Women's Safety in Recovery: Group Therapy for Patients With a History of Childhood Sexual Abuse

Group treatments (1—3) for patients with a history of childhood sexual abuse have typically included outpatients only, excluding those with severe character pathology, current life crises, psychoses, and a history of substance abuse (4-8). It has been argued that outpatients in acute distress cannot tolerate groups focused on sexual abuse because disclosing the abuse history can be destabilizing and retraumatizing (6). Similarly, doubts exist whether inpatients, because of their even more compromised coping capacities, can benefit from addressing sexual abuse issues (9). Moreover, as inpatient lengths of stay decrease, crisis management may be relatively easy to justify, but group models that rely on lengthy inpatient treatments (10) no longer appear to be relevant.

Therefore, new models of group therapies for acutely ill patients that can be accomplished within the context of brief inpatient and partial hospital stays need to be developed. One such model, the Women's Safety in Recovery group, is described here. Because this treatment approach has not been previously reported and is potentially controversial, the theoretical foundation, therapeutic goals and methods, and group structure of the model are described in detail.

Background

The development of group therapies for women with a history of sexual abuse is especially important given what is known about the prevalence of childhood sexual abuse, its long-term psychiatric effects, and the psychological legacies of childhood trauma. Depending on measurement techniques and definitions of what constitutes sexual abuse, prevalence rates for childhood sexual abuse ranging from 9 to 27 percent have been reported in general population studies in the United States (11-14). Even higher rates have been reported among women in psychiatric care (15-17).

Research has confirmed that a history of childhood sexual abuse is associated with adult psychopathology, sexual dysfunction, disturbances in interpersonal relationships, suicide attempts, substance abuse, high-risk sexual behaviors, and self-mutilation (18-20). Multiple medical complaints, health-risk behaviors, somatization, and somatoform disorders are also more common (21,22). The public health impact of these sequelae is significant. Occupational and social functioning are frequently impaired; medical utilization and health care costs may be higher than for the general population (22). Psychopharmacological treatments may ameliorate symptoms suffered by patients with a history of childhood sexual abuse, but additional therapies are required to address the deleterious impact of sexual abuse on psychological functioning.

Women's Safety in Recovery

Theoretical foundation

Group treatments for patients with a history of childhood sexual abuse may have therapeutic advantages. The secrecy, shame, and stigma that are the legacies of abuse may be more significantly alleviated in a group setting than in individual therapy (1,2,7). In addition, the power of the peer group mitigates the influence of the therapist's perceived power, which is an advantage for patients who may resist or regress during individual treatments with a therapist who is perceived as an authority figure (3).

Of course, group therapies must be tailored to accommodate certain patient characteristics, including the severity of psychiatric symptoms (23). The Women's Safety in Recovery model is based on Herman's description (2) of first-stage trauma recovery groups for acutely ill patients. Its primary therapeutic task is to establish safety and control by educating members about traumatic syndromes and strategies for self-care. Detailed disclosures of specific information about the trauma are discouraged to avoid retraumatization.

The curriculum emphasizes psychoeducation about the possible effects of childhood sexual trauma in adulthood. Patients are informed about bewildering emotions and behaviors and their possible relationship to childhood sexual abuse to help them make meaning out of previously incomprehensible experiences. For example, they are told that dissociative symptoms may stem from childhood attempts to adapt to the stress of abuse. The importance of patients' taking responsibility for safety and control is emphasized by identifying deficits in self-care and developing strategies for improvement. Such an approach may minimize regressive tendencies (24). Patients who develop coping strategies and acquire knowledge can gain mastery (25).

Institutional context

The group is conducted on a short-term inpatient unit, the integrated treatment unit, that also functions as a partial hospitalization program. The unit is part of a general psychiatry service in a university-affiliated medical hospital (26). The partial hospital program provides services in lieu of inpatient hospitalization for acutely ill patients and has a six-week maximum length of stay. Approximately 40 percent of the partial hospital admissions are from the inpatient unit.

