For A-plus Writer Only

Book Reference

James, R. K. & Gilliland, B.E. (2017). Crisis intervention strategies (8th ed.). Boston, MA: Cengage Learning.

The Scope of the Problem Be forewarned: The statistics in this chapter l!iJI are some of the most controversial and error prone reported in this book! Given the emotional volatility and cultural artifacts that undergird sexual assault, after reading this chapter we hope you'll understand why these statistics may be so error prone. The benchmark National Violence Against Women Survey (National Institute ofJustice and Centers for Disease Control, 1998) conducted in 1997 in the United States found that 1 in 6 U.S. women and 1 in 33 U.S. men had experienced an attempted or completed rape as a child and/ or as an adult, using a definition of rape that includes forced vaginal, oral, and anal sex. By this writing in 2015, those grime figures have decreased ... some. The National Intimate Partner and Sexual Violence Survey: 2010 Summary reported that 1 in 5 women and 1 in 71 men will be raped (Black et al., 2011) . Those statistics are probably very conser- vative, with other studies ranging from 10% to 15% of American men and 15% to 33% of American women (Lew, 2004; Rowan, 2006).

Contrary to popular myth, these acts were not all committed by sexual perverts and deviants lurking in big-city dark alleys and nabbing unsuspecting young schoolgirls as they walked by. Nearly 1 in 10 women has been raped by an intimate partner in her life- time (Breiding, Chen, & Black, 2014). In 2002, 3 out of 5 sexual assault victims stated that the offender was an intimate, relative, friend, or acquaintance (U.S. Department of Justice, 2003). It should not be surprising, then, that rape, sexual assault, and child sexual abuse demographics tend to mimic domestic violence statistics. In short, it's an odds-on favorite that someone who knows you will be the one who sexually

240

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~aults you (Hassan et al. , 2015; Miller, Cohen, & ~iersema, 1996). What research is starting to find ~r in regard to intimate sexual assault is not just

::'.:ie severity and duration of the sexual abuse as the :nor cause of the trauma but the profound sense of .:c rrayal by someone who should have never, ever done som ething as anathematic as a caregiver (O ' Rinn ::"::al. , 2013) .

This chapter will deal mainly with adult males as ? erp etrators and women or children as their victims. ;-Iowever, no one should labor under the delusion ::3at adult males are not raped (and this excludes the - ereotypes of prison sex or gay sex) (Davis , 2002; Ga r tner, 2005; Isley & Gehrenbeck-Shim, 1997; _ l ez ey & King, 1998; Scarce, 1997), nor should you .JClieve that women are not capable of some of the most ~cinous sexual and physical abuse imaginable upon :hei r own children, whether boys or girls (Allen, 1991; .=. iot, 1994; Gartner, 2005; Holmes , Holmes, & Unholz, :993; Lew, 2004; Rosencrans, 1997; U.S. Department

EJus tice, 2000). Although the majority of assaults are ~rpetrated on children and females under age 25, sex- :!al assault survivors have been identified among males z.ad females from every segment of the population- .:1ildren, adolescents, adults , and older adults (U.S. ::::>ep artment of Justice, 1998). An estimated 10% to _0% of men are sexually assaulted sometime in their lives (U.S. Department ofJustice, 2000). Nor does the ::ni ted States have a corner on either the rape or child w use markets (Chen, Dunne, & Wang, 2003; Lalor & _ k Elvaney, 2010; Sanday, 1998; Schwartz-Kenney, _ Ic Cauley, & Epstein, 2001; Tomoko et al. , 2002) . . ....bout 103,000 children are reported as having been 5<'.X u ally abused in the United States out of 903,000 ~ild maltreatment cases . The true figure is estimated :o be between 250,000 and 350,000 (U.S. Department

[ Health and Human Services, 1997), and Finkelhor ~d his associates (2005) found in their national sur- --ey rhat 1 in 12 children they surveyed had been sex- :.:ally victimized in the study year alone! Statistics in ::arions of Asia, Africa, and Latin America are equally ~(Chen, Dunne, & Wang, 2003; Schwartz-Kenney, _ k Cauley, & Epstein, 2001), and in some cases horrifi- :ally worse: Children are sold into thralldom as child :-ostitutes or indentured servants by their poverty-

·cken parents (Rowan, 2006).

n derreporti ng -=:-ae vast majority of crime survey reports do not re- - rt sexual abuse of children under the age of 12, yet --e certainly see many of those children turnstiling

CHAPTER NINE Sexual Assault • 241

through local child protection centers (Benedict, 1985, pp. 186-192; Brownmiller, 1975, p. 175). The literature consistently estimates that 50% to 90% of all rapes or attempted rapes go unreported. Most instances ofincest and molestation are never reported . Further, date rapes and even stranger rapes are not reported out of shame, humiliation, guilt, cultural taboos, and the very real fear of secondary victim- ization at the hands of medical and legal authorities (Cole, 2006; Matsakis, 2003; Weiss , 2010). Beyond the sensationalism of religious cults that practice polyg- amy with young children (Bottoms et al. , 2003) and Catholic priests who sexually abuse young parish- ioners (McGlone, 2003), it should be very clear that the kinds of sexual assaults this chapter covers are common, are underreported, and the traumatic wake they spread encompasses millions of people.

David Lisek has done seminal research in this area (Lisek & Miller, 2002; Lisek & Roth, 1988). Lisek reports that in 1998 there were 1,687 reported rapes and 526 arrests made in metro Boston. If one multiplies the prevalence number from the National Violence Against Women study (Tjaden & Thoennes, 2000), the true rape incidence for the 1.75 million women living in the Boston metro area was 15,225 rapes. This disparity sug- gests that only 1 in 9 rapes is actually reported.

Abundant evidence suggests that crises resulting from sexual abuse and rape are more intense and dif- fer in nature, intensity, and extent from other forms of crisis (Burgess & Holmstrom, 1985; Finkelhor, 1979, 1984, 1987; Gartner, 2005; Lew, 2004; Matsakis, 2003; Rowan, 2006; Williams & Holmes, 1981). In fact, the psychological traumatic wake of rape both in childhood and adulthood marks it as probably second only to prolonged combat in potential for PTSD, and many of the transcrisis rape treatment approaches closely parallel those of standard PTSD treatment (Cloitre & Rosenberg, 2006; Frazier et al., 2001) .

Defining Rape: The Unique Situation of Sexual Abuse/Rape Survivors There are many definitions of rape. Some IDJI are based on legal constructs; some are derived from other sources. Brownmiller (1975) distinguishes between most legal definitions and what she refers to as a woman's definition of rape. She sees the legal definition of rape as "the forcible perpetration of an act of sexual intercourse on the body of a woman not one's wife" (p. 380) as much too narrow and protec- tive of male supremacy. Brownmiller's preferred defi- nition from a woman's perspective is that rape is "a

242 • PART TWO Handling Specific Crises: Going Into the Trenches

sexual invasion of the body by force, an incursion into the private, personal inner space without consent-in short, an internal assault from one of several avenues and by one of several methods [that] constitutes a de- liberate violation of emotional, physical, and rational integrity and is a hostile, degrading act of violence" (p. 376). That definition appears to encompass the whole scope of rape, as well as other forms of sexual abuse/misuse/harassment. For the purposes of this chapter, your authors will use Koss and Achilles' (2008) definition of rape as an unwanted act of oral, vaginal, or anal penetration committed though the use of force, threat of force, or when incapacitated; sexual assault refers to a broader range of sexual criminal offenses such as sexual battery and sexual coercion up to and including rape (U.S. Department of Education, 2011).

The Dynamics of Rape The etiology of rape has roots deeply embed- Im.I ded in the psychosocial and cultural fabric of the particular society in which it occurs (Brownmiller, 1975; Donat & D'Emilio, 1998; Eisler, 1987-1995; Ullman, 1996a, 1996b). According to Brownmiller (1975) and Eisler (1987-1995), the cultural mecha- nism of male dominance constitutes the driving force in rape in all cultures. The psychosocial, cultural, and personal attitudes and responses of both males and females are important dynamics in considering the phenomenon of rape (Benedict, 1985; Williams & Holmes, 1981).

Social/Cultural Factors Baron and Straus (1989) characterize rape as a social phenomenon and theorize four different causes: gender inequality, pornography, social disorganization, and legitimization of violence. Gender inequality refers to the economic, political, and legal status of women in comparison to men. Pornography reduces women to sex objects, promotes male dominance, and en- courages or condones sexual violence against women. Social disorganization erodes social control and constraints and undermines freedom of individual behavior and self-determination. Legitimization of violence is the support the culture gives to violence, as portrayed in the mass media (such as television programming), laws permitting corporal punishment in schools, violent sports, military exploits, and video games. Social norms theory proposes that male peer aggression andfemale submission are part of the norm and justification for violent sexual interaction (Dardis et al., 2015).

The notion of male supremacy has its roots deep in our cultural history, which has always equated the property rights of men with access to and control over the bodies of women, children, and others who are perceived as dependents (Brownmiller, 1975). Indeed, Eisler (1987-1995, pp. 153-154) describes rape and sexual assault as one of several threats widely used to ensure the continued domination and control of women. Historically, the crime of rape has been seen not as a crime against the woman but as a crime against her father or her husband (Donat & D'Emilio, 1998).

Brownmiller (1975) and others have documented a part of the history of rape as a psychosocial means by which the victors in wars reward thet11selves and humiliate their vanquished foes. The wholesale rape and killing of helpless women and children represents the ultimate vulnerability and defeat of a people. It likewise represents the ultimate humiliation and subjugation of a person. Whether it is inflicted on thousands , as reported in war, or on one person, the purpose is quite similar-the use of unrestrained power to force the vanquished into total submission.

Personal and Psychological Factors Personal and psychological factors unique to men who perpetrate sexual abuse affect both their decision to assault and the way the assault is carried out (Beech, Ward, & Fisher, 2006; Groth & Birnbaum, 1979; Lisek & Miller, 2002; Lisek & Roth, 1988; Williams & Holmes, 1981). The male offender:

1. Acts in a hostile, aggressive, angry, condescend- ing, and domineering manner, and believes he is strong, courageous, and manly even though he often feels weak, anxious, inadequate, threatened, and dependent and believes women are inherently dangerous.

2. Lacks the interpersonal skills to make his point in society and particularly with women.

3. May need to exercise power to prove to himself and to the victim that he is powerful, omnipotent, and in total control.

4. May show sadistic patterns-the sadistic rapist fre- quently uses extreme violence and often mutilates or murders the victim in order to attain a feeling of total triumph over the victim.

5. Sees women as primarily sexual objects and has sexual urges that are uncontrollable and all consummg.

6. Holds stereotypical and rigid views of male and female roles with hypermasculine self-views that validate he is a "real man."

7. Harbors chronic feelings of anger, hostility, and fear toward women and seeks to control them by his sexual "conquests."

Feminists, with good historical reason, have a t tempted to define rape as basically an exercise in ?Ower and control. On that basis most rapists have been cast into one of four categories: anger (mad at women), power exploitative (show they have power over women), power reassurance (continuously feel th at they are powerful over women), and sadistic cake joy in hurting women). McCabe and Wauchope 20 05) found evidence to support these typologies in

cwo studies, one of men who had only been charged with sexual assault and the other of men who were convicted, but they also found outliers who did not fi t the four categories well. A number of researchers (Lisek & Miller; 2002; Lisek & Roth, 1988; Scully & Marolla, 1998; Sussman & Bordwell, 1981) have interviewed convicted rapists and have vividly d emonstrated that each rapist's reasons for assault are individual. For example:

1. Some men use rape to punish or exact revenge because a specific woman has "done them wrong." They see all women collectively as responsible for one woman's supposed transgressions. Some negative precipitating event with an intimate causes them to "take it out" on and "get even" with some woman who is a total stranger to them. It doesn't make any difference who it is as long as it is a female-a generic symbol of their lost power, virility, and masculinity that they desperately want back.

2. Criminals who commit rape in the perpetration of a crime often see rape as an added bonus. It's there for the taking, so why not?

3. For some men, rape is attaining the unattainable woman, the woman they would never otherwise have a chance with. In this instance, sex is the motivating factor.

4. For some men, rape is an impersonal experience and preferred over any demonstrated caring or mutual affection. There is no obligation, and the power, control, and sexual tension release are gratifying.

5. Finally, in its most heinous form, gang rapists see rape as recreation, adventure, and proving they are "macho." These individuals belong to sexually violent subcultures that reflect both the rapist's views of women and the notion that sexual conquest of as many women as possible is a critical measure of manhood. A gang rape is seen as male bonding at its height. While numerous

CHAPTER NINE Sexual Assault • 243

interviewees stated they regretted their actions and were now sorry for them, the immediate impact on them postrape in regard to what they had done was slight. Ominously, if they felt anything, they generally felt good about what they did.

Yet the vast majority of rapes have to do with the power relationships between men and women (Suss- man & Bordwell, 1981, p. 12). Somehow the contem- porary sociocultural milieu produces some males who feel such absence of power and control in their lives that they develop a need to "take it" (control). These males come to believe that it is their "right" (p. 5) and proceed to rationalize and justify thei r be- havior, even though they have invaded and taken by force another person's life and body.

Myths About Rape One of the most difficult obstacles that Im human services workers face in dealing with all forms and aspects of rape and sexual abuse is the abundance of debilitating myths in society (Benedict, 1985; Burt, 1998; Ganas et al. , 1999; Matsakis, 2003). For example:

1. Rape is just rough sex. The notion that rape equals sex is perhaps the most destructive myth of all. If we believe that rape is sex, then it follows that rape doesn' t hurt (physically or psychologically) any more than sex does. We can even believe that the survivor enjoys and is erotically stimulated by its roughness. Rape is violence, torture, and a life-threatening event. It is utterly humiliating, and the joy of"rough sex" has nothing to do with it. However, research indicates that certain types of rapists are aroused by the use of force and violence against victims, and such arousal may be heightened by aggressive resistance of victims (Drieschner & Lange, 1999; Knight, 1999). Social norms theory supports this myth. Dardis and associates (2015) found that college males' beliefs about what their peers thought about sexually aggressive behaviors correlated highly with what their perception of the average college male's beliefs were, although in actuality they were not corre- lated with their friends' actual beliefs. However, perpetrators of sexual assault were highly significant in their belief in overestimating friends ' involve- ment in sexually aggressive behavior.

2. Women "cry rape" to gain revenge. Ganas and associ- ates (1999) hypothesize that this myth permeates our society because such myths (a) provide comfort for our social structure (people don't

244 • PART TWO Handling Specific Crises: Going Into the Trenches

want to believe that rape really occurred), (b) serve to focus the blame for sexual violence on victims rather than perpetrators, and (c) are easier to believe than the reality of knowing that rape can happen to anyone. As such it is one of the most heated and controversial issues in sexual assault. "Revenge" reports are sometimes heard, and at times the cry of"rape" has been used for secondary gain, such as getting back at a jilted lover, black- mail, job security, or covering up an unwanted pregnancy. A 2% rule has been used by the FBI in its training as the percentage of false accusations. Lisek and his associates (2010) found about a 6% false accusation rate in their investigation of rape allegations. Yet according to police reports, rapes are no more likely to be falsely reported than other crimes (Lear, 1972).

3. Rape is motivated by lust. Eisler (1995) and Scully and Marolla (1998) believe that the motivation for rape is most likely to be domination, power, anger, revenge, control, frustration, or sadism. Benedict (1985, p. 8) and Eisler (1995, pp. 237-239) report that some men may come to associate sex with violence, thereby viewing women not as human beings but as objects of prey and/ or domination and viewing sex as an act of power, control, and triumph. However, one counterpoint view, based on studies of the evolutionary theories of rape by Thornhill and Palmer (2000) , suggests that the motives of rapists are primarily sexual, with the exercise of power mostly a means to an end. This idea is supported at least in part by Scully and Ma- rolla (1998) , who found that some of the rapists they interviewed saw it as the only way to get sex- ual access to women who were unwilling or "out of their league."

4. Rapists are weird, psychotic loners. No such conten- tion can be supported by the research. Rapists come from every walk of life. People who rape and commit other forms of sexual abuse/ misuse have been identified in every stratum of society- from judges to messenger boys, from weaklings to bodybuilders, from vagrants to corporate ex- ecutives, from husbands and fathers to strang- ers, from partners, known friends, and relatives to unknown intruders (Benedict, 1985, pp. 9-10; Burt, 1998). The idea that rapists were mentally ill held sway for a long time (Groth, 1971) and was seen by feminists as a particularly odious way of rationalizing the• male-dominated societal power and subjugation motives that undergirded and upheld a repressive, patriarchal society. The sheer

number of rapes make it statistically impossible that the typical rapist is "mentally ill," given the small number of psychopathic men in the popula- tion (Scully & Marolla, 1998).

5. Victims or survivors of rape provoked the rape or wanted to be raped, so no harm was done. By acting sexy, wearing sexy clothes or lots of makeup, being at a bar and "coming on" to a man, walking along a road alone at night, or doing laundry or grocery shopping late, somehow or other a woman does something that clearly says "Come rape me!" The bottom line is that through a series of weak inferences and rational- izations, the rapist is able to condo n e his sexual assault. The rapist is no longer responsible for the way he acted because the woman, by her actions , brought it on herself (Burt, 1998). Al- though most rapists deny that they are rapists, rationalize that women provoke or want it, or deny that their sexual assaults are rape, there are virtually no documented cases in which women have lured men into raping them . Ganas and associates (1999) and Sussman and Bordwell (1981) have clearly shown that what the survivor does before the rape has little if anything to do with the rapist's decision to assault.

6. Only bad women are raped. This myth is one of the most blatant examples of a "blame the victim" at- titude (Brownmiller, 1975). This myth is taken to mean that if the woman has a "bad" reputation, the rape is justified. The stereotypical "damaged goods" notion means that a woman who has said "Yes" once can no longer legitimately say "No." She has lost her value (Burt, 1998). For many, the extension of this myth means that prostitutes are so devalued that they have no worth at all and therefore cannot be raped (Silbert, 1988). Whether the person is a professional hooker or a minister should make no difference. Neither deserves to be assaulted, and both are entitled to equal protec- tion and treatment.

7. Real rapes happen only in bad parts of town, at night, in abandoned buildings or lonely fields by strangers who have knives or guns and who engage in brutally beat- ing the victims when they resist heroically-even unto death. That's pretty much rubbish! While there are rapes that happen that way, remember that half or more of the perpetrators are someone who knows the victim. Most rapes do not involve a weapon or sustaining an injury beyond minor bruises or scratches. And most occur in either the victim's home or the assailant's (Burt, 1998).

8. If the woman doesn't resist, she must have wanted it. The old stereotypical notion, which has had some coinage in the courts, is that the woman needs to resist unto death or be so physically drained or hurt that she can't resist any longer. Resisting may get a woman killed, particularly if the assailant is armed and is more physically powerful. Furthermore, there are many psychological obstacles in the way of resisting that have to do with the historical power differential wherein women do submit. Ominously, Kassing and Prietio (2003) found that both male and female counselors-in-training thought that male rape victims should fight back. There is no conclusive evidence that fighting back or not fighting back is better for the victim (Matsakis, 2003).

It is not easy or simple to eradicate or even to refute the preceding myths in society at large (Ganas et al., 1999). Feminists argue that it is to the advan- tage of the entire patriarchal society to believe such ~yths, and it is certainly to the advantage of the rapists (Burt, 1998).

Myths about rape and sexual assault are not the sole domain of females. Here are some of the more prevalent myths about males and sexual assault Male Survivor, 2011).

1. Boys and men can'tbe willing victims. Let's suppose that a 350-pound NFL noseguard decides to have his way with you. What do you think will happen? Boys and adult males are often physically weaker than their attackers or are threatened with weapons. Or the perpetrator may have power and control over the victim through position, influence, knowledge, and prestige. There is essen- tially no difference between males and females in regard to this myth .

2. Homosexuals are usually the perpetrators of sexual abuse of boys. Pedophiles are pedophiles whether they sexually abuse boys or girls. They are not gays or lesbians but pedophiles who happen to have different sex and age preferences.

3. Boys are less traumatized than girls. While some studies have found boys to be less negatively affected initially, long-term effects are quite damaging, and when the perpetrators are trusted others (which is often the case, as you will read later in this chapter), they become a psychological abattoir for boys.

4. Boys abused by males will later become homosexual. How and why adult sexual orientation develops is a complex question. While being sexually assaulted

CHAPTER NINE Sexua l Assault • 245

• by an adult is almost a guarantee for sexual role confusion, it does not mean one automatically becomes gay as a result (Tremblay, 2013). In fact, with males, our own experience is that a number of those who have been victimized by males become homophobic or overcompensate by attempting to prove their manhood by having sex with as many females as possible. The bottom line is, though, that at present this is only one variable in a multi- tude of variables that influence sexual orientation.

5. Vampire/zombie syndrome. The notion is that once you are bitten you become one. This is an especially dangerous myth because it can stereotype victims as perpetrators when the victims desperately need help rather than punishment, ridicule, isolation, and abandonment. Generally, getting psychological help early on is critical to not become a perpetrator later in life.

6. If a boy (or girl) experiences sexual arousal or orgasm from abuse, this means he enjoys it. We are hardwired for sex. Physical stimulation is likely to happen during sex. That does not mean the child wanted the experience, fully participated in it, or "got off" or "wanted it" as many perpetrators try to rationalize.

7. If the perpetrator is female, the boy just got lucky. This is a widely held belief and a very, very dangerous stereotype. Some of the most disturbed clients we have seen have been children and adolescent boys abused by females in authority positions and consanguine relationships. The conflict, confusion, rage, and other extremely volatile emotions and thinking they display toward women as adults mark them as threats for harm to females . Above all, these boys should receive treatment immediately after discovery of the assault.

For men these myths have profound effects. One of the major ones is the shame, embarrassment, and guilt they feel that militates against coming forward, and there is still considerable stigma attached to be a male who has been raped (Easton, Saltzmanm, & Willis , 2014). The problem is that, even among "edu- cated" people, these myths have remarkable staying power. Heppner and associates (1995) found that col- lege students believed many myths about rape. That study identified many differences in men's and wom- en's perceptions of rape during and after a session on rape prevention intervention consisting of didactic, video, and question-and-answer discussion . During the intervention, both men's and women's attitudes

246 • PART TWO Handling Specific Crises: Going Into the Trenches

showed decreased belief in rape myths; at a 2-month follow-up, however, men had regained more of their former beliefs than women had. Research by Varelas and Foley (1998) indicated that both black and white college students who strongly believed rape myths were more tolerant of rapists and less tolerant of vic- tims than those who had weaker beliefs. In addition, women with strong beliefs in the myths were less likely to report sexual assaults or to assist in legal ac- tions against rapists .

