (1) to strongly agree (6). A composite measure—the Account Development Scale—was then created by adding scores on the six items (range = 6–36), with higher scores indicating a more developed account. All of the items were significantly correlated with one another (see Table 2). The Cronbach’s alpha for the scale was .737.
Results for Mental Health
A Pearson’s product-moment correlation coefficient was conducted to assess the relationship between account development and mental distress. The results indicated that there was a negative relationship between scores on the Account Development Scale and mental distress (r = –.175, n = 487, p < .001).
Implications
Previous research has found a positive relationship between account devel- opment and coping and adjustment for sexual assault survivors (Harvey et al., 1991; Orbuch et al., 1994). These studies collected qualitative data on accounts, rated the extent and depth of the narratives, and then examined the relationship between account development and adjustment. The current study attempted to develop a scale to measure account development and
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354 S. D. Easton
then assess its relationship to mental health using a standardized, validated measure of mental distress. The results are consistent with previous research and provide support for the beneficial effects of account development for mental health. However, not all of the elements of account development were included in the Account Development Scale (e.g., naming the experi- ence). Future studies should more fully assess the psychometric properties of this scale, examine its relationship to mental health using a probability sample of sexual abuse survivors in the general population, and explore how it may be related to the stage of account development.
REVISIONS TO THE ACCOUNT-MAKING MODEL
Progression
Because survivors of trauma or severe stress may become emotionally over- whelmed during initial and intensified account-making efforts, many survivors may periodically return to the earlier stages (i.e., denial, intrusion). Rather than following a linear progression through the stages of the account- making process, a survivor may go through regression loops to earlier stages during the recovery process. In describing the recovery process during rehabilitation from mental illness, Anthony (1993) explained that recovery often does not feel like a linear process, but rather one filled with periods of growth and setbacks. Ridgway (2001) wrote: “Recovery is an evolving process, one that sometimes spirals back upon itself, and may result in a frustrating return to active disorder after periods of positive functioning” (p. 339).
To explore this possibility, participants in this study of male survivors of CSA were asked to assess their level of agreement with the following state- ment: “My progress toward understanding the effects of being sexually abused has been filled with temporary setbacks.” The response choices were based on a 6-point Likert scale ranging from strongly disagree (1) to strongly agree (6). The results for somewhat agree, agree, and strongly agree were 17.4%, 28.0%, and 34.2%, respectively (see Table 3). Thus, most participants agreed with this statement (79.7%; n = 384). Because temporary setbacks were common in this sample, these results suggest that account-making is not always a linear, sequential process but rather one filled with periods of progress and regression. If these findings can be replicated with other trauma survivors, a more accurate visual representation of the account-making process may include bidirectional arrows or even loops connecting the different stages of the model.
Turning Points
Another question surrounding the account-making process is: What propels an individual from earlier stages to working through and eventually
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completion? Because MSAC may spend a great deal of time in the denial and intrusion stages and experience painful emotions when starting to think about or discuss the CSA experience, it is unclear what causes them to inten- sify account-making activities during the working through stage. Some research has suggested that MSAC may reach a turning point and make a conscious decision to deal with the effects of the CSA experience (Harvey, Mishler, Koenan, & Harney, 2000; Kia-Keating, Grossman, & Sorsoli, 2005; Lamar, 1984). One example of a turning point is that a survivor may grow tired of being depressed and commit himself to healing and developing more effective coping skills. Another example is that a survivor may experi- ence an unexpected or sudden revelation that may help him to reframe his CSA experience and commit to improving his health.
To examine this possibility, an item asked participants: “Some adults who were sexually abused struggle for years and then reach a turning point where they decide to commit to healing and improving their health. Did you experience such as turning point?” (no = 0, yes = 1). Overall, 57.7% (n = 276) of the sample responded affirmatively (see Table 3). Because the experience of a turning point may be related to a survivor’s stage in the account-making process, a chi-square test of independence was conducted between turning point (0 = no, 1 = yes) and end stage (0 = no, 1 = yes). The chi-square results were significant, χ2(1, n = 472) = 50.90, p < .001. Interestingly, 77.8% (n = 144) of the MSAC who were in the end stage reported that they experienced a turning point in their recovery, compared to only 44.6% (n = 144) among participants who were not in the end stage. Thus, the findings indicate that
TABLE 3 Results for Items for Revising the Account-Making Model.
Item % Mean (SD) n
Experienced temporary setbacks 482 Strongly disagree 3.7 Disagree 8.1 Somewhat disagree 8.5 Somewhat agree 17.4 Agree 28.0 Strongly agree 34.2 Experienced a turning point End stage 185 Yes 77.8** No 22.2 Not in end stage 287 Yes 44.6 No 55.4 Engage in maintenance activities Entire sample 4.18 (1.6) 482 End stage 4.77 (1.47)** 189 Not in end stage 3.78 (1.58) 289
**p < .001.
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turning points may be an integral part of the account-making process for men with histories of CSA. Future research should explore the possibility of turning points for survivors of other severe stressors.
Maintenance Activities
Finally, although the model has a stage called completion (and proponents use the term completed account), it is unclear whether MSAC who go through the account-making process ever actually end their account-making activi- ties. Even after reaching the final stages of account-making, it is possible that many survivors periodically engage in activities to maintain and advance their progress (e.g., participating in annual rituals or memorials, writing or journaling, joining online discussion groups, engaging in public advocacy efforts related to CSA). These maintenance activities may fulfill a role similar to that of booster sessions in clinical treatment (Schlup, Munsch, Meyer, Margraf, & Wilhelm, 2009) and prevention programs (Nation et al., 2003). If a high percentage of MSAC in the later account-making stages participate in such activities, then another stage—ongoing maintenance—could be added to the model to reflect the ongoing, dynamic nature of the account-making.