Participants

The group was initiated in July 1995. By August 1996, approximately 350 women admitted to the inpatient unit or the partial hospital program were screened, 140 of whom reported a history of childhood sexual abuse before age 18. Twenty-five refused to participate in the group, 59 could not be enrolled because of an inpatient stay of less than five days, termination from the partial hospital program less than one week after admission, florid psychosis or mania, mental retardation, or refusal to participate in routine unit activities. Thus 56 women were enrolled in the group. The majority of group participants had comorbid psychiatric diagnoses of major mood disorders, substance abuse or dependence, or personality disorders.

Among the 56 participants, the median length of stay was 14.5 days on the inpatient unit and 22 days in the partial hospital. The median number of group sessions attended was nine. The mean±SD age of the participants was 38±10.34 years. Fifty of the group members (90 percent) were white, and the remainder were black. Forty-nine (88 percent) had more than a grade school education, and 43 (76 percent) had more than a high school education. Twenty-eight participants (50 percent) were married, 19 (34 percent) were single, eight (14 percent) were divorced, and one (2 percent) was widowed.

Group admission

On admission to the inpatient unit or partial hospital program, every female patient is asked two screening questions about a history of unwanted sexual experiences: "At any age, have you been the victim of rape or other sexual assault?" "Has anyone ever pressured you, at any age, into doing more sexually than you wanted to do?" Screening questions are asked by the unit primary therapists; the answers are recorded and submitted to the Women's Safety in Recovery group coordinator.

Childhood sexual abuse is defined as any sexual contact before the age of 18 with a family member at least five years older than the patient, any unwanted sexual contact with a family member less than five years older than the patient, or any extrafamilial sexual contact that was unwanted. Sexual contact is defined as physical contact of a sexual nature, from hugging and kissing to fondling to sexual intercourse.

To be included in the group, women must have a specific memory of an unwanted sexual experience, rather than an intuition that sexual abuse may have occurred or memory fragments suggestive of sexual abuse. This criterion was established to minimize the possibility that patients would be influenced by the process of group identification to believe falsely that they had been sexually abused. Given concerns about false memory syndromes and childhood sexual abuse, such a precaution seems prudent (27). No attempt is made to corroborate patients' self-reports of sexual abuse (28).

Prospective group members are individually informed about the group by the group coordinator in this manner: "The Women's Safety in Recovery group is designed to help women establish safety and control in their current lives. Past abuse experiences are considered with regard to how they may or may not be having an impact on your current life, especially on how you experience yourself and others. Group members are not asked or encouraged to describe details of past abuse experiences. Detailed discussions of past abuse experiences can be helpful for some women in groups, but that is not what this group is for. The group focuses on the here-and-now problems in women's lives that may have contributed to your need for hospitalization. Group members will talk about how to make choices that keep them in control of their body, emotions, and environment."

Group leaders

The Women's Safety in Recovery group has been co-led by female and male therapists with master's degrees in social work, nursing, art therapy, or education. By providing each other with emotional and intellectual support, coleaders may reduce the psychological distress for therapists that can result from working with abused patients (29).

When one coleader is a man, many participants are reassured to find that mixed-gender teams can work harmoniously. Despite concerns that patients might be unable to work with men (30,31), advantages may exist for women who are able to have a positive emotional experience with a male authority figure. A few factors appear critical in successfully addressing this issue. First, patients are invited to voice their feelings about a male coleader. Second, the highly structured format of the group may reduce patients' fears that they will re-experience uncontrollable vulnerability with an authority figure.

Group structure

The group meets three times weekly for one hour, and participants attend in lieu of routinely scheduled activities. The defining feature of the group is its three-week curriculum. Each week, or module, has a distinct focus within the framework of establishing safety and control of the body, the environment (defined to include persons, places, and things), and the emotions. Didactic components, topic-focused discussions, art therapy exercises, and homework constitute the curriculum, a routine that is structured to be as predictable as possible. An open format is used, meaning that a patient can join the group at any point in the three-week cycle and may even attend for more than three weeks, depending on her length of stay on the inpatient unit or in the partial hospital.