Date and Acquaintance Rape Much of the research reported on date and Im acquaintance rape deals with sexual assaults on college campuses. Little is known about date rape as it applies to high school students, although at this writing there were 4,000 reported incidents of sexual battery and more than 800 reported rapes and attempted rapes (Robers et al., 2010). According to a 2003 U.S. Department of Justice report, rape is the most common violent crime at U.S. universities. The incidence of rape is 35 per 1,000 female college students per year. Women may decline to report rape out of shame, self-reproach for drinking too much, or fear of social isolation from the perpetrators and her friends. Ninety percent of the college women who are raped know their assailants, and most rapes occur in a social situation such as partying or studying together in a dorm room (Cole, 2006).

Because most of you reading this book are sitting in a college classroom, be advised that nearly 20% of your female classmates will be victims of attempted or actual assault, as will about 6% of the men (Krebs et al., 2007). Frazier and her associates (2009) conducted an online survey that examined the incidence of trau- matic events among a large and diverse population of college students. When all of the different types of unwanted sexual contact were combined, they ranked second only to unexpected death in frequency of response to trauma, and Fisher and associates (2003) found that more than 90% of sexual assaults were not reported! Indeed, the really interesting fact in all sex- ual assault reporting is that a great deal of it doesn't get reported at all, so you can assume that any statistic you see is probably a pretty conservative estimate of what is really happening (Kariane et al., 2005; Weiss, 2010).

Mills and Granoff (1992) found that 28% of col- lege women sur\;Cyed acknowledged that they had been victims of rape or attempted rape. In a national

survey of college men and women, Koss (1998) found that 8.3% of the women felt they had been forced to engage in unwanted sex. Conversely, only 3.4% of the men felt they had forced a partner to engage in un- wanted sex. Few told anyone about the encounters, although those reporting attempted rape were more likely to tell someone than were those who had actu- ally been raped. A number of male respondents ad- mitted to committing what is legally defined as rape and admitted to continuing to make sexual advances even when their dates had told them "No!"

One of the bigger myths of rape is: Date rape isn't really rape. The girl went out with him, didn't she? He probably spent a good deal of money on her. What if she kissed him back and engaged in heavy petting? Then she turned him off? That's a "prick tease"! She deserved it and probably even wanted it even though she said no. Even if it was a boyfriend of long stand- ing, and whatever else may have happened before the rape in terms of sexual foreplay, and no matter how much money was spent, "No! " is "No!" and no one has the right or justification to rape a date.

Date Rape Risk Date rape survivors in college have been found to be more likely to have experienced stress, maltreat- ment, and negative home environment/ neglect during childhood than were women who reported no date rape experience (Sanders & Moore, 1999). Date rape participants in the Sanders and Moore study were also more likely to have experienced sex- ual abuse during childhood. Himelein, Vogel, and Wachowiak (1994) suggest that child sexual abuse is an underlying risk factor for both heightened sexual activity and sex ual victimi zation in dating. Shapiro and Chwarz (1997) further suggest that precocious knowledge of sex, confusion about sexual norms, iso- lation, and neediness might predispose a young abuse survivor to early and frequent sexual activity, which may in turn increase the risk of dating victimization.

Candy Is Dandy, but Liquor Is Quicker-and More Violent. Alcohol, partying, sex, and college students combining those activities a lot as they become emancipated from parental governance make sexual aggression shockingly high among male college stu- dents (Shorey et al., 2015). Indeed barroom groping, kissing, and touching are pervasive and seen as part of the course of partying (Becker & Tinkler, 2015), and alcohol consumption has also been linked to date and acquaintance rape as a risk factor (Cole, 2006;

_-orris & Cubbins, 1992). A study by Abbey, McAuslan, = d Ross (1998) found that the mutual effects of .:ollege men's beliefs and experiences with regard to ::acing, sexuality, and alcohol consumption increased ::ie likelihood that a male would misperceive a female .:ompanion's sexual intentions, and that this misper- -. tion might lead to sexual assault. Jozkowski and ~iersma (2015) found that in a large sample of ~dents across the United States that alcohol con- " mp tion prior to sexual activity was associated

ith both external consent (verbal and behavioral .:ues) and internal consent (feelings associated with pving consent). Ominously, childhood sexual abuse !acreases the risk for alcohol abuse, and that in turn ;_;]C reases the chances of engaging in sexually risky :iehavior (Walsh, Latzman, & Latzman, 2014).

In contrast, the use of a date rape drug (gamma i::yd roxybutyrate, or GHB) in the commission of a sex- t:al assault constitutes a premeditated and deliberate z.ssault (Boyd, 2000). Ullman, Karabatsos, and Koss 19 99) found that both victim's and offender's use of

alcohol prior to attack was directly associated with :nore severe victimization of women and that alcohol !.!Se played both direct and indirect roles in the out- ;:omes of sexual assaults.

Schwartz and Leggett (1999) found that women who -ere raped while intoxicated were not less emotionally

affected and did not blame themselves any more than women who were raped by force while not intoxicated. :::r is interesting to note that most of these women did aot classify their experiences as rape, although all were ·;ctims under criminal law. Norris and Cubbins (1992) :'ou nd that three-fourths of acquaintance rapes in- --olved drinking and that if both members of a dating couple had been consuming alcohol, the rape was not _:Udged as severely as when only the woman had been tlrinking. In the latter case, the man was likely to be ,;ewed as taking advantage of a vulnerable woman.

Preventing Date, Acquaintance, and Other Fo rms of Rape _fills and Granoff (1992) and Dunn, Vail-Smith, and Xnight (1999) suggest that continuing educational and supp ort services (for both men and women) are critically ::ieeded to address, in a culturally unbiased manner, the causes and prevention of date and acquaintance rape . Sexual refusal assertiveness and sexual abstinence do :-educe chances for sexual assault (Wigderson & Katz, 20 15), and learning assertiveness techniques seems w be a key ingredient in any education program for women. Assertiveness skills seem critical and reduced

CHAPTER NINE Sexual Assault • 247 •

rape and attempted rapes between experimental and control groups (Senn et al., 2015), less sexual victim- ization (Rowe et al., 2015) and even where there were no differences in sexual assaults between controls and experimentals, women in the experimental group ex- perienced less self-blame than controls (Gidycz et al., 2015). Educational programs, especially at the second- ary school level, have been recommended as preventive measures in reducing date and acquaintance sexual assaults (Page, 1997). Ullman, Karabatsos, and Koss (1999) recommended that rape and alcohol abuse pre- vention efforts can benefit from incorporating infor- mation about alcohol's role in different sexual assault contexts. It seems reasonable that such prevention ini- tiatives should also address strategies to avoid assaults connected with the use of date rape drugs.

Frazier, Valtinson, and Candell (1994) demon- strated that coeducational and interactive rape prevention programs can succeed in the short run. Their preventive interventions, presented to members of fraternities and sororities, showed that partici- pants endorsed significantly fewer rape-supportive attitudes immediately following the interventions than did control group members. But, like Heppner and colleagues' (1995) participants, experimental and control group members no longer differed after 1 month. Indeed, most studies of rape education pro- grams indicate they do not hold up over time (Garrity, 2011; Vladutiu, Martin, & Macy, 2011). Hillenbrand- Gunn and her associates (2010) have taken a different approach to rape education. They conducted a pro- gram for high school students that focused on social norms theory (Perkins & Berkowitz, 1986), which is based on what one thinks one's peers do and believe rather than what the peers actually do and believe. Their program was based on a men as allies philoso- phy and combined it with social norms theory as their theoretical framework . Group psychoeducationalj discussion sessions were administered to both male and female high school students through a variety of formats that challenged sexist, coercive, and abusive behavior that is a precursor to thinking that sexual assault is acceptable. Pre- to postprogram results in- dicated that attitudes changed in the experimental group and not in the control group. The results of this methodologically sound experiment held at a 4-week follow-up for both males and females suggest that it holds promise as a creative approach focusing on peers, a formidable force for this age group. Clearly, the research indicates that rape prevention pro- grams should be comprehensive and ongoing, rather

248 • PART TWO Handling Specific Crises: Going Into the Trenches

than programmed as onetime interventions. Rowe, Jouriles, and McDonald (2015) used a MY Voice, MY Choice assertive resistance training program that used a virtual immersion program emphasi zing assertiveness skills and found at 3-month follow-up that the adolescent girls reported less sexual victim- ization than a wait list group. They also found that psychological victimization and psychological dis- tress were reduced for those girls who had greater prior victimi zation at baseline. Daigneault and her associates (2015) conducted sexual assault awareness workshops for 15- to 17-year-old high school students and were effective in improving general knowledge regarding sexual assault and awareness of resources in the event of experiencing sexual assault. They also found improved attitudes regarding sexual assault along with their ability to recognize sexual assault in a dating context and diminish responses that deny or minimize assault awareness workshops.

Finally, studies by Sawyer, Pinciaro, and Jessell (1998) on the effects of coercion and verbal cons ent on university students' perception of date rape con- cluded that, in an act legally defined as rape, male students are generally more prone to deny that a rape occurred unless an assertive or aggressive "No!" is verbalized by the potential victim . The value and effect of profoundly verbalizing "No! " in situations in which women are vulnerable to rape cannot be overestimated.

Perhaps even more disheartening, Kassing and Prietio (2003) found that male counselors-in-training who had no experience working with sexual assault victims were willing to believe myths about male rape victims, and both male and female counselors- in-training believed that the male victim should have resisted more. The conclusion with regard to training therapists is clearly that they need to be disabused of some myths about sexual assault!

Intervention Strategies for Rape and Battery: The Case of Melody Melody Swanson is a SO-year-old teacher. IDl'I She has been living alone in a small house since the younger of her two children went away to college 2 months ago. Melody was divorced 7 years ago. She had a long weekend off from school and decided to go away to a casino for a minivacation. When she returned home from her trip at 9:30 yesterday evening and emerged from. her car in her driveway, she was met by a gunman in his middle 20s.

She dropped a small bag of groceries and some items from her purse as she was abducted at gunpoint and forced into the gunman's car, which was parked on the street. Melody was beaten, driven away to an isolated area several miles from her home, raped, beaten again, robbed, and abandoned, bleeding and bruised, with her clothing in shreds. She was weak and dazed, but managed to find her way to the nearest house in the early hours of the morning, where she called for help. It is now 8:30 A .M . and Melody is at the trauma center of a hospital in a large metropolitan city, where she has just been taken by the police. Melody is experiencing physical and emotional trauma. She personifies a traumatized person. She is in shock, shaking and trembling, has both eyes black, numerous contusions, abrasions, and cuts, and is still in the muddy clothes she was abducted in. She is about to meet what will become a very important person in her life - a crisis worker from the local sexual assault and domestic violence center who specializes in rape cases.

Immediate Aftermath In most situations the most helpful and appropriate immediate response from a crisis worker is empathy and assurance that the survivor is still alive. Nowhere in crisis intervention is it more important to provide the core facilitative conditions of building trust, dis- playing unconditional positive regard, using empathic listening and responding, providing concreteness and clarity, and demonstrating patience. The crisis task is predispositioning the client in regard to what she is going to go through, from vaginal examinations to police questioning to the acute stress symptoms that are likely to follow the initial onslaught of emotions she is now experiencing. The worker is going to quickly build what in the psychotherapy trade is called a working alliance (a cooperative and trusting work- ing relationship) . Melody's rape is a case in point of how this operates in the immediate aftermath of a trauma. Cloitre and her associates (2004) report that building this alliance is as critical as , if not more important than, mastery ofany intervention techniques.

The impact stage (Matsakis, 2003, pp. 82 - 90) occurs during the assault and for approximately 2 weeks following it. During this time a kaleidoscope of emotions, thoughts, and behaviors may occur, or conversely the client may be in a state of shock and dissociation, with both physical pain associated with the sexual assault and dissociation, somatic reactions, hypervigilance, nightmares, and startle

:-esponses that are symptomatic of the acute stress di sorder that often follows. Stability both from a ?hysical and psychological standpoint are critical at m is time (Briere & Scott, 2006, pp. 273). It is the cri- sis worker's job to do a number of things as soon as [he client comes into the hospital or the crisis center.

Some sense of control needs to be restored so the cl ient can go through the physical exam and police report. Paramount is restoring a sense of safety and security to a person whose world has just been turned upside down. To do this , the crisis worker must ac- cu rately assess the client's state of mobility and equi- :.ib rium and gently but also with assuredness and confidence enter into this upside-down world. The wo rker needs to gather information while walking a therapeutic tightrope between sensitivity and the need to ask specific behavioral closed-ended ques - tions. Maximum sensitivity means using empathic p refacing statements followed by gathering behav- io ral information on the assault. To ask for informa- tion without voicing sincere concern for the person's u auma is not only callous and insensitive, but likely will terminate intervention before it starts (McCart et al., 2009). To that end, it is critical that the crisis wo rker immediately start the predisposition task of our crisis intervention model. Courtois and Ford (2 009) propose the following capstone statement in regard to treating survivors of prolonged complex trauma, but we believe it also fits well here. Your job at this point is to provide relational conditions that encourage the safety of the attachment between the cl ient and the worker (p. 190), and this may be any- t h ing but easy for you or the client.

CW: (talking slowly while she gently picks up Melody 's hand in an examining room in the ER) Hi, Melody, I'm Jolee Mabry. I am a counselor from the Metro Sexual Assault Unit. You have been through a terrible ex- perience, that no one should ever go through, but you survived it. I can't begin to know what it feels like to experience all the feelings and thoughts you are having right now, but I do understand as traumatic as this is you have survived and I am going to be with you while you go through this, if you would like.

Melody: (looking fearful and strugglingfor words) I don't ... I don't know ... what to think, do, ... what will happen? Where is he? Who was he ? Why me? Can he get in here? So many things ... I ... I am so cold and it feels like my heart is about to pound through my chest. Is this a nightmare? But I know

CHAPTER NINE Sexual Assault • 249

it's real ... I think. Where ... am ... I? I'm so sorry. I ... I ... I don't remember your name. Who are you?

CW: (Picks up a blanket and gently pulls it around Melody.) I'm Jolee Mabry. I am a nurse and a counselor at the sexual assault center here. You are safe here. You were brought here by the paramedics and the police. You are in the Elvis Presley Trauma Unit. I'm Jolee Mabry, a counselor here in the trauma unit. You were beaten physically by the man who assaulted you and the paramedics brought you here. You were raped and assaulted, that is very real. That's why you are here to get taken care of, and we do a very good job of taking care of people who have been sexually assaulted. That is my job, to take care of you, steer you through this experi- ence and act as your advocate and just take care of things for you. Do you understand what I just said and know where you are?

Melody: Yes. What's going to happen to me? (Starts to shake.)

CW: (Reaches over and slowly strokes the client's arm with her hand and holds her other hand.) I can't say it will be pleasant, but the medical staff and police officers who deal with sexual assault here know their busi- ness . The nurse who will do the rape kit exam is a specially trained Sexual Assault Nurse Examiner (SANE). She will make it as painless as possible. You will be asked by the police to describe what happened, and there will be a number of medical procedures. As I said, I'll be with you every step of the way, and when they are done I'll be with you to make arrangements to see that you stay safe and do what's necessary to get some stability and con- trol back in your life.

Melody: Absolutely, please stay. (Grabs Jole e's hand and grips it.) It was horrible-the rape. I don't know how I came out alive and without any broken bones. He intended to kill me. Part of the time I was in a daze . I don't know what came over me. I must have blacked out. He may have thought I was dead. I don't know how long I lay out there alone after he left me. I certainly didn't fight back or protest. Look at me, I am so dirty. (Recoils in disgust.)

CW: Melody, I'm so proud of you for the way you handled it. You did whatever it took to stay alive. You saved yourself, and that took courage. What- ever you did, whether it was blacking out or offer- ing no protests, was right, because it preserved your life, and that's the important thing right now. We are going to get those clothes off of you and get you

250 • PART TWO Handling Specific Crises: Going Into the Trenches

cleaned up, but we need to get some pictures and take some samples first, so hang in there a bit longer.

Melody: I feel so damn stupid. Always watchful and just let my guard down. So damn angry at me. I'd kill that bastard ifI had a chance. Shoot his nuts off! Lord! Did I just say that! I don't say things like that, but that scurrilous low life SOB ... degrading ... How can I go back to face my students .. . I feel like I'm in a sort of twilight zone. Maybe part of me did die. I'm feeling so alone and vulnerable. It's like this whole damn thing isn't real. It couldn't be happening to me, but I know it is. I know I keep going back to that and all this whirl . .. I don't know if I can hold it together.

There is no universal response to rape. Melody rep- resents a few of the conflicting emotions that rampage through someone who has been sexually violated. Dis- sociative responses are a common defense mechanism to try to bring some stability back into the survivor's life as a whirlwind of emotions blow through the sur- vivor's mind. The laundry list of responses that follows this dialogue represents a good deal of, but not all of the dirty emotions the client is trying to wash out of her mind. The crisis worker's job is to continuously provide support, safety, and practical assistance. While it may seem to be minimizing and discounting the gravity of the situation to call it psychological first aid (National Child Traumatic Stress Network and National Center for PTSD, 2006; National Insti- tute of Mental Health, 2002), that is exactly what the worker is doing. Psychological first aid comprises three primary tasks of our intervention model: predisposi- tioning/ bonding, exploration/ assessment, and safety. However, how this usually gets done is anything but stepwise. Crisis workers who ply the trade in the field of sexual assault are indeed engaging in a stand-up act where they have to be quick in changing strategies and responses to meet the kaleidoscope of emotions that may range from catatonic-like shock to unbridled rage.

CW: It's really scary, the thought oflosing control with all those thoughts and emotions racing around in your head, Melody, but that is common for sexual assault survivors. It may be hard to imagine, but your mind and body are attempting to get order back into what for the past few hours has been complete chaos. It's your mind and body's normal defensive response to a completely abnormal situ- ation. It will pass , and to help move that process along we are going to take this piece by piece, one step at a time, until you get control back.

Melody: I don't know. I guess , but . . . (Pause, with appre- hensive look.) I'm a teacher, I maintain control, but I just can't seem to get a handle on this ... (Starts to break down again with muffled sobs.) I'm so sorry, I'm such a mess , and can't get a grip.

CW: You don't have to be sorry about anything. You are not a mess. Grief is also part of this. You have lost a lot tonight. (Sits patiently while Melody holds on and sobs quietly with her arm around her.)

The crisis worker acknowledges her grief, which is a common response to the many losses the client has suffered (Matsakis, 2003, pp. 111-127). She also starts to slowly give her information about the psycholog- ical processes occurring within her as a start to de- veloping coping skills and regaining emotional and cognitive control. It is important to start providing basic psychoeducation to clients who are experienc- ing extreme psychological stress (McCart et al., 2009). Melody is suffering from what we call peritraumatic stress symptoms. Those are traumalike symptoms that almost all persons would suffer given similar cir- cumstances . Whether these symptoms turn into acute traumatic stress disorder, which we discuss in other parts of the book, or turns into PTSD will depend a lot on what happens in the next few hours and days. The worker has to be judicious in how much information on psychological coping mechanisms she gives out to avoid cognitive overload. Indeed, engaging in any for- mal therapeutic intervention or formal assessment in the next few days is not recommended. What is recom- mended is planning thoroughly for the next few hours and days to keep the client safe, supported, and sta- bilized. Healing from a rape requires concentration, effort, thought, and time and cannot be rushed (Matsakis, 2003, p. 14).

CW: This whole procedure is going to take about 3 to 4 hours to complete. We want you thoroughly checked out in regard to not only your sexual assault but the physical assault as well. The police will interview you. Lt. Lenise Balay is going to do the interview. She and I work together a lot on these cases, and I trust her completely. She is one of the most empathic po- lice officers I know. She will ask you some pretty pointed questions, but understand she wants to get this just right so we can catch who did this to you. You are also going to get a pelvic exam and a rape kit done. Andrea Little is a SANE nurse who specializes in doing this. It won't be pleasant, but again she is a specialist in this business and will be very thorough and gentle. I'll be with you every step of the way. OK?

This is a brief synopsis of the practical medical 2.lld legal information the worker gives the survivor. Ji rape cases, thoroughly explaining what is going :o h appen is critical to not secondarily revictimizing :he survivor. The sensitivity that needs to be mani- :est ed in doing a rape exam is best demonstrated in 3ennett's (2015) article on getting a bra drive going :or raped women who did not want the embarrass- :nent of going braless by having to turn their bras over Eo r evidence. The Riverside county multidisciplinary Sex ual Assault Response Team conducted a very suc- cessful bra collection drive so the SANE nurse could ::-ep lace the survivor's evidence bra. Sexual Assault Re- sp onse Teams (SARTs) are growing multidisciplinary rea ms that provide a variety of support and coordina- rion services for sexual assault survivors throughout the country (Moylan, Lindhorst, & Tajima, 2015).

CW: (after the police lieutenant and SANE nurse are done) Excellent! Dr. Zanzar has gone over all your tests and has okayed your release. You got through that well. Where would you like to go and who would you like to be there with you, someone you really trust?

M elody: Well, my brother, Tom. I'd want him there with me. He's an ex-Marine. Although I don't know how he'd feel about all this and his stupid sister who he's always yapping at to be more vigi- lant and careful. God! I just feel so ashamed to let him know this happened. But I don't know ifI can go back in my driveway or not. That's ridiculous but it still scares me, just the thought of it ...

CW: I understand how you could feel that way, and the last thing you want to do is tell him about this. Would you like me to call him and get him down here and talk with him? I have done this before and I think I can help you out with that.

Using Support Systems and Stopping Secondary Victimization. In the immediate aftermath of l!!iJ rhe rape, getting support and safety measures in place is a high priority, as is educating the significant others in the survivor's life to the foregoing dynamics. A critical component is steering the person through the m edical and police procedures that can have a high po tential for secondary victimization (Howell, 1999; O chberg, 1988; Pauwels, 2003). Secondary victim crisis intervention may also be necessary if there are persons in the support system who might either be- co me homicidal or turn on the survivor and blame her (Pauwels, 2003). Particularly husbands , fathers , and

CHAPTER NINE Sexua l Assault • 251

boyfriends may need very firm, cl~ar instructions on how they are going to meet the survivor in their first encounter. The difficulty of this initial encounter af- ter the rape cannot be overemphasized. Both from the survivor's and significant others' standpoint, it may be very easy to affix blame as a way of trying to make sense out of what happened. Secondary victimization must not be allowed to occur, so the crisis worker's job will be to educate the significant others on how they can best support the client.

