Journal of Substance Abuse Treatment, Printed in the USA. All rights reserved.

Vol.

0740-5472/92 $5.00 + .OO Copyright 0 1992 Pergamon Press Ltd.

9, pp. 311-318, 1992

ARTICLE

An Incest Survivors’ Therapy Group CHARLESWINICK, Pm, * ARLENE LEVINE, m&-f AND WILLIAM A. STONE, MAX of New York Graduate School, tPrivate Practice, New York, New York (formerly Vice President-Clinical Services, Odyssey House, New York, New York), Par, St. Petersburg, Florida (formerly Data Coordinator, Odyssey House, New York, New York)

*City University

ioperation

Abstract-A weekly therapy group for women who have been incest victims and are residents of Odyssey House, a therapeutic community for drug abusers, is described. Women participating in the group have a significantly greater retention and graduation rate than other women in the program. The group reduces isolation; helps in dealing with denial; clarifies relations with children, other family members, and significant others; and facilitates dealing with incest-related guilt and shame. The impressive therapeutic progress of the incest survivors, which is attributable to the group, suggests the possible utility of such a group for other therapeutic communities and treatment programs. Keywords-incest

survivors; therapeutic community;

drug abuse; group therapy.

vors’ group.” Incest is defined as involving actual physical activity, either fondling, oral, anal, or genital, by an adult, family member, sibling, or any other relative or family significant other (i.e., mother’s boyfriend). The program has traditionally been willing to accept high-risk applicants who are more likely to have severe psychiatric problems, physical ailments, parental alcohol and drug use, and rape or incest histories than are the members of other therapeutic communities (Walker, 1988). The founder, psychiatrist Judianne DensenGerber, originally developed the incest survivors’ group because women incest survivors were often reluctant and ashamed to discuss their experiences in the presence of others who had not shared similar experiences. Even though the program has many other therapy groups, a number of women are not able to violate the secrecy that has surrounded their incest and discuss such experiences in a heterogeneous group that includes men as well as women who have not experienced incest. The incest group provides a way of sharing a secret in a supportive group that maximizes bonding. Because the sharing of previous drug abuse and living together in the facility strengthens empathy, the sharing of such a powerful secret becomes facilitated. Secrecy is central in incest because the behavior usually occurs in isolation. The child is often ashamed because the perpetrator may indicate that the activity is wrong and the child’s fault, but emphasizes that the child must keep the secret. The child may feel abandoned by the mother, after disclosure of the incest sit-

ODYSSEY HOUSE IS A THERAPEUTIC community for the treatment of the chemically dependent that has had a special program for the female incest victims in its population for over 20 years. The program involves identification of incest victims, at the time of entrance into the program or later, and their regular participation in a weekly 2-hour incest survivors’ group, led by a psychodynamically oriented female therapist. Originally the therapist was a psychiatrist and more recently, has been a psychologist. The program has always had a special interest in women’s issues, and the survivors’ group has been a productive and valuable contributor to residents’ therapeutic progress. Recently, other therapeutic communities have begun incest survivors’groups. Project Return, in New York, has two such groups, each of which is limited to 12 members and meets for 11 sessions. One group is led by a male and another group is led by a female. Residents’ attendance is encouraged but not required. The term “survivors” is used to describe persons with an incest history in order to convey an identity based on efforts at positive adaptation, rather than a passive victim status (Haller & Alter-Reid, 1986). Within the program, the group is usually identified as the “survi-

Requests for reprints should be sent to Charles Winick, Pho, Training Program in Behavioral Science Research in Drug Abuse, City University of New York Graduate School, 33 West 42 Street, New York, NY 10036.

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uation. Since the experience is associated with rejection by authority figures, the resident may think that her disclosure of incest could make her stay in the program more difficult. In recent years, there has been a growing awareness of the substantial number of women involved in incest experiences. One survey of adult women reported that 16% had been sexually abused as children (Russell, 1983). Of those cases, only 2% had been reported. Other investigations suggest that the rate of disclosure of incest experiences varies between 2% and 10% (Herman & Hirschman, 1981; Rosenfeld, 1979). There is a significant connection between incest and chemical dependence. A Minnesota study found that approximately 30% of women treated for incest had been chemical abusers (Coleman, 1982). Of all 118 women in treatment for heroin addiction in 1974 at the various branches of Odyssey House in several states, 44% were incest victims (Benward & Densen-Gerber, 1975). The commonalities between incest and chemical dependency are so large that professionals handling such cases have been urged to examine their own feelings concerning incest in order not to contaminate the client’s interpretation of what happened (Yeary, 1982). One reason that the relationship between incest and drug abuse is close is that the survivor and drug abuser both may be escaping from aspects of reality and feelings of guilt and self-blame. Incest perpetrators often are alcohol and/or drug users who are under the influence at the time of the experience. In California, 63% of the men committing incest had been drinking at the time of the offense (Rada, Kellner, &Winslow, 1978). Other studies have reported alcoholism among such men to range from 20% to 50% (Gebhard, Gannon, Pomeroy, & Christenson, 1965; Geiser, 1979; Meisselman, 1978; Virkkunen, 1974). Group therapy can reduce the isolation and sense of deviance that many incest survivors find so disturbing and provide therapeutic relief after disclosure of such a burdensome secret (Cole & Barney, 1987). The group can validate the victim and the affective experiences that are often denied by the survivor. Disclosure of such a powerful guilt-related trauma must be paced by the therapist, because of the potential for triggering anxiety and departure from the group. In one study, almost two-fifths of the members of an incest survivors’ group withdrew after one to five sessions (Blake-White & Kline, 1985). A short-term approach, with 12 weekly sessions, was used successfully in an outpatient setting in order to maximize regression and highlight the group members’ strengths (Goodman & Nowak-Scibelli, 1985).