All sessions begin with a review of the group's purpose and guidelines. The importance of feeling intrapersonally and interpersonally safe in the group is emphasized by group leaders. To set the frame of containment, each session begins with an introduction that restates the general information presented individually to the potential members by the group coordinator. Issues of confidentiality are addressed. Patients are then informed about the focus of the group for that week—body, environment, or emotions—and the material to be covered is previewed. Homework is assigned at the end of each meeting and is reviewed at the beginning of the next. To ensure that a standardized body of information is conveyed, leaders follow a detailed outline in group sessions, after which they complete a checklist indicating the topics that were covered.

Psychoeducational curriculum

Module 1: control of the body.

The goals of this module are related to participants' recognizing how a history of childhood sexual abuse may affect adult physical health through distorted perceptions about the body and sexuality, anxiety-related and depression-related health problems (for example, headaches, stomach aches, and diffuse aches and pains), fears about receiving medical care, and self-harming behaviors (for example, substance abuse, self-injury, aberrant eating behaviors, and high-risk sexual behavior). Participants learn about problems in sexual functioning that can arise, including sexual avoidance and high-risk sexual behavior, as well as problems with sexual desire, arousal, or satisfaction.

Each participant identifies her individual health concerns and makes a plan to address them—for example, with medical assessment and treatment, nutrition, and exercise. Participants plan ways of controlling self-harming behaviors by developing safe sexual practices, obtaining treatment for substance abuse or eating disorders, and seeking social support from reliable friends or family members.

Issues about body image are central in this module. Many women with a history of childhood sexual abuse are dissatisfied with their physical appearance, and they may be ambivalent about making changes that could attract sexual attention. Concerns about poor nutrition, overeating, and restriction of food intake are common. Some women complain of physical malaise, often accompanied by depression, which robs them of the energy to exercise or take care of their bodies. Others speak about their discomfort with health care providers, particularly gynecologists, and their apprehensions about disclosing sexual abuse histories to practitioners.

Case vignette. Ms. A, a 29-year-old clerk with diagnoses of major depression and alcohol abuse, was experiencing a marked deterioration in her physical health in conjunction with acute psychiatric disturbance, including intrusive memories of childhood sexual abuse. These symptoms were apparently triggered when her employer hired a paroled sex offender. During the module on control of the body, Ms. A created a collage depicting her health concerns that highlighted her major deficits in self-care. Through psychoeducation by the group leaders, she learned that individuals with a history of sexual abuse may neglect physical health, especially during periods of stress. In a homework assignment, Ms. A prioritized a list of health concerns and formulated a behavioral plan to address them. She began to feel safe and in control when she acted on these strategies to discontinue her alcohol consumption, resume a regular sleeping regimen, and bathe and eat regularly.

Module 2: control of the environment.

The goals of this module are related to participants' recognizing ways in which childhood sexual abuse may affect judgments about safety and danger in the environment; for example, they might have difficulty knowing who is trustworthy, underreact to potentially dangerous situations, or experience excessive fearfulness. Participants learn about elements in the environment necessary for safety in relationships, at home, in the workplace, and during recreational activities. Each participant identifies ways of increasing her safety in her own environment and plans ways to develop a safe social support network.

Group members readily identify ways in which they can make their home environment safe—for example, by having sturdy door locks, keeping windows locked, and keeping outside lights on at night. Some women are concerned that their homes have become a fortress and may be the only places they can feel safe. For many women, social withdrawal has created painful isolation, which may force them to deal with crises alone. Participants often find it very difficult to distinguish safe from unsafe people. Ongoing contact with the perpetrators of the abuse is an issue for some group members.

Case vignette. Ms. E, a 42-year-old unemployed mother of three with a history of bipolar disorder, was very hesitant about enrolling in the group. She doubted her capacity to contain her self-disclosures and feared becoming dependent on the group leaders. She was skeptical of the male group leader, who reminded her of an abusive uncle. When she observed that the leaders effectively helped contain other members' disclosures, her participation in the group activities gradually increased.

During the module on control of the environment, Ms. E learned about the negative psychological consequences of extreme social withdrawal. She completed a worksheet on the characteristics of safe and unsafe people, which helped clarify relationship boundaries that were crucial to her feelings of safety. As she began to trust her capacity to make good judgments about who was safe, she began to develop a safe support network by making social plans with a few acquaintances outside the hospital.