Therefore, it is extremely important that a coun- selor from a rape crisis or sexual assault unit be contacted immediately, as in the preceding example . A nationwide nursing service called the Sexual Assault Nurse Examiner (SANE) program provides specially trained nurses for first response medical care and crisis intervention. The SANE program pro- vides comprehensive and consistent postrape medical care, such as emergency contraception and sexually transmitted disease prophylaxis, documents foren- sic evidence accurately, provides expert testimony, promotes psychological recovery, and coordinates mul- tiple service providers to provide comprehensive care for rape survivors (Campbell, Patterson, & Lichty, 2005).

CW: (Meets brother Tom at the center reception desk .)

Tom: (excited, agitated, and loud) What's this all about? What's going on with my sister? What's she doing at the Rape Crisis Center? Is she in trouble? Did she get raped? WHAT THE HELL IS HAPPENING AND WHERE IS MY SISTER?

CW: Your sister has been beaten and sexually as- saulted and .. .

Tom: What the . . . where did it happen ?

CW: In her driveway, about 9:30 last night. She was just coming back from the casino.

Tom: Casino! What the hell was she doing at the ca- sino? Jesus Christ, when I get hold of her ...

CW: (Becoming assertive and using a well-modulated but commanding voice, immediately interrupts his ranting.) I understand that you were in the Marines, so tell me this . Is it the Marine Corps creed if a guy gets wounded to go yell at him and tell him how stupid he has been?

Tom: Well no I .. . um ... but this is different.

CW: Tell me how so. You took care of your wounded buddies, didn't you? What was your rank anyway?

Tom: Well, uh . .. Master Sergeant. But, uh ... I don't see what that's got to do with it.

252 • PART TWO Handling Specific Crises: Going Into the Trenches

CW: (well-modulated but clearly assertive) I'll tell you what, Tom. I didn't get a chance to introduce my- self I am Jolee Mabry, a counselor and nurse with the sexual assault center. I was a nurse in the Gulf War, wore the Eagle, Anchor, and Globe (Marine Corps insignia) myself First Lieutenant Mabry, USMC retired, at your service. I served in Saudi Arabia and Iraq with mobile surgical units there. If you are as good a marine as I think you are, you retrieved your wounded and did everything pos- sible to keep them alive and safe, did you not? Is that correct, Master Sergeant Swanson?

Tom: (sort of snaps to attention and in a rather tentative voice) Yes, ma'am. That is ... uh ... affirmative, ma'am.

CW: Good, so you have a wounded sister. You know about PTSD, right? We don't want her going out on a date with that now, do we? What she needs is all the care and support you can give her, don't we now? No blame, no fault finding , don't you agree? No going out hunting the bad guy because your job is taking care of your troop, and your sister is surely that and more, is she not? A lot of care and understanding, compassion and empathy, for the terrible combat experience she has been through, and make no mistake, it is indeed that. So, Master Sergeant Swanson, can you take this mission on, or do I get somebody else?

Tom: Yes , Lieuten . .. uh, er, ma'am. I can certainly do that.

CW: Semper Fi. Now go in there and take care of your sister. Hold her and tell her how much you love her and take her home. Also tell her how brave she was and how smart she was to survive this. You can- not give her too many "way to go's"! Got it? I'll be in touch with both you and her. Here's my card. If you need help, call me. Marines look out for one another. I'll be back with you two after you spend some time together.

Tom: (sheepishly, wringing his baseball cap in his hands) I am sorry for my initial behavior, ma'am. I was pretty wound up. I am squared away now. Thank you for straightening me out. I won't mess this up .

Secondary victimization of a rape victim is al- ways close at hand. It is certainly not uncommon for relatives to become angry and blaming of the victim when they are confronted with news of a rape as they seek to get control over what they perceive as an un- controllable situation. The crisis worker changes her

approach as soon as she detects the brother's nega- tive attitude and becomes very directive with lots of "I" assertion statements to get the brother's attention. She lays something of a guilt trip on him to get his attention and change his cognitive sets about what needs to happen. She uses a technique that we would generally be critical of, but works well here. That is, she uses a number of negative interrogative state- ments ("Don't you think/ agree?") that ask for agree- ment with her point of view. By doing so, she shifts focus to positive rather than negative support for this wounded survivor.

Although you are probably not a marine nor usu- ally would by chance meet a survivor's brother who was, the crisis worker manifests the best of creative and adaptive thinking to create a bond and reframe this in terms he can understand. Although he is not now an active sergeant, she knows that once a marine always a marine and that's why her responses aren't to "Tom" but "Sergeant Swanson." That's an all-star per- formance which goes to the heart of the adaptability that great crisis workers have.

CW: (Reenters the room with Melody and Tom.) You're going to have a lot of different reactions to this. They are not the same for every person, so don't be alarmed if you have some and not others. We will talk about all of this when things settled down. People have lots of different ways of coping with this . The main thing is for you to feel as safe and secure as you can. I am going to give you a number that is on call 24 hours a day. Do not feel guilty about calling. I am going to be your main contact from the Center, so don't be afraid to call me. I will be doing some checking in with you, if that is OK.

The crisis worker's intuition is right when she guesses that the place of safety and comfort for Melody would be her own home but that the frightening part would be getting past the place in her driveway where she was abducted. The crisis worker is also correct in reassuring Melody for her actions, which brought her out alive. Clients will immediately begin second-guessing themselves as to what they should have done and negative emotions of guilt, shame, and embarrassment will start building (Courtois & Ford, 2009, p. 188; Matsakis, 2003, pp.118-119; Weiss , 2010). The crisis worker dispels this notion by clearly and empathically stating that what she did was just right because it got her through the ordeal and out the other side alive. If she is able, the crisis worker immediately starts education in gentle and small

d oses. Primary education concerns getting the client di rough the next 24 hours, which are indeed going to

e unreal for her. Her brother is a critical support and will need to be given some primary education about ra p e dynamics.

An important issue for rape survivors is control. Whatever will allow Melody to bring some control back in her life is important to do and is a major goal .or the crisis worker. That may or may not be attempt- ing to remember details of the assault. She may want w take a long, hot shower, or just sleep. Melody has experienced an emotionally draining loss of control rn the attacker, and she needs to be reassured that her loss of control is neither total nor permanent. She did what she had to do to survive, and that took courage. fr is important to her for others to recognize her and

ive her credit. There is no wrong way to survive a rape 'H owell, 1999)! Nonjudgmentalism and support are cr itical so that the client immediately starts moving from victim to survivor status (Ganas et al., 1998).

Responses. Women may exhibit a wide variety lml of responses to the rape and the subsequent recovery process (Benedict, 1985; Matsakis, 2003, pp. 81-98; Williams & Holmes, 1981). The female who 1s assaulted:

1. May respond by exhibiting no emotions-appearing unaffected.

2. May feel humiliated, demeaned, and degraded. 3. May suffer immediate physical and psychological

injury as well as long-term trauma. 4. May experience impaired sexual functioning. 5. May blame herself and feel guilty. 6. May experience difficulty relating to and trusting

others-esI?ecially men. . 7. May experience fantasies, daydreams, and mght-

mares- vividly reliving the assault or additional encounters with the assailant-or may have men- tal images of scenes of revenge.

8. Will never be the same, even though most survi- vors, over time, develop ways to recover, cope, and go on with their lives.

9. May be fearful of going to the police or a rape cri- sis center.

10. May be reluctant to discuss the assault with mem- bers of her family, friends, and others because of the risk of rejection and embarrassment.

1 1. May become severely depressed and suicidal. 12. May be extremely angry and revenge seeking to

the point of becoming lethal.

CHAPTER NINE Sexua l Assault • 253

The Following Three Months Rape has high potential for PTSD, depression, IDB suicide, panic attacks, generalized anxiety disorder, social adjustment disorders, sex ual dysfunction, eating disorders , dissociation, and more negative worldviews and cognitive distortions . The crisis worker must not let the client regress and retreat into the past. Blaming external factors , self-blaming, and perseverating on why the rape happened are not help- ful along with the guilt of "What if-ing?" oneself to death about where one was, what type of clothing one wore, not paying attention to surroundings, and on and on (Frazier et al. , 2001 ; Matsakis, 2003, pp. 81-98; Weiss , 2010).

Follow-up, proactive, and continuous supportive therapy is essential and may include any of the fol- lowing topics (Ganas et al. , 1998, 1999; Howell, 1999; Matsakis, 2003; Pauwels, 2003).

Critical Needs. During the 3 months following a sexual assault, a survivor such as Melody:

1. May need continuing medical consultation, advice, or treatment; she may experience soreness, pain, itching, nausea, sleeplessness, loss of appetite, and other physical and somatic symptoms.

2. May have difficulty resuming work; the added stress of the sexual assault may create too much stress in the workplace.

3. Needs to have people reach out to her, listen to her, and verbally assure her-not shun her or fear continuing to relate to her.

4. Needs the acceptance and support of family and fri ends.

5. May have difficulty resuming sexual relations and needs understanding without pressure.

6. May exhibit unusual mood swings and emotional outbursts, which others will need to understand and allow.

7. May experience nightmares, flashbacks , phobias, denial, disb elief, and other unusual effects.

8. May go into depression, which may be accompanied by suicidal ideation or acute traumatic stress disorder.

Critical Supports. Support people can be of great help during this phase of recovery. In fact , one of the most important things a crisis counselor can do is getting and coordinating support systems in place. The recover y of survivors of sexual assault is enhanced by

254 • PART TWO Handling Specific Cr ises : Going Into the Trenches

the empathic help and understanding of the people close to them. Whether the survivor's support people are family, friends, associates , medical or legal per- sonnel, crisis workers, or long-term therapists, the important ingredients in the helping relationship are acceptance, genuineness, empathy, caring, and nonjudgmental understanding (Baker, 1995; Benedict, 1985; Howell, 1999; Remer & Ferguson, 1995). These support people can help survivors of sexual assault by:

1. Understanding and accepting the survivor's changed moods, tantrums, and so on, and allow- ing her the freedom to act them out.

2. Supporting and being available- but not intrud- ing-while encouraging her to regain control and to recover her life.

3. Ensuring that she doesn't have to go home alone (without overprotecting her).

4. Realizing that recovery takes a long time and lots of hard work.

5. Allowing her to make her own decisions about re- porting the rape and prosecuting the assailant.

6. Leaving it up to her to decide whether she wants to change jobs or place of residence.

7. Responding to her in positive ways, so she does not sense that the support person blames her for "letting it happen" or feels she is not capable of taking care of herself.

8 . Allowing her to talk about the assault to whom- ever she wishes, whenever she wishes, but not dis- closing the assault to anyone without her prior consent.

9. Showing empathy, concern, and understanding without dominating her.

10. Recognizing that she will likely suffer from low self-esteem and finding ways to show her that she is genuinely valued and respected.

11. Recognizing that her hurt will not end when the physical scratches and bruises are gone- that her emotional healing will take a long time.

12. Finding ways to help her trust men again- assist- ing male associates (friends, coworkers, brothers, her father) to show tolerance, understanding, and confidence.

13. Encouraging female coworkers, friends , sisters, and her mother to believe in her and not avoid her or avoid talking with her openly about the rape.

14. Including her children, if she has any, in many of the considerations concerning help toward emo- tional recov~ry.

15. Referring her to sexual assault support groups for survivors and family members .

16. Recognizing that her husband, partner, or lover may develop symptoms similar to those of the sur- vivor (nightmares, phobias, rage, guilt, self-blame, self-hate, and such) and may need help similar to that needed by the survivor herself.

17. Encouraging her husband or lover to give her time to recover, free from pressure, before resuming sexual activity and to let her know he or she is still interested in her, still desires her, but that former patterns of sex life will be resumed at the survivor's own pace. It is important for a husband or lover to talk this out openly with her, to clear the air for both parties.

The foregoing is not a grocery list to just be handed to support persons. It is something that the interventionist needs to do as part of a psychoeduca- tion program that lets people know what to expect and works with them as they struggle through what will be a period of transcrisis events and points .

PTSD. As previously indicated, rape ranks sec- lmliJ ond only to combat in the potential for PTSD. Because it is a less noxious approach, your authors would first use EMDR as a therapeutic intervention. It is far less intrusive than the cognitive-behavioral approaches generally recommended. If EMDR didn't work, then we would use a combination of the three recom- mended cognitive-behavioral treatments (Briere & Scott, 2006; Cloitre & Rosenberg , 2006; Courtois, Ford, & Cloitre, 2009; Foa & Rauch, 2004; Frazier et al. , 2001):

1. Exposure treatment, which calls for repeated emo- tional recounting of the traumatic memory

2 . Affect regulation, which focus es on teaching cli- ents skills to reduce painful internal emotional states

3. Cognitive therapy, to replace dysfunctional cognitions with new, more adaptive thoughts

These procedures will be demonstrated shortly in this chapter in the case of Heather, an adult survi- vor of childhood sexual abuse. Two supplementary therapy issues that are specific to rape need to be mentioned. First, there is the fact of opening up the old wound of the rape. Confronting the rape may be painful, but it is absolutely necessary, and the client needs to clearly understand what is going to happen. However, opening this wound, whether it be the re - cent rape of Melody or the old ones of Heather's ado- lescent abuse, needs to be done in a carefully gauged manner. To start exposure therapy means pushing

away defenses that are in place to keep the client sta- :.:>i li zed, although that stability may be anything but aealthy (Courtois, Ford, & Cloitre, 2009). However,

ecause these defense systems are being rent asun- er, sexual assault survivors have a tendency to go

:-arher blindly in harm's way. While therapy is occur- ri n g, they are almost a sure bet to experience tran- sc risis points as they form new defensive systems and coping mechanisms. As a result, it is not just the ?sychological safety but the physical safety of the cli- ent's with which the worker needs to be concerned.

Adult Survivors of Childhood Sexual Abuse Th ere is ample evidence that the sexual abuse lmll of children wreaks lasting damage in their lives that continues into adulthood (Briere & Runtz, 1987, 1993; Briere & Scott, 2006; Browne & Finkelhor, 2000; Courtois & Ford, 2009; Kessler & Bieschke, 1999; Lamoureaux er al., 2012; Maschi et al., 2013; Mitchell & Morse, 1998; Rosencrans, 1997). If survivors are left untreated, they ;nay experience recurring episodes of revictimization and exhibit debilitating symptoms (transcrisis points) for many years (Briere & Runtz, 1993; Cloitre & Rosenberg, 2006; Davis, Combs-Lane, & Jackson, 20 02; Kessler & Bieschke, 1999; Noll et al., 2003; Van Bruggen, Runtz , & Kadlec, 2006).

Psychological Trauma and Sequelae Effects on Adult Survivors. Histories of adult survi- vo rs of childhood sexual abuse show higher incidence of (1) depression, anxiety, shame, and humiliation Briere & Conte, 1993; Briere & Runtz, 1988; Browne

& Finkelhor, 2000); (2) borderline personality disor- de r, dissociative disorder, and posttraumatic stress di sorder (Briere & Runtz, 1993; McLean & Gallop, 20 03; Mitchell & Morse, 1998); (3) social stigma- rization, alienation, inhibitions, introversion, and interpersonal hypersensitivity (Browne & Finkelhor, 20 00; Lundberg-Love et al., 1992); (4) more contacts with medical doctors for somatic complaints including ch ro nic pain problems, such as fibromyalgia and irri- rable bowel syndrome, and long-term serious physical ile alth deficits such as pulmonary, heart, and liver dis ease, unintended pregnancy, and obesity (Hertel & !oh nson, 2013; Kendall-Tackett, 2008; Moeller, Bach- :na nn, & Moeller, 1993; Stevenson, 1999); (5) negative self-image (Courtois, 1988; Herman, 1981); (6) poor interpersonal relationships and poor parenting skills Browne & Finkelhor, 2000); (7) suicide (Ullman &

CHAPTER NINE Sexual Assault • 255

Brecklin, 2002; Tripodi & Pettus-Davis, 2013); (8) substance abuse (Bender et al., 2015); (9) incarcera- tion in prison (Tripodi & Pettus-Davis, 2013); and (10) probably worst of all sexual revictimization (Waldron et a l., 2015; Zlotnik, 2014) . Yet these are not all of the evil bumblebees that fly out of the Pandora's box of childhood sexual assault. Hertel and Johnson (2013) found in their examination of over 17,000 respon- dents to the Adverse Childhood Experiences study, that the higher the number of adverse experiences children suffered the worse the effects became. Those pernicious effects ranged across physical health prob- lems such as obesity, heart and liver disease, sexually transmitted diseases, unintended pregnancies, part- ner violence, illicit drug use, suicide attempts , and other mental health and emotional issues.

A long list of studies have found that a significant number of female clients (institutionalized, outpa- tient, psychiatric patients, and clients in clinics) were sexually abused as children (Briere & Runtz, 1987; Hertel & Johnson, 2013; Kessler & Bieschke, 1999; Maschi et al., 2013; Salter, 1995). Adult female survi- vors consistently demonstrate symptoms similar to those of Vietnam veterans, in addition to compulsive sexual behavior, sadomasochistic sexual fantasy, sex ual identity issues , and loss of sexual interest (Briere & Runtz, 1987; Courtois, 1988; Finkelhor, 1979; Herman, 1981; Mitchell & Morse, 1998). And, like combat veterans, child sexual abuse survivors are prone to use alcohol and drugs to submerge bad memories from awareness, as well as to engage in sui- cidal ideation and attempts (Duncan, 2004; Hien et al. , 2009; Rew, 1989; Ullman & Brecklin, 2003) .

Male survivors who were abused by adult males fare no better and report essentially the same symptoms, with concomitant sexual orientation ambiguity, mistrust of adult males, homophobia, hypersexuality, poor physical and mental health, lower emotional and social support, reduced activity, and body image disturbances (Choudhary, Coben, & Bossarte, 2010; Gartner, 2005; Lew, 2004; Myers , 1986; Rowan, 2006). Perhaps more impor- tant, Monk-Turner and Light 's (2010) study of men who had been sexually assaulted and raped found that if actual penetration of a male 's body occurred, it was the major variable in not seeking treatment.

Revictimization. Many of the foregoing symptoms appear to be even more profound and multiple if women suffered both sexual and physical assault in childhood (Cloitre & Rosenberg, 2006). Early assault

2 5 6 • PART TWO Handling Specific Crises: Going Into the Trenches

is additive, and it appears that the higher the incident rate and the more profound it is, the higher the po- tential for later problems. If the abuse continues into adolescence, the potential for adult sexual assault also increases (Van Bruggen, Runtz, & Kadlec, 2006). Further, if both sexual and physical abuse occur in childhood and adolescence, the chance for revictim- ization again increases (Ullman & Brecklin, 2003). Survivors of childhood sexual abuse do not usually experience repetition of their victimization on the conscious level; that is, they do not intentionally precipitate abuse . It may be that revictimization or repetition of the sexual abuse tends to recur through the survivor's reenactment of the physical, sexual, or emotional abuse that was experienced during childhood (Schetky, 1990). Just like their female counterparts, males who were sexually assaulted in childhood are more likely to be assaulted as adults (Aosyed, Long, & Voller, 2011).

Our own feeling from treating such clients is that they have received very few of the typical parental warnings and admonitions that would naturally have been taught to them if they had had a normal child- hood. As a result, they tend not to be aware of or reac- tive to warning signs and cues that would say to most people, "This is not a safe place to be or a safe thing to do or a safe person to be with." They also may respond very much as our combat veterans do by engaging in risky behaviors to achieve adrenaline highs that let them know they are "still alive and kicking." Because of this , the crisis worker needs to provide psychoedu- cation on warning signs and cues that may stop survi- vors from blithely going into dangerous settings and engaging with people who will do them harm.

Child Abuse as a Predictor of PTSD. Child sexual abuse has been shown to predict the development of PTSD in later life (Darves-Bornoz et al., 1998; Kessler & Bieschke, 1999; Pfefferbaum, 1997; Regehr, Cadell, & Jansen, 1999). In a comparison of the prevalence of PTSD and other diagnoses in abused children, Ackerman and associates (1998) studied three groups: sexual abuse (SA) only, physical abuse (PA) only, and both (BOTH). Children in the BOTH group had more diagnoses overall. PTSD was significantly comorbid (disorder or trauma caused by two variables) with most affective disorders. A younger age of onset of SA and coercion to maintain secrecy predicted a higher number of total diagnoses. Also, children had more diagnoses when PA had come from males rather than from females. The research of Darves-Bornoz and

associates (1998) indicated that adding physical as- sault during the rape of children was predictive of chronic PTSD. However, to suppose that PTSD is the only or major pathological outcome of child sexual abuse is to severely underestimate the negative con- sequences that accrue . Developmental processes associated with affect regulation and interpersonal relational skills may be severely disrupted and pave the way for future assaults (Cloitre & Rosenberg, 2006).

False Memories The "false memory" concept, applied to work lm:D with both adults who were abused as children and perpetrators of abuse, has raised concern and contro- versy among human services workers (Rubin, 1996). This debate raged in the 1990s, and while it has now subsided you should understand that it still plays a role in criminal defense of accused abusers. The Fals e Memory Syndrome Foundation was created in 1992 by Pamela and Peter Freyd, who had been accused by their daughter of sexual abuse. They propose that false memories occur for three reasons . First is coun- tertransference, in which mental health professionals who have been abused themselves plant the memories to exact revenge and satisfy their own power needs. Second, angry adolescents who are seeking emancipa- tion lash out at their parents by making accusations of sexual abuse. Third is the child who projects her own strong sexual feelings onto the father as his own toward her (Freyd, 1993). The studies oflost and dis- torted memories of childhood traumas by Bremner (1998) have raised doubts about the degree to which traumatic memories are susceptible to distortion due to misleading and suggestive statements (as may oc- cur during psychotherapy).

The findings also suggest that stress as well as the adult's neuroanatomical conditions can lead to mod- ifications in memory traces. Studies indicate that a significant percentage of women claiming abuse have only foggy memories of the sexual abuse and some have little, if any (Briere & Conte, 1993; Elliot & Briere, 1995; Williams, 1995). Leavitt (2000) confirmed that women who had been sexually abused- both those who had continuous memories and those who had recovered memories of the abuse-produced sig- nificantly different Rorschach interpretations com- pared to those who had not been abused.

Conversely, from their "recovered memory" sur- vey of 154 psychiatrists, Feigon and de Rivera (1998) concluded that the numbers of false accusations of childhood sexual abuse appearing to emerge from the

?sychotherapy of adults constitute a real problem re- ;:uiring public acknowledgment as such by the men- :al health professions. Their study indicates that the s:>ecific content of false memories extracted from cli- mr interviews depends on the particular interviewer, :he way questions are asked, the context in which the ~-irerview takes place, and the emotional state of the :...-irerviewee. Mitchell and Morse (1998 , pp. 67-93) ~ave laid out a clear structure in regard to what kinds o memory systems are involved and how one goes ,;illout legitimately retrieving memories. The worker - ould collect a good psychosocial history and per- son ality assessment but not uncritically accept or -on firm suspicions without corroborating evidence. -:-h e clinician should avoid leading questions, not i'.adeavor to pull up "repressed" memories, remain neu- ::-al, and remember that a particular set of symptoms :nay not be exclusive to sexual abuse (Courtois, 1999).