To examine this possibility, participants were asked the extent to which they agreed with the following statement: “I periodically engage in activities to maintain my progress in dealing with being sexually abused (e.g., read self-help books, attend self-help groups, volunteer).” The response choices were based on a 6-point Likert scale ranging from strongly disagree (1) to strongly agree (6). The mean score on this item for the entire sample was 4.18 (SD = 1.6). However, additional analysis showed differences in scores for ongoing maintenance that were based on the stage of account-making, t(476) = −6.89, p < .001 (see Table 3).
Participants who were in the end stage scored higher on this measure (4.77; SD = 1.47) than participants who were not in the end stage (3.78; SD = 1.58). These results suggest that ongoing maintenance activities may be a common, important practice even in the later stages of the model for men with histories of CSA. Thus, account development may never be “complete” but more accurately described as an ongoing, continually dynamic process. Future research should explore this possibility with other survivor populations.
DISCUSSION
The purpose of the current study was to assess the viability and utility of the account-making model for understanding the recovery process for trauma survivors. Because account-making is an inherently subjective, constructivist process, most research studies to date have used qualitative approaches.
Trauma Processing Reconsidered 357
Nonetheless, account-making may also be useful in quantitative research with trauma survivors. Although more work is needed to develop and refine measures of account stages and account development, the current study offers an example of how account-making constructs can be operationalized. It is hoped that this study will stimulate discussion of account-making as a framework for future research that advances our knowledge of the recovery process for survivors of loss and trauma.
A second aim of the study was to explore the relationship between account-making and mental health for trauma survivors. Among a large, nonclinical sample of men with histories of CSA, account-making appears to be related to better mental health at the bivariate level. These findings are consistent with previous studies on survivors of sexual assault that found that account-making is related to positive adjustment and coping (Harvey et al., 1991; Orbuch et al., 1994). The use of a standardized, validated measure of mental distress in the current study, however, extends the empirical support for account-making. Beyond coping and adjustment, account-making may actually be related to a reduction in psychological symptoms (e.g., depression, anxiety, somatization, suicidality). If future research replicates these findings with other populations, account-making may have important implications for clinical treatment of trauma survivors.
A third aim of the study was to provide suggestions for refining the theoretical framework of account-making. The results suggest that three concepts—regression loops, turning points, and ongoing maintenance—may be important components that should be incorporated into the model. Although the results of the current study are suggestive and based on a specific subpopulation, it is likely that these concepts may be applicable to other trauma populations as well.
Many of the limitations of the data set used in the current study (e.g., cross-sectional design, non-probability sample, retrospective self-report data) have been described elsewhere (Easton, 2011). However, in interpreting the results, three limitations deserve consideration. First, an aim of the current study was to describe how account-making concepts can be operationalized for quantitative research (e.g., Account Development Scale). Although initial reliability analyses were encouraging, the validity and reliability of the scale were not fully established. To develop a standardized measure of account development for survivors of CSA, additional research is needed to assess the psychometric properties of the scale in more depth. Second, bivariate analyses provided support for the relationship between account stage, account development, and mental health. Future research can build on the findings using advanced statistical models that control for other variables related to the CSA severity, disclosure, and demographic background (e.g., age). Multivariate models can also handle interrelationships and possible interactions between variables such as account development and stage of account-making. Third, an important element of the account-making
358 S. D. Easton
model—productive confiding (Harvey et al., 1991)—was not included in the current study. Other researchers have found that aspects of disclosure (e.g., timing, discussion) were related to long-term mental health for adult survi- vors of CSA (e.g., O’Leary, Coohey, & Easton, 2010). Future studies should examine the role of disclosure in account-making and account development for this population.
Despite these limitations, the results suggest that account-making is a useful, viable theoretical framework for understanding recovery from trauma or loss. To complement existing qualitative research, quantitative studies that incorporate account-making can extend our knowledge base of trauma recovery. This is especially important as evidence suggests that account- making may promote mental health for trauma survivors. Additionally, the incorporation of regression loops, turning points, and ongoing maintenance into the model will refine the theory and more accurately describe the trauma recovery process.
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APPENDIX: SURVEY ITEMS
Account-Making Stages
1. Because the sexual abuse is hard to deal with emotionally, I try not to think about it.
2. Whenever I am reminded of the sexual abuse, I do something to take my mind off of it.
3. Even when I don’t want to, I can’t stop thinking about the sexual abuse. 4. Whenever I think about the sexual abuse, I get overwhelmed with strong
feelings. 5. I am actively working to understand how the sexual abuse has affected my
life. 6. At first the sexual abuse was hard to deal with and I tried not to think
about it. Later, even when I wanted to, I couldn’t stop thinking about it. But now I’ve worked through it and understand how the sexual abuse has affected my life.
Account Development
1. The sexual abuse was not my fault. 2. The person who sexually abused me is responsible for the abuse. 3. I understand why I initially responded the way I did to the abuse. 4. I understand why my caregivers responded the way they did to the abuse. 5. I understand how the sexual abuse has affected me emotionally. 6. I understand how some of my negative behaviors are related to the sexual
abuse.
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