Module 3: control of the emotions.

The goals of this module are related to recognizing ways in which past abuse may affect current emotional experiences (for example, shame, guilt, and anger) and interpersonal relationships (for example, by creating difficulties with trust). Participants learn the definition of trauma and trauma response and recognize typical posttraumatic stress symptoms. Each participant identifies situations that trigger painful emotions, including posttraumatic symptoms, and plans ways of managing emotions safely—for example, by using social supports, physical activity, psychotherapy, and relaxation techniques.

The review and discussion of trauma and posttraumatic symptoms provoke strong and mixed emotions in group members. Patients may feel validated and reassured to have a framework for understanding their bewildering emotional experience. At the same time, they grieve and are angry about the impact of childhood sexual abuse on their lives. Some group members veer toward despair, fearing that they have been hopelessly damaged by the abuse. Group leaders find that trauma symptoms, particularly dissociation and numbing, must be destigmatized for patients. Many members are motivated to plan ways of modulating the extreme emotional responses that disrupt their relationships.

Case vignette. Ms. C, a 32-year-old child care worker, had developed severe depressive symptoms and suicidality in response to conflicts with her mother and sisters. Although these family members demanded emotional and financial support from Ms. C, they were highly critical and unsupportive. Moreover, she had been very disappointed by their lack of empathy when she divulged past sexual abuse by a babysitter. During the module on control of the emotions, Ms. C used an art exercise to represent visually the feelings and thoughts that belonged to her public self and to her private self. In doing so, she learned more about her power to choose to share private feelings with others.

During a group discussion, Ms. C said that her feeling of helplessness in response to demanding family members was similar to her experience with the abuser. She decided that by disclosing personal information to her family, she was unnecessarily making herself vulnerable. She developed a plan to structure her communications with family so as to avoid personal disclosures. As she learned to set limits on these interactions, she was better able to maintain emotional equilibrium during contacts with family members

Conclusions

The questions of whether and how a history of childhood sexual abuse should be addressed in psychotherapy with psychiatric patients in acute distress are critical. In our sample, 40 percent of the 350 female patients who were screened reported such a history. A substantial number of inpatients report that their history of childhood sexual abuse has a major impact on their current lives (9). If those concerns are not addressed in psychotherapy, patients must struggle alone or confide in others.

The Women's Safety in Recovery model represents an attempt to respond to patients' expressed concerns about childhood sexual abuse. Leaders and other staff have found that the group is generally beneficial to its members; most participants have reported a high level of satisfaction with the group. Nevertheless, group sessions can elicit painful emotions and memories, especially when disclosures of abuse histories are not effectively curtailed. Although the dropout rate in the group is relatively low, approximately 10 percent, some patients have cited the disclosure of specific details about the abuse as their reason for leaving.

It would be useful to identify whether patient characteristics and group composition predict outcome. For example, research on outpatient groups has examined demographic characteristics, symptoms, abuse history, economic dependence on a spouse, and psychiatric history as potential outcome predictors (32- 34). Ideally, these patient characteristics, as well as others, could be examined in a test of the effectiveness and efficacy of the Women's Safety in recovery model.

The model described here has been used only with women. A group for men, or men and women, could change the group process sufficiently to require modifications in the model (35,36). Other changes may be required to accommodate the model to a different institutional setting, such as a brief-stay inpatient unit without an associated partial hospital or aftercare group program.

Acknowledgments

The authors thank Tom Milliman, M.S.Ed., and Bess Greene, M.A., for contributing to the group's development and implementation.

Dr. Talbot and Dr. Houghtalen are assistant professors of psychiatry, Dr. Duberstein is assistant professor of psychiatry and oncology, and Dr. Wynne is professor of psychiatry in the department of psychiatry at the University of Rochester School of Medicine and Dentistry, 300 Crittenden Boulevard, Rochester, New York 14642. Ms. Cyrulik, Ms. Betz, and Ms. Barkun are primary therapists at Strong Memorial Hospital in Rochester.