Your authors' own experiences indicate that at som e unconscious memory level, the sexually abused :erson almost never forgets at least some of the essen- :ial details of the source of the trauma. Knauer (2000, ?- xi) supports our own experience, but she works :nainly with children who are not as far removed ;.:..'1 ro nologically from the traumatic event. Perhaps :::iore important, we find that when sexual assau lt survivors are regressed back to the traumatic event, ~,ey are not much different from any other kind of ?TSD victim in regard to memory, and they start to =..11 in the blanks in the same ways.

The debate notwithstanding, psychotherapy with = d advocacy of survivors should be done by work- ~ who are highly trained and skilled in dealing with :::ie trauma, the repressed and dissociated memory ..5Slles, the risks, and the needs of survivors of child s.c.xu al abuse. Similarly, professionals who deal with ;:-erpe trators ' memories should have a thorough ..:ade rstanding of the complex forms of abuser mem- ~, and forgetting that are frequently encountered.

-:-· e discrepancies, emotions, dissociations, memory ~ :ackouts, and discomfort with traumatic memories =ay affect the way both survivors and perpetrators ::_rceive the past abusive events (Rubin, 1996). To :wit end, anyone who does this work absolutely must

• b ring their own parental or abuse agendas into --era py. We have witnessed such a happening, and - was extremely destructive for clients and the ther-

:.:isr. Clinicians must strive to neither suggest nor -?p ress reports of remembered or suspected abuse -d t rauma. Instead, they must practice from a stance :: supportive neutrality (Courtois, 2001).

CHAPTER NINE Sexual Assau lt • 257

Intervention Strategies for Adult Survivors: The Case of Heather Heather was sexually abused by her stepfather lmlJ regularly from ages 8 through 15. For 20 years she suppressed most memories and emotions related to the sexual abuse, which had included fondling, digital penetration, and intercourse. She has vivid memories of the physical abuse she suffered at both her stepfa- ther's and her mother's hands. It is somewhat ironic that her stepfather was employed as a psychologist at a major university. Now, at age 35, she has regained her memory of the sexual abuse and is experiencing severe symptoms of delayed rape trauma syndrome.

Her marriage is breaking up; her career is in shambles; her communications and relationship with her three children are adversely affected by her personal turmoil; her rage toward her stepfather and her anger toward her mother have robbed her of her self-respect and her affection toward her parents, who live across the state from her. Her only daughter, the middle child, recently had her eighth birthday, and Heather is deeply obsessed with her daughter's safety. Heather feels a great deal of guilt, shame, remorse, and loss of self-esteem. For several years she has been experiencing some suicidal ideation, and since the recovery of her memory of the sexual abuse, this ideation has seriously intensified.

Interventions with Heather included both indi- vidual counseling and support group work, in which she willingly participated. In support group meet- ings, Heather received the encouragement, validation, and information she needed to absolve herself from guilt, shame, and remorse. She also acquired essential advice from support group members on implement- ing safety measures she could take to ensure that her 8-year-old daughter would not fall prey to the kinds of sex ual abuse she herself had suffered. That advice allayed her fears and concerns about her daughter's vulnerability. Often the affirmation and informa- tional resources obtained in support groups are key elements in the emotional healing, fear reduction, en- hancement of self-esteem, and rehabilitation of adult survivors of child sexual abuse. It was certainly so with Heather (Mitchell & Morse, 1998 , pp. 231-238) .

Assessment Particularly among older women such as Heather who suffered childhood sexual abuse under severe societal and family strictures of secrecy and denial, the abuse will be disguised and repressed. Often such clients will

258 • PART TWO Handling Specific Crises: Going Into the Trenches

have been under the care of mental health profession- als and been diagnosed with a variety of mental ill- nesses ranging from schizophrenia to depression to borderline personality.

Presenting problems are typically depression, anx- iety, dissociation, and compulsive disorders (Courtois, 1988). Although the client may present as competent, responsible, mature, and otherwise capable, these characteristics are a facade for underlying emotional problems. Affectively, behaviorally, and cognitively, abuse victims may present themselves in a bipolar manner, rigidly adhering to one end or the other of the continuum-"I'm great" or "I'm terrible"-or rap- idly oscillating between the two (Courtois, 1988).

Triage assessment of these people can be problem- atic, to say the least. At one moment they present as affectively calm and controlled, perhaps to the point of rigidity. At the next moment, because of some real or imagined slight, particularly in interpersonal re- lationships, they may become extremely labile (emo- tionally unstable) with angry tirades or uncontrolled crying and then offer profuse, guilt-ridden apologies for their behavior. It should come as little surprise that many individuals with a diagnosis of borderline personality disorder have suffered from child sexual abuse.

Cognitively, they may present themselves as com- petent and perceptive thinkers and then, when fac ed with a stimulus that causes a flashback or intrusive image, completely dissociate themselves from present reality and respond in a confused, disjointed manner. Behaviorally, such individuals may run the gamut of DSM-5 (American Psychiatric Association, 2013) diagnostic categories-and then appear perfectly ap- propriate! If there is any key to making an accurate assessment of adult survivors of childhood sexual abuse, it is their consistent inconsistency across triage dimensions . The astute crisis worker who is struggling to make an assessment in which such inconsistency is displayed should consider childhood sexual abuse as a working hypothesis.

A crisis invariably initiates therapy; as in other forms of delayed PTSD, the crisis may seem unre- lated to a past traumatic event. During the intake in- terview, if some of the common symptoms of PTSD are revealed, then childhood sexual abuse should be suspected as a causative agent and further assessment should target it as a possibility. Construction of a traumagram (Figley, 1985) will ofren provide clues to the origin of the precipitating event. The crisis worker who suspects• PTSD in an adult due to childhood

sexual abuse should immediately make plans to refer the client for a comprehensive psychiatric assessment after the initiating crisis is contained.

Heather initially presented at a community mental health center with suicidal thoughts and actions. She had overdosed on sleeping pills, was discovere d comatose by a girlfriend, and had been taken to the emergency room, where her stomach was pumped. At intake she showed the counselor cuts she had inflicted on herself with a box cutter. She was dissociative and saw herself"out of her body" as she drew the knife u p and down her arms. (Note: Cutting on oneself and other types of bloodletting, as opposed to slashing one's wrists, is not a suicide attempt but rather a ten- sion reduction mechanism, or letting the "bad blood" out. Some cutters save their blood and bandages and find comfort in them. Further, the scar can be a sym- bol of healing. By doing all this, cutters validate in a very physical way the tremendous emotional pain they feel and have a way of seeing that they really are alive [Mitchell & Morse, 1998].) She had also cut off her parakeet's head (a much more ominous suicidal sign of taking out a prized possession), although she was extremely remorseful about its death and could not imagine why she would have done such a terrible thing. She was currently d epressed and saw no reason for living.

The counselor rated her overall on the Triage Assessment Form at 27, set up a stay-alive contract with her, and referred her to a psychiatrist for eval- uation and medication for depression. After several false starts and stops at counseling, Heather finally admitted the real issue, that she had been abuse d sexually and physically as a child by her stepfather from age 8 to 15 and that the abuse had been denied by her mother. Both parents had engaged in physical abuse of Heather during the same time period. At 16 she went to live with h er father, who was a functional alcoholic. Those arrangements were chaotic, but no further physical or sexual abuse occurred. That lasted until she moved away to college.

She reports that the behavior that got her to the ER and into counseling has been getting progres- sively worse, and she can no longer keep thoughts of the abuse submerged. She is experiencing severe social estrangement and has very few social relationships- none of which are with males. She wears numerous layers of clothing that hide her female figure , even in very hot weather. She wears no makeup and appears almost unisexual. She is a talented artist and is em- ployed part-time at a graphic design business.

reatment of Adults _ _,_ m ajor component of therapy is to use a posttrau- :::::i atic stress treatment model that uses some combina- :::o n of prolonged exposure and cognitive processing or cognitive restructuring (Cloitre & Rosenberg, 2006; :::'o a & Rauch, 2004; Nishith, Nixon, & Resick, 2005) along with techniques to deal with the severe affec- :ive dysregulation (inability to monitor and control one's emotions) that accompanies this form of trauma Briere & Scott, 2006, pp. 76-77; Courtois, Ford, &

Cloitre, 2009). A meta-analysis by Ehring and asso- ciates (2014) that dealt exclusively with PTSD with .::hild sexual abuse as a causative agent in adult survivors examined standard CBT treatment, trauma-focused CBT treatments, and EMDR. Overall Parcesepe and h er associates' (2015) comprehensive review of treat- ::nent results found that all three interventions-be- h avioral, exposure therapy, and EMDR-were more effective in alleviating symtoms than no treatment. However, they did not find significant differences in treatment effectiveness between the three. They fo und that trauma-focused CBT was the most ef- ec tive, and treatment including individual sessions

faired better than group treatment alone. However, Fi nkelhor (1987) proposes that the trauma of child- h o od sexual abuse goes beyond other causal agents of PTSD because of the unique dynamics of traumatic sexualization, social stigmatization, betrayal of trust by loved ones, and powerlessness of children, so that trust building and affirmation activities are particu- la rly critical.

It is interesting to note that virtual reality treat- me nt (Como & Bouchard, 2015) and online counsel- in g targeting sexual abuse (Webber & Moors, 2015) a re beginning to appear as well (see Chapter 6, Tele- phone and Online Crisis Counseling).

Discovery and Admission For survivors of childhood sexual abuse, particular p roblems arise in the therapeutic process that are ab- se nt with victims of other traumatic experiences. If the client is otherwise in crisis and childhood sexual a buse is suspected, do not explore incest material im- me diately because of the likelihood of compounding the present crisis through decompensation, regres- sion, or dissociation. Client safety is paramount and sh ould always be a primary or conjoint consider- ation with exploration of the incest (Courtois, 1988, p. 173). At the time the client chooses to own the t rauma of incest, the potential for crisis rises expo - n entially. Stige, Traeen, and Rosenvinge (2013) report

CHAPTER NINE Sexual Assault • 259

that when attempts to self-manage the trauma finally give way, a high level of distress is reported prior to help seeking. Sensitivity in respecting and exploring the individual's process of seeking help when offering trauma treatment to survivors cannot be over empha- sized. This is a huge undertaking that typically has a mountain of stigma attached to it and is positively re- lated to trauma symptom severity (Deitz et al., 2015). The worker needs to be very sensitive to the client's admission, gently encouraging the client to disclose the abuse and directively and positively affirming the client for doing so. Trust here is critical. Not only have these clients learned that adult caretakers are untrustworthy (Elliot, 1994), but it is more than likely that others in the helping professions have victimized them as well (Ochberg, 1988).

Heather: (apprehensively) I don't know what you'll think about this. But I guess I can trust you . I just can't live with this anymore. (Pauses.)

CW: (suspecting from previous indicators what is coming) Whatever it is, I can see how deeply troubling it is and how difficult it must be. I am here to listen and try to understand. Whatever it is, I want you to know that you will still be the same Heather, and that person is not going to be any different in my eyes. I hope what I've just said makes it easier for you to get it out.

Heather: (starts sobbing) This is really bad.

CW: Heather, I am going to reach over and hold your arm, is that OK? (Heather nods. Counselor softly touches Heather's arm and speaks gently.) I'm guessing this is about something that somebody did to you or that happened to you, and it's OK, really OK, to talk about it.

Heather: I had sex with my stepfather. (Relates a long history of sexual and physical torment by her stepfather and mother, with the counselor listening and empathi- cally responding.)

Heather: (gently weeping) I know you're a counselor and all, but you must think I'm horrible.

CW: I understand how terribly difficult that was. I also want you to know that I believe what you said. I don't think you're horrible at all. What I think is that you were a victim and that you are a survivor of those terrible things that shouldn't have happened and did. I want to correct one thing you said. You did not have sex with your stepfather. You were 8 years old and had no choice. He had, and he forced sex on you. That's a big difference.

260 • PART TWO Handling Specific Crises: Going Into the Trenches

Now I want to give you an idea of what is happen- ing to you, why these bad memories keep coming back, and what they do to disrupt your life.

The crisis worker uses affirming and support- ive statements throughout this opening scene . She touches the client only after being given permission because touching can sometimes be construed as any- thing but supportive by the client.

There are three general phases to this treatment. The first is safety; the second is processing, remem- bering, and mourning; and the third is reconnecting and reintegration (Courtois, Ford, & Cloitre, 2009; Mitchell & Morse, 1998, pp. 184-195). The first or- der of business is keeping the client safe and in full knowledge of what is going to occur. There have b een far too many secrets in these clients' lives . There are no secrets here .

Psychoeducation. Psychoeducation about the role that PTSD plays in incest trauma is important at this point because it can help allay clients' fears that they are "different," "dirty," or "mentally ill," and it assures them that PTSD is responsive to treatment. Educa- tion about PTSD also removes the mystique, confu- sion, and "craziness," anchoring present maladaptive behavior as purposive and reasonable given the survi- vor's traumatic history. It also allows the client to be- lieve that something can be done through treatment (Courtois, 1988, p. 173).

CW: (after an explanation and showing Heather the DSM-5 PTSD classification) So you are not "nuts." Those are the reasons these things are currently happening. We can treat this. It is a long road, and at times it is going to seem as if things are getting worse instead of better. We will have to go back and dig into those memories, and they are going to be painful. I want you to think about this because it is not an easy task. It is something you will need to choose. If you choose to do so, I want you to know that we'll go through this together. (The counselor then explains what the treatment procedures will be and answers questions the client has abou t different compo- nents of the treatment.)

Grounding Grounding refocuses clients' attention onto the im- mediate therapeutic environment or, when over the phone or Internef, on the physical surroundings they are presently inhabiting as opposed to flashbacks ,

intrusive thoughts, and dissociative states that are beginning to overwhelm them (Sanderson, 2013, pp. 167-174; Briere & Scott, 2006, pp. 96-97). They propose the following five steps:

1. Attempt to focus the client's attention on the ther- apist and the therapy. "I am right here. We're together in this room and we are doing exposure therapy. You are not back in the bedroom 20 years ago" are typical verbal responses to a client "going into the wind." At times, gentle touching may also be appropriate.

2. Ask the client to describe the internal experience he or she is presently having. "Describe what's going on right now." If the client has difficulty or appears frightened or otherwise unequal to the task, then move to step 3.

3. Orient the client to the immediate environment that he or she is in-the room with the worker, where it is, how it looks, what's in it, and how safe it is, and that it is not in the bedroom 20 years in the past.

4. If the client is still indicating stress, start deep breathing and relaxation techniques (which we recommend teaching to these clients).

5. Repeat step 2 and assess the client's ability to return to therapy.

Grounding is a critical component of this ther- apy, in which clients are taught to literally put their feet on the ground, get physically and psychologi- cally anchored, and stop the fragmentary thought processes and heightened affect that lead to deper- sonalization, flashbacks , and overpowering emotions (Matsakis, 2003, pp. 57- 58; Mitchell & Morse, 1998, p. 198). Sutherland (1993, p. 23) proposes that focus- ing on gravity in relation to the body starts to make the client aware of the numbness and disowning of various body parts that she uses to dissociate from the trauma. The client is asked to find and identify a "spot of safety" where she can practice grounding. That spot of safety is a place the client can go and feel absolutely safe. One anchor that grounds clients is carrying a talisman with them, something that can literally be touched to connect them with reality. Coins, charms, key chains, totems, worry stones, and so on can all serve this purpose. Your authors use this technique with abused and neglected foster children a lot and see no reason it shouldn't work with adults as well. Matsakis (2003, p. 58) proposes physical grounding, such as holding a familiar or safe item like a teddy bear; emotional grounding by writing oneself

an e-mail or leaving a message on one's answering ma- ch ine and then reading or listening to it; or mental grounding by describing aloud the room one is in, si nging, or reading out loud from a magazine.

CW: So the safest place in the house is the bathroom, with you sitting on the commode. Fine! When some of these cues that we've talked about start happening and you start to feel things sliding away, I want you to go into the bathroom, put your feet flat on the floor, and with the toilet lid down, have a seat, pick up a copy of Car and Driver (or any other magazine), and say to yourself, "It is 9:15 P. M ., Tuesday evening, January 25, 2016. I am sitting on the toilet in my home, reading Car and Driver, and I feel a little silly sitting on the toilet lid, but I am quite safe." So just relax and enjoy that. Just notice your eyes scanning over the ar- ticles and looking at the pictures.

At times when the client is in crisis and away from rh e worker, grounding the client over the telephone is critical. This can be done by reassuring her she is safe a n d asking her to describe what she sees and hears around her. Ask her if she can feel her feet on the floor a nd if not, press down with her feet and grip some - cliing with her hands. Finally, she should keep a list of people she can call a nd go through the grounding exercise with (Mitchell & Morse, 1998, p. 199).

M indfulness. A variation on stabilizing a person who is d issociating and derealizing is using mindfulness exercises. Mindfulness is the art of relating to one 's experience in the present moment with full aware- ;:iess and accepting whatever comes to mind (Brown, ~1arquis , & Quiffrida, 2013). Using mindfulness ~echniques can significantly reduce distress (Sass, Berenbaum, & Abrams , 2013) by opening attention to one's experience and keeping an open mind to what- ever one encounters (Bishop et al. , 2004). This is not a "just do it" exercise but takes practice and should :10t be done until an individual receives a good deal of psychoeducation (Williams et al., 2007), practice, and tryout with the technique. The major idea is that :houghts are just thoughts-not fixed and immutable =acts that can't be changed (Greason, 2015).

CW: So sit on the toilet and focus your attention on the lavatory and just tell me what you see on the countertop as you see it.

Heather: All my hand lotions and pills and stuff and shit! My frickin' razor!

CHAPTER NINE Sexual Assau lt • 261

CW· OK, the razor's there, but for the moment focus on something else.

Heather: It's that new oatmeal soap I got at the health- ful food store.

CW: Tell me what's going through your mind as you look at it.

Heather: Well erh, ah. It's suppose to really clear your complexion up; deep scrubbing gets the oil out and that. I could sure use that after the day I've had and ... oh man! I am starting to lose it again.

CW: That happens, but now remember the exercise of watching those thoughts we did and how we moved them. You can just watch them float away.

Heather: Ha! I did! By golly I did it! Ha! They just sorta went down the shower drain.

CW: Good! Now let's try something. Get a washcloth and soap up and wash your face . Can you do that?

Heather: (Gets up, wets washcloth, and goes back on the stool and starts soaping her face .) OK I'm washing my face . I did it with cold water. It's rough but it feels kinda good. Cool and like scrubbing you know. Like maybe I could just take a shower and feel clean.

CW: So you have that in your mind, what your face feels like and can start to imagine how that would feel like if you did take a shower and could just feel that sensation of cleanliness.

Heather: I umh, yeah, I think I could. I am back to- gether pretty much. Thanks Dr.].

CW: OK! Are we good to go?

Heather: Yes!

The crisis worker uses the "watching" technique to shift the client's attention when she starts heading back down old ineffective trauma-filled paths to give her a sense of control and power over her thoughts (Greason, 2015). The face wash utilizes a different type of mindfulness technique called body scanning (Kabat-Zinn, 2013, pp. 75 - 97) . In body scanning the individual monitors physical sensations throughout the body and gently allows himself or herself to feel, experience, and accept the physical sensations that emanate from various body parts. The crisis worker doesn't panic or attempt to get Heather to stop when she starts to dissociate again. Rather, he acknowl- edges that in a matter-of-fact way, but gently guides her back to ground. If you have ever been camping and got up on a frosty morning and washed your face in a cold mountain stream you surely understand how quickly you are grounded in that moment with

262 • PART TWO Handling Specific Crises: Going Into the Trenches

all that cold freshwater on your face and very much aware of the world around you!

Validation As the client starts through the process of therapy, numerous transcrisis points will occur as long-buried trauma is brought back to awareness. In an active, directive, continuous, and reinforcing manner, the human services worker (Courtois, 1988, pp. 167-170; Longdon, 1994; Mitchell & Morse, 1998, pp. 90-91, 184-188):

1. Validates that the incest did happen, despite denial of this fact by significant others; the client is not to blame, it is safe to talk about it, and the worker does not loathe the client for having been a participant.

2. Acts as an advocate who is openly, warmly inter- ested in what happened to the survivor as a child and makes owning statements to that effect but stiII maintains neutrality and neither advocates for nor dismisses legal action. The worker also un- derstands there is a high potential for transference/ countertransference and is clear and consistent in maintaining boundaries.

3. Reinforces the resourcefulness of the victim to be- come a survivor.

4. Provides a mentor/ reparenting role model to help with childhood developmental tasks that were missed.

Extinguishing Trauma Extinguishing trauma means effecting a psycho- logical extinction- that is, facilitating the reduction or loss of a conditioned response as a result of the absence or withdrawal of reinforcement. In practi- cal terms, this means the reduction or loss of both Heather's negative beliefs about herself and her de- bilitating behaviors that were responses to her child- hood sexual abuse. It also means getting rid of the perpetrator.

When the survivor is in therapy, there are always at least three people there- in Heather's case, there are four (Mitchell & Morse, 1998, p. 198): the worker, Heather, and the perpetrators- her mother and her stepfather. The crisis worker sought to extinguish Heather's negative beliefs and behaviors by systemati- cally leading her to mentally refute her erroneous per- ceptions that she was responsible, culpable, or guilty and had her reframe her previous beliefs to help her gain a new insight that she was an innocent victim

and can now view herself more realistically as a guil t- free survivor.

When working through traumatic events, the cli- ent will experience a dramatic increase in affective and autonomic arousal (Ochberg, 1988). The human services worker must be very careful to provide pal- atable doses of the traumatic material that do nor exceed the client's coping abilities (Courtois , 1988, p. 174) and prompt a crisis within the therapy ses- sion. Careful processing with the client before and after each session of extinguishing and reframing traumatic memories is important in preventing suc h crises.

CW: Let's take a look at what we did today.

Heather: I'm pretty scared. I didn't remember a lot of that stuff until we dug that memory up.

CW: That's pretty typical. Any reasonable person would bury that stuff. If you really start to fe el like you're losing it, I want you to call me.

Heather: (later that evening, calling) I really hate to disturb you, but I've really got this urge to start cutting myself I'm also having thoughts about killing my other pet bird. They're starting to get pretty real.

CW: (very directively) Do you feel like you're losing it enough that you need to be hospitalized?

Heather: I don't know. Maybe ifI just talk this through.

CW: OK. Go get on the toilet seat, put your feet on the ground, and let's talk. (Heather does so.) OK, you there? Feet on the ground? OK! Remember what I said about this being rough. What you went through today brought back a lot of old memories and some ugly fresh ones. That's normal. It's nasty, but it is normal. Now I want you to think of how we changed that scene, how you told yourself all those negative things about yourself being dirty and no good, and what the reality of that scene is. (A dialogue ensues that recaps the day's events. Heather is able to regain control, and after a 20-minute dialogue is able to feel secure enough to relax and go to bed.)

The worker should be aware that extinguishing one traumatic event does not lessen the fear and trepi- dation of moving on to other events. This is particularly true in the case of adult survivors of childhood sexual abuse, who may experience increased intrusive behav- ioral symptoms and regress to former maladaptive behaviors even though they are making good prog- ress in erasing bad memories (Cogdal & James , 1991).

Clients may appear to be getting worse instead of :::>etter-which is threatening and scary for both client and worker.

The worker should be prepared for this contin- -ency, tell the client of its likelihood, and affirm that ic is totally acceptable for the client to check in with :he worker if these symptoms and behaviors reemerge '.:>e tween sessions. The worker's role when this happens is to be understanding, affirming, and calming. Con- srant validation is important because many clients will be discouraged at the length of treatment, afraid and angry over revictimization and extension of the :r aumatic experience's "life," and flee from therapy Courtois , 1988, p. 177). The second phase of therapy

i.·wolves reclaiming the self. It is a painful business :o watch, and there is every urge to rescue the client. Th is must not happen! The work must be done by the su rvivor, and dependence cannot be allowed to occur ~itchell & Morse, 1998, p. 190).

Prolonged Exposure/Cognitive Restructuring ~eframing the client's negative and distorted beliefs about himself or herself is critical in allowing the client to separate the fact and fiction of an abusive childhood (Courtois, 1988, p. 181). While imaginally

o oding the most abusive childhood scene the client can tolerate, clients paste mental billboards under :he scene (Cogdal & James, 1991). These billboards ~·pically deliver all the myths and distorted mes- sages that the abuser gave in addition to the client's own childhood negative self-talk . The image of the ;o.ssault scene is enhanced though prolonged exposure or flooding by loading all the sights, sounds, smells, and noises as if it were happening in real time to the :nost distressing level the client can tolerate. The idea !S to build the noxious stimuli to such an extent that :~ fi nally loses it malignant power over the client and '.:ieco mes benign.

CW: (with the client deeply relaxed, eyes closed) Picture that videotape, the bedroom, the "game," him making you get on him and suck his "peter," a lmost strangling as you do so. Feel the pain and t he disgust. But he makes you keep doing it until h e gets off, and the semen is running all over, sticky and wet. Notice the messages underneath t hat scene. "This is what fathers do to educate t heir daughters to become women." "You aren't a good daughter if you don't do this." ''I'll kill you if you don't keep our secret." Feel the confusion, t he fear, and the repulsion as you do this . Put

CHAPTER NINE Sexual Assau lt • 263

those messages in big block letters underneath that scene. Do you see them?

Heather: (eyes closed and body twisting) Yes!

CW: Freeze that scene and the billboards. Take a snap- shot of it. Let it develop. Hold it in your hands.

The client is then asked to destroy the image along with the negative parental injunctions and her own negative self-injunctions (Cogdal & James, 1991).

CW: Now I want you to get rid of that scene. It is in your past, and it is gone, so now get rid of it from your memory also. Do that now, and tell me what is happening.

Heather: I set a match to it. It is burning. It's a huge fire now with yellow, sick-smelling smoke.

CW: Let it burn.

Heather: It's just a crisp cinder now, all gone.

CW: All gone? Is there anything else you want to do with it?

Heather: CRUSH IT!

CW: Do it! What's happening?

Heather: I'm grinding it up with my boot heel. It's nothing; he's nothing.

CW: Fine. Now relax and slip back into that soft, cool mountain glade. Just relax and feel the tranquil- ity, calmness, and peacefulness.

The client then replays the scene, but this time substitutes positive, self-enhancing counterinjunc- tions based on the facts and not on the fictional mes- sages of the event. The worker guides the image and reframes the stepfather in a truer psychological image (Cogdal &James, 1991).

CW: Go back to the bedroom with him now. Picture the scene, but change it. See him as small, very small, weak. He is a small, selfish, pouting boy, dressed up in a man's pajamas. He looks ridiculous. Put these billboards under the scene. "The only people he has power over are little girls." "It is his fault this is hap- pening." "It is WRONG!" "It is criminal!" "I should have felt confused, fearful. I had the right to feel that way!" "I also have the right to be angry about it." "Nobody has the right to do that. Nobody! " Now freeze that picture and snapshot it. Let it develop. Look at it. What are you feeling and thinking?

Heather: (yelling) You asshole! You bastard! You are gone from my life, you puke! You lied to me, you

264 • PART TWO Handling Specific Crises: Going Into the Trenches

scared me to death, and kept at it. You used me because you were afraid of everybody else. I was the only one you could use, you scumbag. You've got no power over me now, you pissant, or my memories. You are history!

CW: I want you to save that picture. Put it someplace else, safe in your memory, and every time that image starts to come back, pull out the picture and look at it. See that scene for what it really is, and see those billboards, flashing. Have you got it?

Heather: Yes. I've got it.

CW: How do you feel?

Heather: Better, relaxed, relieved maybe .

As the client works through a series of traumatic events, each one is set up as it happened with all of the negative distortions and self-talk that accompanied it. These negative self-attributions carry over into the present time and form maladaptive operating schemas for how the client lives. By rooting out these distortions and modifying them into more positive self-enhancing and enabling counterinjunctions, clients are able to compare "old" and "new" schemas and not only modify and rid themselves of the debili- tating memories but also begin to incorporate those new schemas into their present-day lives (Cloitre & Rosenberg, 2006).

Relearning Feelings. Like combat veterans, survivors of childhood sexual abuse have developed excellent coping skills to deny and numb feelings. But this is even more problematic for survivors of childhood sexual abuse because learning to differentiate feel- ings is a skill that develops in childhood. For most of these survivors, their childhood environments were anything but nurturing, and their caretakers may have suffered from severe affective dysregulation, alternating between a flood of feelings and none at all. As a result, a condition called alexithymia develops in many survivors of childhood sexual abuse. Alexi- thymia is the inability to recognize and label feel- ings. Recognizing and labeling feelings is of utmost importance in helping clients give voice to shunted emotions and warded-off feelings. Heather's bitter and angry emotions are not unlike those of combat veterans as they relive and extinguish bad memories.

Developmentally, clients have to literally relearn and identify their emotional states. Cloitre and Rosenberg (2006) use part of their group format on skills training in affect and interpersonal regula- tion (STAIR) to teach clients to recognize feelings,

monitor emotional intensity levels, learn emotional triggers, and formulate coping/reaction responses. Many of the students in survivor groups have abso- lutely no idea what the visual cues are that others give them. For example, a professor who gives one of thes e women a quizzical look after asking a question might well be described as angry or mad by the woman. I n work with survivors, one of your authors commonly uses an elementary school classroom guidance tech- nique to train students to recognize feelings. Each student in his survivor groups gets a handout show- ing faces with different emotions and feeling words attached to them to help the students relabel feelings and discriminate emotional cues from others. Far from seeing this exercise as childish, clients report that they pull out and use these sheets on a daily ba- sis to validate their present emotional state.

Grief Resolution Beginning to recognize past, buried feelings is t o start on the road to acknowledging feelings of anger and rage, as Heather does in the preceding dialogue (Courtois, Ford, & Cloitre, 2009, pp. 93-94). Thes e feelings will ultimately end in sadness and grieving for the loss of a happy childhood, her loss of who she might have been without the trauma, and the los s of a psychologically healthy family instead of the malevolent one she grew up in (Courtois, 1988, p. 181). It is likely to be one of the most painful stages as the client comes to grips with the reality that there is no retrieving the past or changing it and that attempts to do so are fruitless. Only the future holds promise for her, and she can control only that (Hays, 1985). Griev- ing and resolution, particularly with perpetrators of the abuse, are other transcrisis points in therapy. At this time, the crisis worker will have to move into a grieving and loss mode (see Chapter 12, Personal Loss: Bereavement and Grief).

Heather: I had a call from my mother last night. I wanted to be assertive with her and tell her how I felt, like I had worked out in group. But when it came down to it, I just couldn't. I haven't got the guts. (Starts crying.) I'll never get rid of this . Why couldn't she have been different? Why does she still try that stuff of browbeating me? Wasn't what she did enough?

CW: You have every right to feel sad that she wasn't or still isn't what you'd hope a mother might be. I wish she could change, but I have my doubts. So if she won't, what will you do?

H eather: I guess she won't. I guess I'll just kiss her off

CW: You survived with her battering you, and you've survived for 10 years without her. Perhaps it's time you did say good-bye. (Patiently lets Heather silently weep.)

Confrontation. The tremendous push-pull between ove and hatred survivors feel for their perpetra- rn rs is a difficult issue to resolve. Role -playing with h e empty chair technique, writing letters, drawing,

and journaling may be ways of mourning the loss. Whether the survivor will ever actually confront the abuser is a question only the survivor can answer. T h ere are a number of reasons it may be good for the su rvivor to confront the perpetrator, such as empow- er ment, closure, "setting the record straight," anger, orief, and forgiveness (Cameron, 1994). However, this must be the survivor's decision, and the crisis worker ;nust remain scrupulously neutral in this debate. Confronting the abuser is not mandatory for healing M itchell & Morse, 1998, p. 162). Further, to believe

ch at the perpetrator will "confess" to the abuse may ;:ie very wishful thinking indeed.

The following questions generated by Bass and D avis (1992 , p. 134), or some variation of them, need o be asked and processed with the survivor before the

decision to confront is made.

1. What is motivating you to do this, and are you prepared to do this?

2. What will you possibly gain, and what will you possibly lose?

3. Could you live with being excluded from fam- ily functions and risk losing contact with family members who did not abuse you?

4. Will you be able to handle it if you are labeled "crazy''?

5. Can you handle getting no reaction or denial?

Ch anging Behavior Through Skill Building and econnecting. Although coming to terms with past

:rau ma and stopping maladaptive present behavior ~e critical to the adult survivor, changing behavior :o m ore self-determining choices is the major end 5o al of therapy. The vacuum left by the removal of :-ad memories and the psychic energy previously ex- ::-end ed to maintain control of those memories is not :2.Sily filled. Pearson (1994) and Mitchell and Morse :998) recommend using several categories of tech-

- ·ques for skill building, listed earlier in this chapter.

CHAPTER NINE Sexual Assault • 265

Reeducation is necessary for survivor skill build- ing, and the worker may assume a teaching role in transmitting basic life skills such as communica- tion, decision making, conflict resolution, cognitive restructuring, and boundary setting (Courtois, 1988, pp. 181-182). Herman (1981) likens the survivor to an immigrant who must literally rebuild her life in a culture that is absolutely foreign to what she expe - rienced as a child. From that standpoint, the crisis worker should not be unsettled by the emergence of some rather unusual and personal questions.

Heather: Er, ah, I was just wondering, Dr. James, how you treat your kids. I mean, if they act up do you ground them, or what? What do you talk about at dinner? And do you and your wife ever argue?

Although such questions may be construed as in- truding on the private life of the worker or attempts by the client to shift focu s from her problems or cre- ate dependency, it is important to answer these ques- tions as honestly and succinctly as possible, without shifting the focus away from the client's personal concerns. The client is testing her perceptions against the most valid and stable validity check she currently has-her therapist. For that reason, it is important to urge survivors to join therapy or support groups so that new behaviors can be tested out and discussed with peers. Because many families of survivors such as Heather's are so completely dysfunctional, cli- ents need education on what a functional family is and how it operates. Duncan (2004) has defined the characteristics of a functioning family (not the Hol- lywood ideal one), and we believe they are well worth spending time on in a support group.

As these survivors reconstruct their lives and start to become interested in developing meaning- ful relationships , Sheehan (1994) proposes five basic fears that they will have to deal with: abandonment, exposure, merger, attack, and their own destructive behavior. Fear of abandonment comes because there never were protectors in their young lives. Thus they avoid emotional encounters because they vow never to be hurt in the same way again and constantly test whether significant others are really committed to them. Fear of merger means fear oflosing control and oflosing one 's selfhood. Survivors have to learn what personal boundaries are because parent/ child bound- aries were merged into sexual ones . Fear of attack has to do with real or imagined assault, something quite common in most survivors' backgrounds. The anger and rage that accompany the traumatic wake

266 • PART TWO Handling Spec ific Crises: Going Into the Trenches

can make survivors wonder whether they can control their own destructive impulses and rage toward them- selves or others. These are all topics that involve group work and support and can occasion many transcrisis moments for these people.

Support Groups for Adult Survivors For victims, groups provide a number of po- lmll tential positive outcomes and help them move from victim to survivor. Victims may be reluctant to par- ticipate, but they should be encouraged to do so, al- though not all victims may be ready or immediately able to participate in groups. Education as to what the group is about, who the members are, confiden- tiality issues , what kinds of problems members are working on, and the safety and support of the group format is a critical component in assessing, selecting, motivating, and committing survivors to group work {Courtois, 1988, pp. 253-262).

Courtois (1988, pp. 245 - 249) lists the following benefits of group treatment for survivors of child- hood sexual abuse:

1. The individual's sense of shame, stigmatization, and negative self-image are reduced by meeting other survivors who appear "normal."

2. Commonality of experience raises members' consciousness about incest, so the experience becomes more normalized and may be seen from an interpersonal and sociocultural perspective rather than an "only me" perspective.

3. The group serves as anew"surrogate" family where new behaviors and methods of communicating, interacting, and problem solving can be practiced in a safe, accepting, and nurturing environment.

4. The group allows for safe exploration and ventila- tion of feelings and beliefs that have been denied and submerged from awareness .

5. Childhood messages and rules that were generated within the abusive environment can be challenged and dissected to determine how they still influence the survivor's maladaptive behavior patterns.

In summary, the case of Heather should make very clear that dealing with an adult survivor of childhood sexual abuse is a complex, tedious , meticulous, and stressful process that is filled with many crisis events . It should come as no surprise that one of the toughest customers a worker will face, the borderline personality disorder, runs rampant in this population. It takes a great deal of expertise, patience, empathy, and per- sonal resiliency to work with such cases. The case

of Heather should vividly illustrate why compassion fatigue , vicarious traumatization, and burnout are high probabilities in this kind of work.

Religiosity and Spirituality. In a just world where a benevolent and caring God is ever present, rape and childhood sexual assault never happen. Yet they do quite regularly, so what happens to a person who has a belief that there is that just God out there some- where who has abandoned her or him? To examine the role religiosity plays in trauma, ter Kuile and Ehring (2014), queried 293 trauma survivors on their changes in religious beliefs as a result of their trauma. Nearly half reported changes, and as the researchers predicted, shattered assumptions about a just world and a fair God caused a decline in their religious be- liefs and increased their chances of "catching" PTSD. Those who experienced increases in religious activities used them as a positive coping mechanism, and that finding has been supported in other studies as well (Baty, 2013; Glenn, 2014). This issue is covered exten- sively in Chapter 12, Personal Loss: Bereavement and Grief, and in Chapter 11 , Family Crisis Intervention, but suffice it to say that if at all possible, it appears that finding meaning making in a higher power is a critical ingredient in getting though a sexual trauma.

Helping individuals who have been traumatized after traumatic events to find meaning in what has happened to them is probably the second most im- portant thing after getting them stabilized (Altmaier & Prieto, 2012). Probably above all other traumas, finding forgiveness and resolution and obtaining posttraumatic positive growth are tremendously dif- ficult particularly when the offender is a family mem- ber. For each member of the subset the crisis worker must assess the sexual abuse's impact and what part spirituality and religion can (or can't) play in help- ing them forward in a posttraumatic growth mode. To that end the crisis worker should attempt to deter- mine whether the spiritual distress comes from God for not being there when the abuse happened or not giving the person the strength to get through it. This is a slipp ery slope, particularly when the person has been strong in his or her faith. At such times referral to a pastoral counselor with expertise in the area is highly recommended (Young, 2015).

Sexual Abuse in Childhood The fact is that child sexual abuse has always been with us (DeMause, 1974; McCauley et al., 2001), but a variety of political, social, and cultural factors have

ept child abuse-and most particularly, child sexual abuse-behind closed doors in the United States Cos tin, Karger, & Stoesz, 1996) and throughout the

world (Schwartz-Kenney, McCauley, & Epstein, 2001). By the time one of your authors was a school coun-

selor in 1966, mandatory reporting laws for physical ab use had been enacted in all 50 states (McCauley er al., 2001)-although there was considerable comment a r that time on just how exactly one was to report such abuse and the still unclear question of whether one could get sued or fired for doing so no matter what the law said! (Indeed, no matter what the law says today, , ·ou should be aware that when the subject of child ? hysical or sexual abuse rears its ugly head in a school ::m ilding, there can be and often are repercussions when abusing parents are confronted.) Oftentimes ~egal, ethical, moral, and political considerations (see Ch apter 15, Legal and Ethical Issues in Crisis Inter- --ention) collide when child physical and/ or sexual abuse is involved. (For that reason, you should know exactly what you need to do and how to substantiate it when making a report. We believe it is absolutely man- daro ry to consult with another professional and have ~m or her bear witness when doing so.)

However, it wasn't until the rise of the women's :novement and child advocates in the 1970s and their ~ bbying efforts to open up the blinds that had been do sed on this topic that the public really started to '.:>eco me aware of the extent of the problem. In 1974, :h e Child Abuse Prevention and Treatment Act was : ass ed in the United States, and its definition of who

'ght be covered under the law included sexual abuse. ::isr as Leontine Young's book Wednesday's Children :9 64) raised consciousness levels about the physical ~use of children, David Finkelhor's book Sexually -U:timized Childre'n (1979) did the same for awareness ;.:>out child sexual abuse.

e Numbers. Child sex abuse numbers are stagger- -.::,,,. This compiled report from the National Sexual · -olence Resource Center's (2015) compilation of ::aild sexual abuse is mind numbing. One in four ~ls and one in six boys will be sexually abused before -:.ey turn 18 years old (Finklehor, Hotaling, Lewis , & .=:nith, 1990). Thirty-four percent of those who sexu- ~ 'y ass ault children are family members (National ~al Violence Resource Center, 2011). Twelve percent

: wo men were age younger than 10 at the time _:their rape, and a staggering 28% of men were age • o r yo unger (Black et al., 2011). An estimated :~ -.0 00 children are at risk of becoming victims of

CHAPTER NINE Sexual Assault • 267 •

commercial sexual exploitation each year (Adams, Owens, & Small, 2010). Michael Salter's (2013) book, Organised Sexual Abuse, provides a chilling look into all of the different groups that organize to sexually abuse children. The good news is that Finklehor and associates (2008) found a 58% decrease in the num- ber of substantiated child sexual abuse cases in the United States between 1992 and 2008. Finklehor and his associates suggest that two decades of prevention, treatment, and criminal prose.cutors may have caused this decline. However, we agree with Tabachnick (2013) that the change in the media's reporting of the graphicness of Jerry Sandusky's sexual assaults at Penn State moved the full light of media attention onto perpetrators and caused massive public revulsion of a person who was coach in the national spotlight and who was supposed to be a role model for young men being anything but that in one of the most repel- lant ways possible.

Dynamics of Sexual Abuse in Childhood Manifestations of PTSD do not just spring l:mm forth full blown in adulthood (McLeer et al., 1992). Sexually abused children have significantly more spe- cific PTSD symptoms than do physically abused and other psychiatrically hospitalize d children (Deblinger et al., 1989; McLeer et al ., 1992; Wolfe, Gentile, & Wolfe, 1989). Sexually abused children are at high risk for PTSD and symptoms of posttraumatic stress, anxiety, and depression in the immediate period after disclosure and termination of the abuse (McLeer et al ., 1998). PTSD, aggressive behavior, and sexually related problems following sexual assault are greater for boys than for girls (Holmes & Slap, 1998). For example, Kuhn, Charleanea, and Chavez (1998) found that sexually assaulted male adolescents were more emotionally distressed, socially isolated, deviant (for example, lying and stealing), and likely to affiliate with deviant peers than males who did not report sex- ual assault. Even when considering clustering of other types of childhood traumatic caregiver events such as physical abuse, neglect, domestic abuse, emotional abuse, and noncaregivers ' trauma such as natural disasters or severe medical problems, when sexual abuse was factored in child sexual abuse had a potent and additive effect on the duration and degree of trauma experienced (Kisiel et al., 2014). Probably the most ominous finding of this rogue's gallery of behavioral outcomes was a study that Fox and associates (2015) did on over 22,000 delinquent juveniles in Florida. They found that each additional adverse traumatic

268 • PART TWO Handling Specific Crises: Going Into the Trenches

event the child suffered on the Adverse Childhood Experiences Index increased their movement toward becoming serious violent and chronic offenders.

Even when rape and sexual assault on children and adolescents do not later result in full-blown PTSD, the emotional and behavioral fallout is far reaching and destructive. In addition, these chil- dren have a wide variety of other problems that include concentration difficulties, poor grades , aggressive behavior, social withdrawing , somatic complaints , overcompliance, depression , antiso- cial tendencies, behavioral regression, poor body image/ self-esteem, eating and sleep disturbances , encopresis and enuresis (loss of bowel and blad- der control) , hyperactivity, suicidal ideation, and extreme, generalized fears (Conte & Schuerman, 1988; Knauer, 2000; Miller-Perrin, 2001 ; Sgroi, Porter, & Blick, 1982) .

Although the foregoing symptoms may be indica- tive of many disorders of childhood, the following are not, and are rarely ever found with any stressor other than sexual abuse (Goodwin, 1988; Knauer, 2000, pp. 3-30; McLeer et al., 1992; Miller-Perrin, 2001; Salter, 1988, pp. 230-235) . Sexually abused children come to school early, stay late, and are rarely or never absent. They barricade themselves in their rooms or otherwise hide and attempt to seal them- selves off from their assailants. They may be "perfect" children to the world and to their teachers .

To the contrary, they may engage in inappropriate and persistent sexual play with peers. They may have a sexually transmitted disease . They will have a detailed and age-inappropriate understanding of sexual behavior. They may have physical and somatic symptoms with overlying sexual content such as vaginal or anal bleeding and odors. Sexual drawings , stories, or dreams are common occurrences. They may sud- denly have money or gifts that can't be explained. They may display blatant sexually suggestive poses such as wide-open legs , rubbing of genital areas , and provocative dress. They may engage in excessive, compulsive, and even public masturbation, and may even approach other adults sex ually. Small children may act out sexually with real or stuffed animals. Teenagers may run away and engage in prostitution.

They may engage in self-mutilation by either cut- ting or burning themselves. They may have a sudden dislike for someone or demonstrate inordinate cling- ing behavior. These behaviors provide a template with which varying patterns of psychopathology seen in adult surviv~rs are drawn.

A particular subset of childhood PTSD are t he effects of parental abuse and neglect that often occurs in the course of childhood sexual assault. T he differences between how PTSD manifests in abused children with PTSD versus adults with PTSD has b e- come profound enough that a team from the Nation al Child Traumatic Stress network has designated a new disorder called developmental trauma dis or- der (DTD; DeAngelis, 2007). DTD is characterized by exposure to one or more developmentally adverse interpersonal traumas such as abandonment, b e- trayal, physical or sexual abuse, and emotional abuse. Emotional outcomes range across rage, fear, betrayal, resignation, defeat, and shame. A major marker of DTD is dysregulated developme~t that affects physi- cal health, behavior, cognition, relationships, and self-attribution. Negative expectations about care- givers develop because of their abusive history. As a result, these children stop expecting protection from others and believe future victimization is inevitable (van der Kolk, 2005).

Dynamics of Sexual Abuse in Families The incestuous family may operate much like Imm an alcoholic or battered family does in developing a series of messages or rules that pivot around denial, duplicity, deceit, role confusion, violence, and social isolation (Courtois, 1988, p. 45). Children receive messages such as:

1. Do not show feelings, especially anger. 2. Be in control at all times; do not ask for help. 3. Deny what is happening, and do not believe your

own senses/ perceptions. 4. No one is trustworthy. 5. Keep the secret because no one will believe you

anyway. 6. Be ashamed of yourself; you are to blame for

everything.

Intergenerational Transmission of Sexual Abuse. Typically, there is high potential for intergenerational transmission of sexual abuse in these families. Parents who themselves have been abused often seem to have blind spots for what is occurring in front of them . Further, Knauer (2000, pp. 18 - 19) proposes that the original attraction to the abuser is because of the familiar traits that the person sees in him that ring true within her own abusive family of origin.

Incestuous fathers display inordinate amounts of jealousy and paranoia over their daughters' dating

an d relationships with other males and attempt to rigidly control behavior through threats and intimi- d ation, and the same may happen with mothers who abuse their sons (Knauer, 2000, pp. 49-61; Rosencrans, 1997., 99·· fi2-8J:, &1.lr.t>J::., 1...~, 'P· 1~1). ~1uffiirve fa'thers a re controlling tyrants who erect a facade of respect- ability in the community and often try to isolate rheir children and spouses or partners by forbidding ch em to socialize outside the home and refusing to let them have close friends. However, because of their sen- sitivity to power, they become meek and contrite when confronted with their abuse (Herman, 1981, p. 178).

Mothers are often oppressed and economically d ependent, abused by their mates, and products of incestuous families themselves (Courtois, 1988, ?P· 54- 55; Herman, 1981, pp. 178-179). Mothers may ~e physically or mentally disabled, causing the eldest d aughter to take on the role of"little mother," which extends to fulfilling the father's sexual demands Herman, 1981, p. 179). Although some mothers may

confront the abuse once they discover it, many others engage in denial and helplessness, and when confronted with the reality of the situation may revictimize the ch ild by physical or verbal abuse (Salter, 1988, p. 209). In effect, the child becomes the scapegoat for the family's ? ro blems (Knauer, 2000, p. 18).

Female Abusers. Females who are abusers are not as much of an anomaly as one might think and are .LIJ.o re than likely underreported as sexual abusers. .-.\llen (1991) believes there are about 1.5 million victims :n the United States, and Elliot (1994, p. 220) reports a figure of about 500,000 in Canada who have been abused by females. While these numbers may be out- ~geously high, they also may not be. A study of Latino and European American adolescents who had been sexually abused found that among male high school srudents, 52.8% reported that they had been abused by :em ales (Newcomb, Munoz, & Carmona, 2009).

A few studies have reported on female sexual abu sers and the outcomes for their victims (Allen, 1991; .31.iot, 1994; Fehrenbach & Monastersky, 1988; Knopp .X Lackey, 1987; Mathews, Mathews, & Speltz, 1989; _.fcCarty, 1986; Nathan & Ward, 2001; Rosencrans, :997). More often they are discovered as coabusers :::ll iot, 1994; Rosencrans, 1997). The traumatic wake

::c'iey leave is generally even more devastating because ::3ey are seen as the primary caregivers and the per- son s in whom most trust and nurturing are placed.

In particular, it is important to disabuse the myth ::ia r boys are not troubled by such sexual behavior

CHAPTER NINE Sexual Assault • 269

and "gain experience from older women." The re- search of Rosencrans (1997, pp. 245 - 253) indicates quite the opposite. The young man who has sex with an older woman is placed in a double bind. If an);' i;>art or the experience felt good, the victim may believe it wasn't abusive. If it didn't feel good, then he may have all kinds of recriminations and start to believe that perhaps he is some kind of deviant homosexual (Lew, 2004, p. 61). Lew (2004, p. 61) believes that this causes male survivors to repress memories of abuse by women far more than they do abuse by men. And when those memories do return with a vengeance, they are far more devastating. That outcome is exponentially true when the perpetrator is the victim's mother.

"Motherfucker" is one of the most pejorative, vulgar, and demeaning terms in the English language and has all kinds of negative connotations for boys who might engage in such deviant behavior. That term presupposes the son is the instigator of such illicit sexual contact (Gartner, 2005, pp. 29-30) . Research indicates that is anything but true. The Freudian notion of an Oedipal complex wherein the son lusts after the mother has little validity. The social myths and cultural artifacts that mask the true malevolence of female perpetrators on male children minimize this problem in much the same way as the issue of male perpetrators was minimized in the past (Speigel, 2003, p. 15). If we turn that term around as "son fucker," does that reframe your thinking on the matter and shed light on who the true aggressor is?

The sexual identity problem that boys face when they have been abused by female caretakers, and particularly mothers, is a psychological abattoir (Elliot, 1994; Mitchell & Morse, 1998; Rosencrans, 1997). Gartner (2005, pp. 106 - 120) proposes that it can be cataclysmic to the victim to acknowledge he is in an incestuous relationship with his mother. Yet, while the erotic excitement he feels is disturbing, it can also lead to a sense of sexual prowess that can plant the seeds of some very deviant and pathologi- cal beliefs about women. This is not a movie plot in which a young man becomes a mature and skillful lover at the hands of an experienced, beautiful, and competent woman. It is sexual abuse at the hands of a woman who is selfish and needy, has failed at marriage, and has severe relationship and patholog- ical problems . Indeed, out of the bad seeds of these relationships may grow some very poisonous adult relationships for these boys. The bottom line is that adult female abuse ofboys is extremely serious and can lead to ominous outcomes (Deering & Mellor, 2011).

270 • PART TWO Handling Specific Crises: Going Into the Trenches

As an example, the two adult males one of your authors has encountered in his own practice who were sexually abused by their mothers were poten- tially the most dangerous to women he has ever seen. They had wildly vacillating "madonna-whore" complexes about women they had targeted for their affection that could turn these women from the pur- est virgin to the sluttiest streetwalker in a moment, all because of some imagined travesty the women had committed. The really scary part of their delusions was that the women had no idea any of this was going on! Rosencrans's (1997, p . 252) informal interview with law enforcement officers tends to confirm that these abused males have a high potential for sexually related crimes .

Our overall knowledge of female sexual abus - ers probably compares to what we knew about male child abusers 30 years ago. Therefore, the astute crisis worker needs to ask the following when doing an in- take interview with a sexual abuse victim who is male.

CW: We have talked about the perpetrator. Did any- body else sexually abuse you? I am wondering if there were any females who ever did those sorts of things to you?

Because of the high incidence of sexual abuse per- petrated on boys and their reluctance to talk about being sexually abused as children, tactful questions should be asked of any age male even when this is not the presenting problem. The plain and simple fact is that we still tend to dismiss sexual acts and the harm- ful aspects they present in males (Alaggia & Milling- ton, 2008; O'Leary, 2009). A case in point is the filing of criminal charges against abusers of male children. While the cases filed against perpetrators when the child is female are woefully small in relation to the number committed, a study conducted by Edelson and Joa (2010) found that charges are even less likely to be filed against perpetrators when the victim is a male child.

Phases of Child Sexual Abuse Sgroi (1982) found that the behavior of the lmFJ abuser can be traced through five phases: (1) engage- ment, (2) sexual interaction, (3) secrecy, (4) disclosure, and (5) suppression. These phases apply to both intra- and extrafamilial abuse.

Engagement Phase. The abu ser's objective in the en- gagement phase is to get the child involved in sexual activity with the a.buser. Both access to the child and

opportunity (privacy) are needed if the abuser is to be successful. Therefore, if one were looking for possible instances of unreported abuse, one would identify times and situations when the potential abuser and the child were alone together. One must also look fo r different strategies that two different types of abusers (child molesters and child rapists) may employ.

Called grooming, molesters enter a seduction phase wherein they successively approximate a child to accept that the sexual abuse is okay, appropriate, educational, acceptable, and even a duty. This se- duction phase is prior to actual sexual abuse and is not well defined, and there is a lack of consensus on what it actually entails (Bennett & Odonahue, 2014). However, molesters tend to use enticement and entrapment to get the child engaged in sexual activity. Enticement may include deceit, trickery, rewards, flattery, or the use of adult authority to tell the child in a matter-of-fact way that the child is expected to participate. Entrapment is used to manipulate the child into feeling obligated to participate through traps, blackmail, and so forth . Molesters may make pornographic pictures or videotapes and convince the child that there is no choice other than going along with the secret activity, and may also seek to impose guilt by making the child feel responsible for the abuse .

Online Grooming. The adage your grandmother told your parents, "Never talk to strangers!" really, really ap- plies here except you don't talk to them on the Internet either. Whittle and associates (2013) examined both familial factors such as close parental supervision of Internet use when integrated with contextual and en- vironmental risk factors (low income, poor schools, decaying neighborhoods) and found heightened risk for potential contact with potential molesters. If you've seen any police sting operations on television, you know how prominent this is and continues to be even with the stings! It is indeed illegal to proposition a child on the Internet for sexual interaction, even if that "child" is a 22 -year-old police officer.

Factually though, and stings aside, not a lot is yet known about how molesters operate. In Seto's report (2013) the median year for online offender research is 2009 with the range from 2000 to 2009. Undoubtedly it has expanded a great deal since his study, but the problem is that molesters get tied in with child pornography, and that muddles the pic- ture even more. Online offenders may engage in only Internet action or become solicitation/traveling offenders. Those are offenders who will attempt to

::-mice a child to meet with them to have sex or en- .:ourage them to run away with them (Seto, 2013). It :s u ndoubtedly safe to say that future editions of this · ook will have a lot more to say about the dynamics of online molesters.

Child rapists use threat (particularly the threat of i arm) or the imposition of superior physical force to engage the child in the abusive activity. Typically, the :a.pist will threaten to kill or injure the child or some- one dear to the child or destroy something the child ::iolds dear like a pet or threaten to commit suicide 3.im self, convincing the child that he or she will be bla med for the rapist's death if the child resists or re- ?O rts the rape. In using superior force, the rapist may sim ply overpower the child, restrain the child by tying 3im or her, give the child drugs or alcohol, or physi- cally brutalize the child into submission.

The vast majority (about 80%) of abusers use the 5.rst two strategies-enticement and entrapment. Abusers tend to repeat their engagement patterns and show little tendency to move from nonviolent to ,-iolent strategies. Molesters are apt to consistently en- rice or trap children, whereas child rapists tend to use Lh re at or force almost exclusively. The strategy used by the abuser is an important issue in treatment, be- cause survivors typically wonder throughout their :ives why they permitted it to occur.

Sexual Interaction Phase. Types of abuse may include b latant or surreptitious) masturbation (the abuser ;:nay masturbate prior to making physical contact with the child), fondling, digital penetration, oral or anal penetration, dry intercourse, intercourse, forcing or coercing the child into touching the abuser's geni- ~ls , forced prostitution, and pornography. Children :nay be coaxed in'to cooperating, though not consent- ing, because abusers-as adult authority figures-often command, engage, or enlist cooperation from the child. Children lack the maturity, experience, and age ~o be able to consent, but they may cooperate because of their subservient status.

Secrecy Phase. Abusers communicate to children diat others must not discover the sexual activity. The objective of abusers is to continue the activity. This ::iecessitates avoiding detection and maintaining ac- .:ess to the child while continuing the abuse. The :echniques for maintaining the secrecy may involve incorporating "rules" or "games," implicating the .:hild in the activity, and setting the child up to be re- spo nsible for keeping the secret.

CHAPTER NINE Sexual Assault • 271

Disclosure Phase. Sometimes the abuser is discovered accidentally. Other times the abuse is disclosed intentionally by the child or someone else. Intentional disclosure is usually made by the child. Intentional disclosure often enormously complicates the discov- ery and existence of sexual abuse, because parents and others refuse to face it or believe it. Accidental discovery may occur as a result of such consequences as pregnancy, STDs, sexual acting out, promiscuity, and physical trauma. The way the abuse is disclosed can affect the child's self-esteem and reaction to treat- ment. For instance, disbelieving adults sometimes respond by blaming and punishing the child-and allow the sexual abuse to continue.

Suppression Phase. The suppression phase may begin as soon as disclosure takes place. Suppression may be attempted by the abuser, the child, the parents, other family members, professionals, the community, or an institution. There are many reasons for suppres - sion: fear of publicity; fear of reprisal; to protect the reputation of a family, an abuser, or an institution; to avoid prosecution; to avoid responsibility; to protect the child; to avoid embarrassment; to avoid the kinds of confrontation and intervention required to deal effectively with the difficult and sensitive situation; and fear of getting involved.

Survival Phase. On the basis of our own experiences and the reports of other writers (Besharov, 1990; Kendrick, 1991), we have added another phase, the survival phase. During this phase, it is important to implement strategies for helping the child and the family respond to and recover from the abuse as much as possible. This phase includes stopping the abuse, providing needed medical and psychological treat- ment for the child, and helping the significant others close to the child to overcome the trauma, fear, anger, betrayal, and despair caused by the abuse (Benedict, 1985). It also involves preventing further abuse (Bass & Thornton, 1983) and prosecuting and/ or getting counseling for the abuser (Benedict, 1985).

Intervention Strategies with Children Assessment Assessment includes thorough documen- Imm ration of the abusive events for possible legal use . Using anatomically correct dolls helps confirm what

2 72 • PART TWO Handling Specific Crises: Going Into the Trenches

actually occurred in the abuse. No specific measures currently exist for measuring the effects of psycho- logical abuse in young children, although a complete psychological evaluation may be useful in gauging the child's overall level of functioning (McLeer et al., 1992; Wheeler & Berliner, 1988, p. 235). The previously mentioned behavioral indicators of childhood sexual abuse and PTSD criteria for children are currently the best indicators that sexual abuse has occurred.

Peterson and Hardin (1997) have developed a guide for screening children's art for sexual abuse. The child is asked not to verbally disclose but rather illustrate different subjects and situations. Differ- ent indicators of sexual abuse may appear as the child illustrates the requested subject matter-such as a picture of people doing something at home. As - sessment includes an analysis of style, treatment of figures , and actions with negative aspects. Point val- ues are awarded for a variety of criteria commonly found in abused children's drawings . Once the point value reaches a certain level, child abuse should be suspected (Peterson & Zamboni, 1998). However, it doesn't take a doctorate in projective techniques to see how different the drawings of children who have been abused are (Kaufman & Wohl, 1992). We would propose that most children do not draw families that are joined by penises and vaginas or have clubs grow- ing out of their arms that are raining blows down on other family members-but sexually and physically abused children do because that's the way their fami - lies interact.

Therapeutic Options Because of the complex nature of child abuse, interven- tions should comprise multiple components targeting a variety of problem areas (Miller-Perrin, 2001). The first component is play therapy (Gumaer, 1984; Malchiodi, 2008; Webb, 2007; White & Allers, 1994). White and Allers (1994) have identified several characteristic be- haviors that maltreated children may manifest during play therapy: developmental immaturity, opposition and aggression, withdrawal and passivity, self- deprecation and self-destruction, hypervigilance, in- appropriate sexuality, and dissociation.

The second component is cognitive-behavioral therapy that is trauma focused (Cohen, Mannarino, & Deblinger, 2006; Neubauer, Deblinger, & Sieger, 2007). Farrell, Hains, and Davies (1998) found that selected cognitive-behavioral interventions (skills learned throu&h procedures such as relaxation train- ing, positive self-talk, cognitive restructuring, stress

inoculation, and emotive imagery) may effectively d e- crease the anxiety and depression levels in sexually abused children ages 8-10 who exhibit PTSD symp- toms. Deblinger, Thakkar-Kolar, and Ryan (2006) propose a cognitive behavioral approach that involves:

1. Psychoeducation that teaches children about faulty misconceptions they may have and offers new information to help children understand they are not so isolated and alone .

2. Behavioral rehearsal and modeling skills that are taught to both children and nonoffending parents to teach them how to regulate emotional expression and develop new cognitive coping skills.

3. Relaxation training and graded exposure treatment to the trauma that allows the child to learn that his or her fears and avoidance of the feared situation, object, or person are not nearly as frightening or upsetting as previously thought.

The third component is a trauma systems ap- proach (Saxe, Ellis, & Kaplow, 2007) . Incorporating an ecosystemic approach that involves not only chil- dren and parents, but community systems such as social services agencies, mental health facilities, and schools, increases the chances of stopping emotional and behavioral dysregulation across the entire system where the trauma operates . Saxe and his associates propose that two major components are operating with a traumatized child. First, a traumatized child has difficulty regulating emotional and behavioral states. Second, the social environment and system of care are not able to help the child regulate these emotions and behaviors.

Saxe, Ellis, and Kaplow (2007, pp. 95-108) propose 10 principles of treatment if the system is to be changed.

1. Fix a broken system, not just the identified client. Relentlessly attack the whole trauma system.

2. Put safety first. Nothing takes precedence over safety.

3. Create clear, focused plans that are based on facts and target specific components of the child's emo- tional dysregulation and the level of instability in the child's environment and system of care.

4. Don't "Go" before being "Ready." Build an alli- ance with the family, understand logistical prob- lems such as child care and transportation, and create an understanding of what treatment will involve and who will be included.

5. Use resources to gain maximum benefit. Carefully plan and coordinate the tactics and strategy with

the system's players for the best possible outcome. Time and money are scarce in the treatment world. Plan carefully so neither gets wasted.

6. Accountability is critical. Accountability has two parts. First is the worker's ability to put words into action and evaluate how well those actions are working and change them if they aren' t. Second, and more daunting, is requiring that chil- dren, parents, and others in the social ecosystem be accountable as well.

7. Deal with the reality of the situation. If resources aren' t there, if family systems are compromised, if children are developmentally delayed, then under- stand the reality of the situation and adjust goals and expectations to it.

8. Take care of yourself and the treatment team. All the king's horses and all the king's men do not put Humpty-Dumpty back together again if the horses and men are broken themselves. There's a chapter ahead of you in this book on burnout. Guess what one specific area of crisis intervention has high burnout rates? That chapter is the real deal if you are going into this business, so read it carefully.

9. Look for the strengths in the system. The trauma system of the child is rife with pathology and failure . It is easy to find things wrong. Yet there is resiliency and strength within this system. It is your job to keep a positive view of it and make lemonade out of the lemons.

10. Leave a better system. As with all crisis intervention, you are not an adoption agency taking on children and families to raise forever. Teaching families how to take care of themselves is the end goal.

' You'll soon meet crisis workers from the Carl

Perkins Child Abuse Center, who operate out of Ja ckson, Tennessee, and cover much of rural west Ten nessee. They operationalize all of the foregoing 10 principles and then some! When the entire ecosys - [em of the child is brought into play, involving all of :he players in the treatment using combinations of ?lay and cognitive-behavioral therapy, outcomes for ?arents include better parenting practices, improve- :nent in depressive symptoms, reduction in abuse - sp ecific emotional distress, and greater support for :he child. Children have less externalization of prob- :em s, fewer depressive symptoms, reduced behavior ?roblems at home and school, and feel less shame, guilt, depression, and anger due to the abuse. Perhaps ~ven more important, social services, schools, law en- :"orcement, judiciaries, and mental health services all

CHAPTER NINE Sexual Assault • 273

play well together. When this happens, the sum is in- deed greater than its parts.

Need for Affirmation and Safety Initial intervention techniques call for intentionally and positively managing the crisis of disclosure and the resulting fear and anxiety. Affirmation and vali- dation are crucial in regard to what has happened, what is happening, and what will happen to the child, the offender, and significant others. The admonition in the PTSD chapter on not using flooding techniques with children holds even more firmly with sexual abuse. If prolonged exposure techniques are to be used, they should be done with gradual and graded exposure to the aversive stimulus, with plenty of time for processing between exposures. Children should also be taught progressive relaxation techniques so that they can learn how to remove themselves from the feared stimuli. Because small children are not fully developed cognitively, most instrumental and operant behavioral techniques that may be used with adult survivors are also not efficacious. Yet anxiety about and fear of the abusive events and the abuser need to be reduced, and this calls for reexposure to the trauma.

Contrary to most popular professional opinions (there are a lot of cognitive behaviorists out there!) , your authors believe this work is best accomplished by the use of play therapy, in which the child is given puppets, dolls , and drawing materials to safely dis- tance himself or herself from the trauma. By gently and directively encouraging reenactment and discus- sion through the safety of the play material, the thera- pist may enable the child to gradually extinguish fear and anxiety feelings and develop skills in communi- cating healthy inner feelings and experiences without revictimizing the child (Baker, 1995; Gil & Johnson, 1993; James, 2003; Malchiodi, 2008; Merrick, Allen, & Crase, 1994; Oates et al., 1994; Pifalo, 2002; Sadowski & Loesch, 1993; Webb, 2007) .

Regaining a Sense of Control Anger and grief are emotional by-products for children of sexual abuse. Venting of these feelings should be encouraged, particularly because most adults are not comfortable with them and may attempt to repress such feelings when children exhibit them (Wheeler & Berliner, 1988, p. 237). Drawing, painting, modeling clay, sand play, writing, and learning to verbalize emo- tions are all therapeutic vehicles to ventilate angry feel- ings and loss. Play techniques can also give the child a renewed sense of empowerment by allowing play

274 • PART TWO Handling Specific Crises: Going Into the Trenches

figures to be acted on, thus reducing long-standing feelings of helplessness (James , 2003; Malchiodi, 2008; Sadowski & Loesch, 1993; Webb, 2007). Punch- ing out a Bobo doll or picking up a play telephone and calling the police can give children a sense of control in a situation in which they have little (Salter, 1988, p. 215). Along with relaxation and other stress reduction measures, play techniques such as sand tray therapy can be used to teach the child to control anger when the child constantly acts out with peers or significant others.

Education Education about adult sex offenders and sex itself is important for children because they will have little if any knowledge of why or what has happened to them. Shame is a predominant feature of the child's response to abuse (Knauer, 2000, pp. 74-82). Children need to know that it is the adult and not the child who made the mistake. Children who have been physically injured need to have these injuries explained and be told that their bodies will be okay. Many children believe that others will be able to tell what happened by looking at them. Children need to know that al- though they may feel different, sexual abuse does not make them look different.

Understanding developmental stages is critical in what kind of education is provided and how therapy is delivered (Saxe, Ellis, & Kaplow, 2008, pp. 7- 12). Cognitively, young children usually have little un- derstanding of sexual functions. Typically they will not initiate questions about sex, but when workers initiate education about sex through slides or books, children will respond with their own questions. Every child who has been sexually assaulted needs some type of sex education and information on what the assault means (Baker, 1995; McLeer et al., 1992; Oates et al., 1994; Salter, 1988, pp. 217- 218) .

In addition to the play therapy techniques (such as drawing, painting, modeling, and sand play, mentioned earlier), a highly effective means of teach- ing important social and survival lessons to children is through outreach services into schools, churches, and community centers with professionally developed puppetry programs. One example is the Kids on the Block (1995) system, which uses the unique and dynamic medium of puppetry to educate children and their adult caregivers on how to think about and respond to important and emotionally charged issues that impaet children's lives. Trained volun- teers perform with puppet characters designed to

realistically represent children and the dilemmas they may face. Through carefully researched and scripted dialogues , these puppets ("children") talk about important issues and then engage in interac- tive question-and-answer periods with children in the audience, who converse directly with the puppets . This form of puppetry has proved to be an effective strategy for expunging children's myths and mis- conceptions about physical and sexual abuse and replacing them with facts and sensitivity (Sullivan & Robinson, 1994).

Assertiveness Training Assertiveness training may be seen as more a preventive measure to keep children out of harm's way than a remedial measure for sexually abused children. Yet, sexually abused children have learned to be compliant to deviant requests and clearly need to learn how to "Just say NO! " (Salter, 1988, p. 219). Because abused children are at greater risk for revictimization, teaching them cues and warning signs and appropriate asser- tion responses is important so that they can avoid future abuse (Miller-Perrin, 2001; Wheeler & Berliner, 1988, p. 242).

Intervention Strategies for Child Sexual Abuse: The Case of Elizabeth Elizabeth, age 8, is the middle child in the family. She, her 11-year-old brother, and a 5-year-old sister live with her mother and stepfather, whom her mother married nearly 2 years ago. Elizabeth's mother, Mona, and father divorced when the youngest child was about 1 year old. Elizabeth's stepfather started off by fondling her. This went on for several weeks . Although Elizabeth was bewildered, scared, and intimidated, no one else knew about the abusive activity. Recently, while everyone else was out of the house, her stepfather raped her. He threatened to kill Elizabeth, Mona, and her sister if she told anyone. The following morning Elizabeth confided in her brother, who in turn, told Mona what had happened.

Incredulous over this discovery and paralyzed as to what to do, Mona called the child abuse hotline that she remembered seeing advertised on TV and in the local newspaper. The following dialogue and discus- sion is representative of what an absolutely outstanding child advocacy agency, the Exchange Club-Carl Perkins Child Abuse Center of Jackson, Tennessee, does.

Disclosure

Mona: (calling the child advocacy hotline; angry, crying un- controllably, barely in control) Hello. Hello! I want to report a (choke, sob) rape. He . .. that bastard . .. he raped my baby. That sonofabitch raped my daugh- ter. Oh, how could I have not seen ... How could I have let this happen? (Continues ranting and raving in hysterics, beseeching the hotline worker for help and railing at her husband.)

CW: OK, I understand you're extremely upset and have every right to be, but I need for you to be in control right now. My name's Delaine. I need to know your name, where you live, and whether you're safe from who did this to your daughter.

,\1ona: (Regaining a bit of control, gives her name and ad- dress.) It was my .. . It was ... my husband ... Leon. Her asshole stepfather ... I found her underwear. It was all bloody ... Oh my God! My baby ... My poor baby. He's gone in his truck . . . He's headed for Chicago on a run . .. I'll kill him ... By God! I will kill him if it's the last thing I ever do!

CW: So you are safe, and he's not in the house. How badly hurt is your daughter? Does she need an am- bulance and medical attention?

_Vfona: I don't know. She's kinda in a daze. Just walk- ing around holding on to her teddy bear. Oh, that bastard! I'll castrate that bastard before I kill him!

CW· Mona, I hear how angry and shocked you are, but I need for you to follow me very closely. This is extremely important. I want you not to do anything with Elizabeth. Don't wash her up or change her clothes. I want you to take her to Madison County General Hospital and bring her underwear with you in a plastic baggie. Do you have a way to get to the hospital? Are you OK enough to get to the hospital? (Gets acknowledgment from the mother that she can get to the hospital.) There are going to be peo- ple at the hospital who are going to want to talk to you and Elizabeth, and we're going to need to do a medical exam of her. This is not going to be easy, but we know how to do this. You did the right thing. I'll meet you at the hospital, and I'll help you get through this. We will get through this! Do you understand? Now tell me what you're going to do and when you'll get to the hospital. (Mona restates what the crisis worker has told her and assures the worker she can do those things.)

The initial shock that accompanies discovery and ::isclosure is invariably highly dramatic and volatile

CHAPTER NINE Sexual Assault • 275

for parents who have been blind to the perpetrator's intent. Because rape is a violent crime, the primary consideration of the crisis worker is to determine if people are now safe from the perpetrator and if they need medical attention. The initiating crisis is multi- fold . The crisis worker needs to make sure that there is no physical injury to the child and that the out-of- control parent is sufficiently functional to take care of the child and do the things necessary to preserve evidence. She will also need to restore the mother to equilibrium. Exacting revenge by assaulting the per- petrator would put both mother and daughter in jeopardy. The scene at the hospital can be extremely threatening, and the crisis worker does all she can to indicate that the mother has done the right thing and that, as difficult as it may be, the crisis worker will be there with her to the conclusion. The crisis worker's initial job will be to do crisis intervention with the mother by making sure everyone is safe and helping her get back in control of her emotions and actions (Bottoms, 1999; Knauer, 2000, pp. 31-47).

Immediate Aftermath In cases where there is physical injury, the survivor will need immediate medical evaluation and care. The crisis worker, after determining that the mother can get herself and her daughter to the hospital, imme diately makes other phone calls to the Department of Human Services and the police department. She also calls the hospital and informs them that a child sexual assault victim is on her way and that a sexual assault team needs to be assembled. After mak- ing these phone calls, she immediately leaves for the hospital.

Mona: (at the hospital, in a room with the crisis worker) All I can think about is that no-good lying creep. He's lucky he's on the road, or he'd be dead now. I'd shoot the asshole's balls right off of him. I've got a .38 Special, and by God ... as God is my witness . .. I will do it. What's happening to my daughter? They took her away. Is she going to be all right? I've read some stuff on this. It's not just him raping her now, but she'll be scarred for life! How could it happen? How could I be so srupid? What in the hell is wrong with me? He was so nice to her, to all of us! How, oh how could I have been so stupid? (Starts uncontrolled sobbing and pacing, slamming her purse down again and again .)

CW: You've certainly been through a lot in the last few hours. And you've done a remarkable job of taking

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276 • PART TWO Handling Specific Crises: Going Into the Trenches

care ofElizabeth. Your concerns about her physical injuries now and her psychological injuries later are certainly justified. I'm not going to sugarcoat this . You're obviously a very good mother who has suddenly been thrust into this-nothing you or Elizabeth did caused it. It was perpetrated on her and you. We are here to assist you in any way we can. We want to provide someone to be with you and Elizabeth during these critical hours , as well as providing aftercare and follow-up counseling.

But right now, even though your husband is away, I'm concerned about your anger. It's certainly justi- fiable, but what Elizabeth needs is for you to be the best mother you can be right now. If you shoot your husband, how will you be able to support your daugh- ter when she needs you most? You won't! You will be in jail. That's where your husband deserves to be, not you. Let the police handle your husband. What we need to do is handle this and care about Elizabeth. Can you do this? That's really what you want, isn't it, to help your daughter get through this?

Mona: I . .. I ... I guess so. I appreciate it. Every- thing happened so fast! I don't know how I man- aged without falling apart. It's like a wild, awful dream-an ugly nightmare. I don't know how I'll handle it when the dust settles. I'm so mad- I could kill him! I feel like I've been raped too. There's so much on me right now. I don't know if I'm capable ofbearing up under all that's got to be done . Damn, damn, damn that man! Excuse me, I shouldn't blow up like that.

CW: That's all right. You have a perfect right to be angry and to say it. It's good that you care enough to be upset, and it's good to see you direct your anger at him- the real cause of Elizabeth's hurt and your anger. Both of you deserve better treatment than he gave you, and no child asks to be raped.

Mona: That's right. I trusted him! And he took advantage of her. She was helpless-a helpless child. I've got to show her where I stand on this . First, I'm going to take good care of her, and then I'm going to send that rotten louse to jail for good!

CW: Mona, I know things are really crazy right now, and you don't know what's happening. I want to take care of that by telling you what's going to happen and how things are going to be done, so you know what's going on and don't feel so out of control. !'fl go through each step of what is going

to happen today and what we can do to ensure that Elizabeth gets through this in good shape. I'm going to explain what will happen very carefully to you. If you have any questions, stop me. The re are no stupid questions about this. I want you to fully understand what's happening, so you can start to get back in control. Mona, the impor- tant thing is that you gain control. Right now, I'm being very directive, and will be doing so until you get past this emergency and back on top of things. You have choices, and if, at any time, you feel like making any of the choices yourself, please feel free to do so. You can stop me at any time, and that will be 0 K. (The crisis worker patiently goes through all the details of what is going to happen, stopping whenever Mona has questions, and checking to see that she under- stands what she's being told .)

The crisis worker permits her to express her anger, isn't threatened by Mona's outburst, encourages her to keep owning and expressing her feelings, and lets her know that neither she nor Elizabeth was to blame for the assault. That strategy is important in letting Mona know that she can be in control and that the worker believes in her, without the worker's jumping in and expressing the anger for her. This is no place for the human services worker who is not calm, cool, and detached in her or his professional demeanor. That the worker must be as solid during a crisis as the rock of Gibraltar is never more true than here. There is probably nothing more heart wrenching and sick- ening than the aftermath of a severe sexual or physi- cal assault on a child. Intervention here clearly calls for a strong constitution. But more important, if the worker manifests her or his own anger directly at the parent or the perpetrator, then that anger may be mis- interpreted as being directed toward the victim.

At times, when the perpetrator is still an imme- diate threat, the worker must take on the trappings of a crisis worker who deals with battering victims. The family may need to be moved to a safe place until the perpetrator is apprehended. The crisis worker continuously reinforces the mother for doing the right thing and for caring about her daughter. This is an extremely important strategy, because adult caregivers may engage in severe guilt and recrimina- tion because they believe they should have been more vigilant. The crisis worker also must make sure that the mother will not exact revenge on the perpetra- tor and put herself in jeopardy with the law (Knauer, 2000, p. 46). It will indeed do Elizabeth little good if

h er mother is facing a charge of assault with intent to commit murder. Finally, the crisis worker patiently educates the parent on what is going to happen. Education about the aftermath of a child assault is critical in giving parents back the sense of control rh ey feel they have lost.

Two components of education are important. First, detailing what the legal proceedings are and what the mother and child need to prepare for allows ch em to know what is ahead of them and not be blind- sided by all the legal, social, and psychological rami- fications of a child sexual assault. Second, giving the parent information on how to deal with the child in rh e immediate aftermath of the discovery is critical in ensuring that the child is not revictimized and that rh e parent does not feel guilty for doing or saying the wrong thing (Bottoms, 1999). An even more shocking revelation may occur during the initial disclosure and interview. That is, it is not uncommon for the par- ent to disclose that she was also sexually abused as a ch ild and swore this would never happen to any of her own children.

M ona: (head in her hands, slumped over) It's my fault. I let this happen. God knows I should have known. Uncle Ralph did the same thing to me when I was 14. I tried to tell Mom, bur she just blew it off 'cause Uncle Ralph helped us out when Mom went through her divorce. And now my own daughter ... I couldn' t even protect her. I'm no better than my mother.

CW: (reacting coolly, letting Mona talk through her own sexual assault) There's a big difference . As I hear you say it, your mother didn't follow up because she was afraid and dependent on your uncle. You weren't afraid, and when you found out you took immediate action. See the difference? A big differ- ence! Right now you are being the best mother in the world. Do you see that difference?

The worker, although taken aback, immediately discriminates between what Mona's mother didn't do and what Mona did do. She underscores and reinforces ~ fo na for taking action and reaffirms her as a fit parent.

Prosecuting the Perpetrator Interviewing the Child Whenever a child is sexually assaulted, there lmlJ are two primary concerns. First is taking care of ::he child and seeing that she or he is safe. Second is

CHAPTER NINE Sexual Assault • 277

obtaining evidence to prosecute the perpetrator. If the child has not been injured or if the discovery is made a good while after the assault, then an interview needs to be conducted that will allow the necessary evidence to be obtained. In the past, report of a child assault would entail numerous interviews with medical staff, police, and social services . The intimidating circumstances and the necessity to repeat the story over and over have a high potential for making the child feel terrorized, guilty, confused, and unequal to the task of meeting the demands of a variety of strange and threatening adults. The potential for revictimizing the child and the parent while going through this procedure is extremely high if not handled appropriately (Bottoms, 1999).

To stop this from happening, the Carl Perkins Center uses an interview procedure that many other child advocacy agencies employ. This approach is a good model for dealing with cases of sexual or severe physical assault on children and is now starting to be instituted across the country. One trained forensic interviewer with a listening device in her or his ear con- ducts the interview and tape-records it at a safe house. Other agencies' staff are behind a one-way mirror. If they need more information on a particular part of the assault, they transmit that information to the worker in the room via the worker's earpiece. Note here the emphasis on trained. Because this is a crimi- nal matter, the worker needs to be able to obtain in- formation without biasing the child's testimony. In other words, the typical mental health worker will not have the expertise to do this. However, the psychologi- cal well-being of the child is critical in the aftermath of disclosure, and a typical police interrogation would likely put the child under severe duress. There- fore , whoever does the interview should be skillful not only in obtaining evidence, but also in making the child feel safe while the interview occurs. At Carl Perkins the interview is conducted in a pleasant, child-friendly room by a very caring child-centered forensic worker at the center, not in the stark confines of a police interrogation room (Bottoms, 1999). The worker may also use "good touch- bad touch" with a doll or a figure drawing to have the child indicate where on his or her body (e.g., genitals, mouth) the assault took place. (Note: Mouth is included here because oral sex is a common occurrence in child sexual abuse [Knauer, 2000, pp. 5-6].)

If there is no prior knowledge of abuse and the child discloses an assault in a spontaneous manner, then the crisis worker needs to be cool-headed, listen

2 78 • PART TWO Handling Specific Crises : Going Into the Trenches

to the child, and be prepared to make an immediate referral. Often the workers at the Carl Perkins Center have staged a Kids on the Block puppet show at a local school. After the presentation on prevention, they in- vite children who may have been victimized to come down and talk to them about their experiences. At times they have been flooded by children! In that case, the worker needs to write down pertinent informa- tion in a calm manner and make an immediate refer- ral to Children and Family Services (Bottoms, 1999).

After the examination, the crisis worker needs to affirm to children that they are okay physically, that some part of their body is not "broken," that they do not now have AIDS, that they will not die, and in the case of a girl, that she is not pregnant (Bottoms, 1999).

CW: (Very empathic, sits down beside Elizabeth and takes her hand.) Elizabeth, I'm Delaine from the Carl Perkins Center for Children. I'm guessing some pretty scary things have happened, and you're probably having some pretty scary feelings right now. I want to talk to you about some of those scary things. It's OK to be scared, because it was a pretty scary deal. But you're safe now, and your mom and we are going to make sure you stay safe. So if you'd like, I'll try to answer any questions you have about what happened and what's going to happen.

Elizabeth: (after the examination and the initial interview by a forensic expert) When Leon did this to me and he stuck his peter in me, it really hurt. Am I gonna die, 'cause I started bleeding? Will I get pregnant?

CW: No, you're not going to die. It's normal to feel sore after all that and to bleed some. But the doc- tors said you were OK, and Dr. Ann will be back to see you and tell you you're OK. I checked with the doctor, and you're not old enough to get pregnant yet. Dr. Ann will tell you about all this, so don't worry about that.

It is extremely important for young children who have little information about how their body functions to immediately allay fears of what may happen to their body as a result of the assault. A somewhat controversial issue is whether the initial examination should be done at the child advocacy center, as opposed to a hospital. Many times the child-friendly atmosphere of the center is much more conducive than a hospital for examining victims . The counterargument is that examinations should not be done at th~ center because the child might associate that frightening procedure with the center's

physical environment and generalize it to the staffs subsequent attempts to work there with the child (Bottoms, 1999).

Preparing the Child for Testimony Interviewing children about their potential sexual abuse is a tricky business and best done by practiced forensic examiners. There is no set protocol free of trail ramifications, so the goal is to elicit reliable and complete information without tainting it (Saywitz & Dorodo, 2013). The last thing that needs to happen is raising the specter of "false memories." Sexual assault is a criminal matter, and at some point the child will probably have to testify in a courtroom. That appear- ance may be terrifying to a small child who will have to give testimony against a caretaker who may have either been very nice to the child or made threats against the child and his or her family. Depending on the age of the child, the Carl Perkins Center uses puppets, books, and videos to educate the child on what testimony in a courtroom entails. Immediately before the child's appearance in court, a staff member from the center will take the child to the courtroom to acclimate him or her to what may be perceived as a frightening experience. The staff explains about everybody's role and how things will happen. He or she will role-play traf. fie court so the child gets an idea of how courts operate. Children can explore the courtroom, ask questions, and sit in the judge's and witness chairs, so that they become familiarized with a courtroom and are not terror stricken when they are asked to engage in the real situation.

Another problematic area is time of court appear- ance. Courts are notorious for not starting on time. Sitting all day on a bench outside a court waiting for it to convene while the perpetrator is seated on an adjacent bench is clearly not conducive to the child's or the family's good mental health. As a result, the Carl Perkins staff keeps the child and the family at the center until a call is received from the courthouse that court is about to convene. Only then are the child and family transported to the courthouse. After the court appearance, the child is brought back to the center and debriefed. Questions such as "How did that feel?" and "What was that like for you?" are posed to alleviate the residual fears of having confronted the perpetrator at close range (Bottoms, 1999).

The span of time from disclosure and discov- ery of the assault to court appearance may be up to a year, and there will be lots of rranscrisis points as time seems to drag on interminably. It is important that each one of these crisis points be met head-on by crisis workers. Thus the Carl Perkins Center staff

immediately swings into action in dealing with the ch ild and the family and stays with them in support and therapeutic roles for at least a year after the ini- rial contact is made (Bottoms, 1999).

Aftermath Ir should be a given from all you have read IDDJ in this chapter that any child who has been sexually abused needs counseling (Knauer, 2000, p. 46). Discovery of an incestuous relationship throws the entire family into crisis. The father, and possibly rh e mother, faces loss of what has become an addic- rive behavior, possible criminal sanctions, loss of his or her family, and social stigmatization. The nonof- fending parent finds herself or himself torn between her or his partner and the assaulted child. The child m ay find herself or himself discredited, shamed, pun- ished, and still unprotected (Herman, 1981, p. 183). The worker will also face a crisis in d eciding what rn do and whether or not to believe the child's story. However, discovery of child sexual abuse is no differ- ent from d is covery of any other physical abuse, and srate laws mandate that it must be reported (Sandberg, Crabbs, & Crabbs, 1988). It is a criminal activity and should be dealt with in that manner. For those work- ers who are unsure of themselves, it may be reassur- ing to know that fewer than 5% of complaints of child sexual abuse are false.

Conversely, it is not uncommon for children to re- rr act their complaints under pressure from the family (Goo dwin, 1982). Therefore, until clearly proved oth- erwise, the child's allegations should be accepted as rnlid, and the worker's primary consideration should be reporting the abuse to Child Protective Services and obtaining safety for the child (Sandberg, Crabbs, & Crabbs, 1988).•

Because the behavior is both criminal and addic- rive, treating the problem via family therapy is fruit- less. What is called for is immediately referring the ;iroblem to and cooperating with family services and law enforcement agencies that do not subscribe to a family reunification policy (Sandberg, Crabbs, & Crabbs, 1988). It then becomes much more possible to ::emove the father from the home through a court or- d er. Removing the child from the home has negative ::am ifications because it may be construed as banish- .:nent and may also serve to strengthen parent bonds against the child. The child needs assurance that she :S no t to blame for the incest; she should be praised :or her courage and clearly told that she is helping, not ::m rting, her family and will not be abandoned even if she retracts her story (Herman, 1981, pp. 184-185).

CHAPTER NINE Sexual Assault • 279

Counseling Aftercare is critically important to prevent a host of maladies from appearing in later childhood and car- rying on into adulthood. Universal characteristics such as lying, stealing, fighting, verbal and behavioral oppositional defiance, and promiscuity are typical af- termath behaviors that will assail children who have been sexually victimized.

Boys will typically perpetrate sexual assaults on other children, bully other kids, vandalize property, and generally direct their anger outward. Girls typi- cally turn their anger inward and engage in alcohol and drug abuse, eating disorders, and promiscuity. Reducing problem behavior is important along with dealing with the trauma (Miller-Perrin, 2001). The Carl Perkins Center attempts to deal with these is- sues before they become major behavioral problems, through play therapy, therapeutic games, and role plays that deal with the inappropriate behavior in both group and individual counseling. The Center follows a variation on the trauma systems approach (Saxe, Ellis, & Kaplow, 2007), including trauma-focused cognitive-behavioral therapy (Neubauer, Deblinger, & Sieger, 2007), play therapy group work (Haen, 2008; Malchiodi, 2008; Nisivoccia & Lynn, 2007), and work with the family, school, and social service systems (Saxe, Ellis, & Kaplow, 2007; Steele & Malchiodi, 2008). This comprehensive approach is all part of the postvention package of a 1-year follow-up (Bottoms, 1999).

Group Counseling Group counseling is used to normalize the assault and help children understand they are not alone. The group breaks the isolation as children start to share their fears and feelings of shame and guilt. Peer interaction leads to expression of shared feel- ings , bonding, and higher self-esteem. By validating their experiences, the group helps shift the focus of responsibility off children and onto the perpetrators. Further, the typical parameters of group rules help children learn behavioral limits, identify appropriate interpersonal boundaries with others, and learn to ex- press feelings appropriately (Knauer, 2000; Nisivoccia & Lynn, 2007). Children meet in groups twice a month for a year.

These issues are not sugarcoated. Group leaders discuss these problems in a straightforward manner and teach children how to deal appropriately with the feelings , behaviors, and thoughts that are likely to confront them as they work through the trauma they

280 • PART TWO Handling Specific Crises: Going Into the Trenches

have experienced. The idea is that if these problems are talked about openly and honestly, then survivors will not be further victimized and will be empowered to start taking control of their lives back (Bottoms, 1999).

The assaulted child may have been told, not only by the perpetrator but also by other family members, that the child himself or herself is the cause of the family's breakup. Constant reinforcement is used to convey to children that the assault wasn't their fault. Workers who are not versed in dealing with sexually abused clients will not understand the importance of driving this point home. The fact is that many, many sexually abused clients will believe it is their fault and that they, and they alone, as a result of their disclo- sure, have caused all the problems that have occurred for the family (Bottoms, 1999).

Groups are set up in age ranges of 2 to 3 years . Groups are not run for 3 - to 5-year-olds because of their short attention span and lack of mature cogni- tive development. The 3- to 5-year-olds receive only individual counseling. Because of the curriculum and techniques used, groups are also divided into readers and nonreaders. Group participants also receive indi- vidual counseling, twice a month on alternate weeks from when groups me et. Different children manifest different problems as they work through the trauma of the abuse. When a child starts to manifest a partic- ular characteristic, such as stealing, then individual counseling is tailored to fit that child's specific needs (Bottoms, 1999). Particularly for younger children, any group therapy should not be entirely devoted to "talking" therapy. Play is the medium that gets the message across; puppets (Webb, 2007), dramatic enactment (Haen, 2007), bibliotherapy (Malchiodi & Ginns-Gruenberg, 2008), sand play (Carey, 2006), art (Malchiodi, 2008), and particularly for older chil- dren, board games (Schaefer & Reid, 2001) all provide mediums to get the message of abuse across and teach children cooperative, prosocial behaviors that many of them lack.

Boundary Issues Boundary issues are endemic to this population. The positive feedback and attention these children receive from engaging in sexual activities with long-term per- petrators transfer over to and generalize to a variety of other situations and people. Thus one of the primary thrusts of counseling at Carl Perkins is to reestablish appropriate personal and interpersonal boundaries.

Sexual assault turns understanding of normal developmental• boundaries upside down and children

may become erotized, meaning that psychologically the children may believe that the only way to gain attention is to be sexual. Physically, the feeling m ay have been enjoyable and they do not perceive it as abuse (Knauer, 2000, p. 10). An example of the lack o understanding that sex ually assaulted children have of interpersonal boundaries is related by the Assis- tant Director of the Carl Perkins Center:

Assistant Director: I was on a home visit working with the mother of a young girl who had been sexu- ally abused. My purpose for the visit was to work with the mother in teaching her parenting tech- niques to use with the daughter. I really wasn't there to deal with the young girl, but she inces- santly demanded attention from ' both me and the mother. Providing her with alternative activities such as coloring books and dolls didn't satisfy her demand for us to attend to her. The little gi rl left the room and then reappeared with a neglige e on and tried to get me to look at her. When that didn't work, the girl got up and sat as close to me as she could. When I still continued to attend t o the mother, she climbed in my lap. When I still did not attend to her, she started kissing me, and finally attempted to stick her tongue in my mouth. In her attempt to get my attention and affection, she knew no interpersonal boundaries. It doesn't take a rocket scientist to figure out how that had come to be. Love, attention, and sex are all rolled into one as far as these kids are concerned. I can't tell you the number of times we have discovered these 6-, 7-, and 8-year-olds having sex with other kids when they should be playing with dolls and trucks with those kids. So a lot of time is spent on talking about what appropriate boundaries are .

Group Support Work with Nonoffending Parents For mothers, the notion of entering a support/ther- apy group may be very threatening. However, it is quite possibly the only way they will be able to get their families back together. Mothers should be told this fact in plain and simple terms and should be strongly encouraged to join such groups. Groups for spouses of abusers enable members to come to terms with doubts of their own womanhood, regain a sense of control and empowerment in themselves and their families, reduce blame and guilt in themselves , and restore mother - daughter bonds (Brittain & Merriam, 1988; Salter, 1988, p. 211).

Preventing Revictimization Perhaps most tragic of all the issues that assail a family is revictimization of the child by the nonoffending parent. O ften a role reversal occurs whereby the child not only is the sexual object of the perpetrating parent, but also becomes the chief confidant and comfort provider for th e nonoffending parent. She or he takes on the role of being the real partner of the nonoffending parent and usurps the nonoffender parent's role . This role reversal may be completed by the nonoffending parent's psychologically taking over the child role.

Therefore, crisis workers spend a good deal of time with nonoffending parents, teaching them to reas- su me the role as head of household and to stand their ground when the child attempts to reassume her or h is pseudo-adult role. Finally, time is spent on talk- in g about the nonoffending parent's not falling into a nother relationship that has the same outcome, as t he parent may be highly likely to do (Bottoms, 1999).

What the Carl Perkins Center does with families who have been involved with sexual abuse is not short- term, brief therapy. The multiple crises that erupt after disclosure should make it readily apparent that there are no quick fixes to this horrific problem. At least a year of continuing crises may be expected as the family attempts to restabilize and reinvent itself, and to be successful, it will need help every step of the way.

Individual Counseling T here are two major purposes in individual coun- seling following childhood sexual abuse. The first is m aking it safe enough for the child to discuss the as- sault. Avoidance is typically a hallmark of a traumatic event for children and children are generally reluc- tant to discuss it (Webb, 2007, p. 51) . Second is reen- a ctment of the trauma and cognitively restructuring it so that it no longer is the axis on which the child's life turns.

Intervention with abused children should never be d one in isolation but should include the nonoffending :nembers of the family (Mohl, 2010). Neubauer and h er associates (2007) and Saxe and his associates 2 007) propose that trauma therapy with children

sh ould have parallel parent training and therapy o ccurring at the same time. Neubauer and her as sociates propose that individual therapy should ? ro gress with the nonoffending parent and child se en separately first. The reason for doing so is to .:reate a safe atmosphere for both the parent and the .:hild to start to openly discuss their thinking and :eel ing about the abuse, which will not be easy to

CHAPTER NINE Sexual Assau lt • 281

do under the best of circumstances. Later on, when both the child and the parent have received a good deal of processing and training, they are brought together in conjoint therapy. At this time the child tells the complete story of the abuse, and the parent openly discusses her or his own feelings and rein- forces the child's proactive behavior. The end result is that emotional and behavioral dysregulation is first stabilized and then, through the course of therapy, psychoeduction, and parent training, both parent and child can transcend the abuse and move on with their lives (Saxe, Ellis, & Kaplow, 2007).

Session 1: Establishing Safe Ground. In this opening session the worker seeks to establish safe therapeutic ground for the child by asking him or her to talk about something they like or want to do.

CW: Elizabeth, I am pleased to meet you. My name is Delaine Uptown, and I am a counselor here at the center. You and I are going to be spending some time together, so I'd like to get to know you a bit better. I'm wondering if you could tell me a bit about things you really like to do or, in fact, might want to do. Perhaps something you did this week- end or today? Which would you like to choose?

Elizabeth: Well, I mostly stay at home now, but I like to ride my bike and go over to my best friend Cindy's and play in her tree house, it's really neat. We play dolls and stuff up there.

CW: OK, great, so you've got a good friend and pal that you can depend on and can go play dolls with. I also know that it's a lot easier for kids to some- times use toys and drawings as ways to express feelings . Take a look around the room, Elizabeth. There are a variety of toys and art supplies here that you can use. There is even a sand tray over here that we can use if you want. The choice is yours, so where would you like to start?

The worker sets the scene with the child in a benign, nonthreatening way. She also introduces Elizabeth to the play materials in the room.

Concurrently the worker will start educating the parent on symptoms and behaviors the child is likely to display as they move through therapy, which will undoubtedly have transcrisis points as the child be- gins to regulate emotions and behaviors and parents learn new communication and behavior management skills. As the child and the worker begin bonding, the worker will move to trauma.

282 • PART TWO Handling Specific Crises: Going Into the Trenches

Session 2: Introducing Traumatic Material CW: I think you are pretty good at expressing your

feelings and ideas about stuff I think you also are a pretty smart young woman and know that we are here to talk about stuff that happened that doesn't make you or your mom feel good. You know what I mean?

Elizabeth: Like what Leon did to me.

CW: Yes, that's right. We could either talk about it or you could show me what happened. I know you like to draw things.

Elizabeth: Well, he sorta touched me in places where he shouldn't have . (Takes markers and star ts drawing randomly with no apparent meaning or form .)

CW: OK. Did he do anything else?

Elizabeth: (Continues to draw and says nothing.)

CW: OK, thank you so much for sharing that with me . So what are you drawing? It looks extremely busy with all those lines.

Elizabeth: Like it's all the lines running everywhere and they don't connect to anything.

CW: Is that perhaps the way maybe you feel sometimes?

Elizabeth: Maybe.

CW: That makes perfect sense to me. Kids who have been abused by people who should take care of them but abuse them would leave anyone pretty jumbled up.

Elizabeth: I guess maybe that's so. The kids in my group talk about that a lot. You wouldn't hurt something you loved like my cat. And my stepfather hurt me.

CW: That is correct, Elizabeth, and that's why he is going to jail. You know I think you ought to write a book about this experience complete with the pictures you have drawn.

This exchange indicates that the worker is moving ever forward in getting Elizabeth to recount and capture the whole episode. Saxe and associates (2007, pp. 269-271) propose that children write a book about the episode that they can then share with their caretak- ers. Saxe and his associates believe book writing allows the child to narrate in both words and pictures the se- quence of the assault. They propose chapter titles like "All About Me," "My Family," "Something Bad Happened to Me," "Things Changed After the Bad Thing Happened,'t "Some Things Stayed the Same," "People Who Care About Me," "What I Can Do to

Protect Myself in the Future," and "Skills I Have Used When My Bad Thoughts Get in the Way." These chapter headings can, in fact , be the topics of counseling sessions. Once recorded, Elizabeth can immediately refer to her chapters so that the behavioral and cognitive sets she will learn-such as deep breathing and relaxation training, sensory and verbal cueing, catching oneself, and setting up cognitive "stop" and "go" signs before things go awry- are readily available and in her own voice rather than the therapist's or what a book says to do.

This initial foray is met with some resistance, but it is a start and the mass of twirling lines apparently d o represent a central part of this youngster's thinking. Concurrently the worker has given Mo11a a homework assignment and discusses her progress in reinforcing Elizabeth and also using natural consequences of actions when she becomes rebellious. The focus here is not on Elizabeth but on Mona's responses .

CW: So, you've gotten through the first part of Becker's Parents Are Teachers [Becker, 1972] and have really upped the verbal M&Ms, reinforcing her a lot more than you did. You have even kept a diar y. Wow! That is really great. That tells me that you are into changing behavior big time, and not just your kid's. What about timeout when she acts out?

Mona: I'm having some trouble with that. I feel so bad about sending her to her room after all that has happened. I love that girl so much, and it tears me up to have to come down on her and ground her when I know it's all from that no good bastard.

CW: So pick a time last week when things were REALLLLLY good and when they were REALLLLY bad. What were the billboards going through you r head that made you continue doing the reinforce- ment and reading the Parents Are Teachers book, and what were the negative ones that made you want to throw in the towel?

Just as she will do with Elizabeth, the worker is not only training Mona in new ways of parenting, she is also teaching her to catch the positive self.enhancing statements she is giving herself and the negative ones that help extinguish attempts at new behavior. In short, she is teaching Mona how to regulate h er emotional behavior as well.

The Carl Perkins staff meet with the nonoffending parent twice a month for a year. After the abuse has been discovered, children tend to behave differently. Without knowledge and training, parents are likely to be shocked by these previously unseen behaviors as the child acts out (Knauer, 2000; Miller-Perrin, 2001).

Thus, home visits and parent training to educate a nd normalize the behavioral changes that are likely to occur are critically important. If such training d oes not occur, then warfare between the parent and rhe child will create another crisis. Forewarned is fo rearmed, and if parents start seeing these behaviors, t he center staff immediately start tackling these is- sues with the child. Therefore, center staff keep close contact with the home to catch and stop inappropri- ate behavior before it gets started (Bottoms, 1999).

A classic example of acting-out behavior is steal- ing or shoplifting. The immediate knee-jerk reaction of many parents is to use shame as a way of modifying t he behavior. Yet using shame to extinguish behavior compounds all kinds of shame-based issues the child may already have. Another example is sexual acting out. A parent who has started to date again after re- moval of the perpetrator will be horrified when the child attempts to become intimate with this new person. Because of the vacuum left by the removal of t he perpetrator, the child's need for love and affection, and her or his confusion over boundaries, the parent's new boyfriend or girlfriend may become a target for the child's commingled notions of how love and sex are intertwined and how she or he can obtain that love through sexual gratification (Bottoms, 1999).

We will speak a good deal about making home visits and their potential for violence in Chapter 14, Violent Behavior in Institutions . However, you should clearly understand that even though one perpetrator has been removed from the home (or thought to be re- moved) you still need to be cautious and planful when making a home visit, and that plan includes your own personal safety. Saxe and his associates (2007) pro- pose an "On-the-SPOT" decision tree (p. 179) that dictates what you will do if you enter a home that is in crisis and violence boils over. The first question to ask yourself is "Is everything cool and calm here, or is something unusual happening that appears headed toward a crisis?" The very next question is "How safe am I?" If the answer to that question is "I'm not sure" or "Not very," then get out now!

Home intervention also includes many case manage- ment activities. Getting ready for court, obtaining an attorney, looking for alternative living arrangements and transportation, dealing with school issues, and applying for victims' compensation and other state support mechanisms for families are but a few of the many support activities that will be needed to help the family restabilize (Bottoms, 1999). As Saxe and his associates propose (2007), this is a systemic effort,

CHAPTER NINE Sexual Assault • 283

and nothing less than dealing with the whole system will do.

Crisis Session . All of the foregoing sounds swell, but the fact is that the therapy of child sexual abuse rarely pro- gresses in a nice, linear, ever upward, ever onward man- ner. There are transcrises aplenty with which to reckon.

Elizabeth: (Tears up the carefully made new family she has been building in the sand tray and breaks down in tears.) This won't ever come true! Some kids at school said Leon's gonna get out just like their daddies did and will be right back at home. I HATE THIS STUPID SAND TRAY! THIS IS HOPELESS. WE'LL NEVER BE SAFE, AND I HATE THERAPY, AND YOU TOO, MISS DELAINE, so you can just kiss my ass goodbye! (Stands defiantly as an 8-year-old can, tearfully regarding Delaine with as evil a look as she can muster.)

CW: (Says nothing but picks up some modeling clay and pop- sicle sticks and starts constructing something.)

Elizabeth: (Sits over in the corner staring balefully at the worker. Slowly comes over to the worker.) Whatcha do- ing with that clay and those stupid popsicle sticks?

CW: I am going to build something I think might help when things are really down. I guess you are so hope- less and helpless right now you couldn't help me.

Elizabeth: I didn't say that. What is it?

CW: (Sweeps the sand away in the sand tray and parts it to reveal a broad swath of blue board.) It is a bridge. I am building a bridge over troubled waters . But it has to be a strong bridge with good foundations , strong girders, and support wire because it has to stay solid and mustn't fall in. It carries very impor- tant people on it ... like your mom and you.

Your stepfather may get out some day, but you will be a grown woman by then. But there are going to be other troubles that will get you down and things that will appear just as hopeless, maybe things you do, or your mom does, or maybe what other people say or do. So it's got to be a strong bridge. I'd like to put this family on the other side with palm trees and beach chairs and sunshine, not on this side with the swamp and all the nasty swamp things that live in it. But I can't build this alone. It is your bridge.

Elizabeth: (Grudgingly starts to help mold pillars for the bridge.) I guess so.

CW: (after bridge is done) How do you feel? You see you have a real way to get out of the swamp. I am going to take a picture of this , and I want you to put it in

284 • PART TWO Handling Specific Crises: Going Into the Trenches

the book. This is very important because it shows that you can get to the other side and you can make your own bridge to get you there. So remem- ber where you have come from. You have indeed crossed over that bridge with all the work we have done . There is no going back, you are across, but every once in a while when things get tough it's good to remember that this bridge we just built really is your bridge, Elizabeth. It is something you now own and can use forever. Now stand over there by the bridge and give me a big cheesy smile!

Drawing or constructing a bridge lets clients concretely fill in gaps when they see little way across "troubled waters." Bridging exercises are mainly used for assessment to determine where people have been and where they are going (Martin, 2008). Here we use bridg- ing as a therapeutic vehicle to get Elizabeth mobilized again and show her where she has been, whence she has come, and where she is going. Here the crisis worker takes action and very actively and directly gets into the game, but as soon as Elizabeth mobilizes herself, the

The sexual assault research consistently finds that the incidence of sexual assault is greatly underreported. The majority of reported rapists and other sexual abus- ers are males, and they come from all walks oflife. Most abusers appear to perceive those they attack as objects of prey rather than as people. They usually assault not out of lust or desire for sexual gratification but out of a perceived need to control, exert power over, punish, vanquish, defeat, hurt, destroy, degrade, or humiliate others. Typically, abusers deny, minimize, and/ or ratio- nalize their behavior to the extent that they themselves rarely define their attacks as abuse. Instead, they usu- ally claim that the survivor asked for, deserved, seduced, wanted, needed the experience in order to grow up, or somehow caused the abusive activity to occur.

Rape is a complex phenomenon that encompasses and affects the psychosocial, cultural, and personal aspects of society. There are no cause-and-effect for- mulas that explain why one person sexually assaults another. Consequently, many erroneous assumptions, beliefs, and myths about rape are held by different people, and women and men often differ in their perceptions about rape. .

crisis worker assumes a collaborative mode and then becomes nondirective as Elizabeth regains control.

Last Sessions: Transcending. What Saxe and associ- ates (2007) call the transcendent phase of interven- tion occurs when the caregiving parent and abused child are brought together in conjoint therapy. The notion is that both caregiver and child are now able to talk openly and honestly about the abuse. The worker may start these sessions by acting as a game show host and asking both clients questions about sexual abuse (Neubauer, Dehlinger, & Sieger, 2007). As survivor and caregiver reaffiliate, the child is en- couraged to read passages from her book; Saxe and associates (2007, p. 276) recommend about three chapters per session. As the child reads the chapters, the caregiver expresses his or her own thoughts about what the child has written and gives the child a whole lot of reinforcement for having done such an awesome job of getting her feelings, thoughts, and behaviors about the sexual abuse down on paper (Neubauer, Dehlinger, & Sieger, 2007).

Date and acquaintance rape, especially on college campuses, has become a pressing problem. The prob- lem is exacerbated by the use of drugs and/ or alcohol that is usually found to be associated with date rape . One impediment to preventing date and acquain- tance rape is the differential perceptions between men and women. The research consistently reveals that men are more tolerant of rape than are women.

Recently, the human services professions have directed a great deal of attention to rape and sexual assault on children. Substantive work has been done in the areas of crisis work, counseling, legal, social, and psychological interventions to help children and to prevent child sexual abuse. Such intervention and prevention have been made even more urgent in ligh t of recent findings that child sexual abuse extends debilitating traumas far into the adulthood of sur- vivors. An enormous amount of research has shown that adult survivors of child sexual abuse often suf- fer a wide diversity of emotional, physical, psychologi- cal, and social pathologies that manifest themselves in various degrees of transcrisis and PTSD symptoms later in adulthood. These findings have produced

g reater urgency than ever before to help victims of sexual abuse and to stop offenders from assaulting.

Crisis intervention and other human services work in the area of rape and sexual assault of chil- d ren require unique and specialized knowledge and strategies. Children are vulnerable to many kinds of pressures, and perpetrators of child sexual abuse k now all the angles needed to ensnare child vic- tims. The legal, medical, social, mental health, law enforcement, and human services professions as well as the court system are becoming increasingly integrated in attempting to stop the abuse and to work with abused children and their families. There is ominous research on sexual predators' use of the Internet, and that arena will surely deserve even more attention in studies on controlling and con- taining child sexual abuse.

In recent years the public, too, has become in- creasingly aware of the phenomenon of rape and other forms of sexual abuse, and that new aware- ness appears to have ushered in a greater sensitivity to and advocacy for the rights and needs of survi- vors . However, much remains to be done. Society still needs to overcome a number of long-standing myths about rape and other forms of sexual abuse . And survivors' families, friends , and coworkers need to be willing and able to respond to survivors with openness, genuineness, acceptance, understanding, and respect, all of which are key attitudes or condi- tions for nurturing recovery from the debilitating trauma and effects of sexual assault. Given the high

CHAPTER NINE Sexual Assault • 285 . incidence of sexual assault and its underreporting, it is highly likely that a number of you-both male and female-may have experienced this crisis. As a result of reading this chapter, you may experience or be experiencing some of the repercussions this chapter speaks of in people who have been sexually assaulted and abused. We urge you to not be ashamed, embar- rassed, or guilty but to understand that this crisis is common to a whole lot of people and to get help! If you don't feel there is hdp in your community or you are too embarrassed to ask, call the National Office on Violence Against Women's hotlines: the Rape, Abuse, and Incest National Network Hotline at 1-800-656-HOPE (4673), the National Sexual Violence Resource Center at 1-877-739-3895, or the National Teen Dating Abuse Helpline at 1-866-331- 9474. If you are attempting to recover on your own from a sexual assault, get Aphrodite Matsakis's The Rape Recovery Handbook (2003). It is a step-by-step help program for survivors of sexual assault. It's user friendly, talks straight to you, and has really helpful exercises in it.

Visit CengageBrain.com for a variety of study 0 tools and useful resources such as video ex- ~ amples, case studies, interactive exercises, fla:~: ~ I cards, and quizzes. __J