position and experience of such a group. In June, 1989, there were 15 women in it. Table 1, Some Characteristics of Members of Incest Survivors’ Group, sets forth some background information on the participants. The group, led by a female psychologist, was very similar in size and composition to such groups in previous years. Over half the members had been less than 8 years old at the time of the first incidents, and more than half the perpetrators were the members’ fathers (5) or brothers (5). The median age of the participants at the time of the group was 25. Most were single parents who had used some form of cocaine before entering treatment. Blacks were the largest ethnic group (n = 1l), with Hispanics (n = 1) and whites (n = 3) representing a minority. All 15 women said that the incest experience had been completely unwanted. In five cases, their moth-

TABLE 1 Some Characteristics of Members of Incest Survivors’ Group Age at Time of Incident Up to 4 years old 5-8 years old 9-l 5 years old Age not known Total Number of occurrences Once 2+ 2+, with same person Total Perpetrator’s relationship Father Brother Uncle Grandfather Stepfather Total Marital status Single Divorced Separated Total

Some details of the survivors’ group that was operating during 1989 may help to convey a sense of the com-

15 3 4 8 15 5 5 4 2 1 17’ 12 2 1 15

Program retention of splittees 5-8 months 3 11-l 6 months 3 24+ months 2 Total 8 Age at time of group 19-22 23-26 27-30 31-38 Total

A RECENT SURVIVORS GROUP

2 6 5 2

4 6 3 2 15

Drug of Choice Crack Cocaine Heroin Amphetamine Total

6 6 2 1 15

Religious preference Protestant 8 6 Catholic 1 Others Total 15 Ethnic background 11 Black White 3 Hispanic 1 Total Legal status Voluntary Probated Total Referral source Self Other program Legal system Hospital Friend School Social agency Total Sexual orientation status as parent Parent Nonparent Bisexual Gay Total

“Total comes to more than 15 because of multiple coding.

15 13 2 15 4 3 3 2 1 1 1 15 and 11 4 2 1 18*

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ers knew about it. Three women told their sisters, but four others did not mention it to anybody. Only one case had been reported to the police, but nothing happened as a result. Eight women were also rape victims, with the incest always preceding the rape. In two cases, the rape followed incest by 5 years, and there was one case each of a gap of 15 years, 14 years, and 1 year. There were no cases of incest following rape. The rape victims participate in a 3-day marathon group, which is conducted annually and is independent of the survivors’ group. Four survivors had also been physically assaulted by the perpetrators. Two survivors were bisexual and one was gay; their sexual orientation did not emerge until years later when they were adults. THE SURVIVORS’

GROUP

Before any woman is assigned to the survivors’ group, she is interviewed in order to determine her readiness and answer her questions about the group. An attempt is made to lessen her anxiety about joining the group. One reason for anxiety is that many women have never discussed the incest experience with anyone before coming to Odyssey House. The typical comment is, “This is the first time that I ever told anybody about it. I never expected to tell anybody.” Some women do not disclose their incest experience at the initial admission or screening group interview (probe) or even after many months in the program, although they are specifically asked about it at the initial screening interviews and openness and honesty are expected of all residents. There have always been enough survivors for a therapy group, which averages around 15 women. Men are not admitted; there is a separate group for males who have been sexually abused when young. Attendance at the group is mandatory for all eligible residents. Many women are reluctant to participate in it. A number of members appear to schedule medical appointments at the same time in order to avoid the session. Any such conflicts must be discussed with the group leader. If a woman has had several such schedule conflicts in a relatively short time, the leader might raise the subject at a group session: “Joan did not come to two of our last four meetings. What do you think is happening?” New members are brought into the group at the beginning of each month, in order to minimize the anxiety that might be experienced by both the new and old members. At this meeting, the leader tries to make the new members comfortable by introducing herself, discussing the group’s purposes and procedures, and asking older members to present their experiences as incest group members. Any questions from the new members are answered and the goals and procedures of the group are clarified. The new members have usually already participated with the older members in other work and therapeutic activities in the house, so they have some

degree of acquaintanceship with them. The newer participants, although less likely to know the group leader, usually are comfortable in the group within one month. Some new members are not able to discuss their incest experiences at their first or other early sessions; they are not required to do so until they are ready. Usually, the women feel sufficiently secure to talk about their incest experiences by the 4th or 5th session. At any time during her participation in the group, if necessary, a member who is experiencing unusual difficulties in the group is referred for extra intensive individual therapy. Women are not able to participate in the survivors’ group until they have reached Level II, which typically is achieved after 3 to 6 months’ residence. By Level II, residents have had an opportunity to adjust to the program and deal with other issues. They have also been in different therapy groups and had considerable experience as group members. Women in the facility all participate in a Women’s group, which meets weekly. Those women who are parents - approximately 70% -also meet weekly in a parents’ group. In addition, each Level has a weekly therapy group meeting, which includes men and women and could have a male or female leader. There is also individual psychotherapy for every resident later in the program. Members stay in the group until, in Level III, they begin either to work or attend school outside the facility, so that they cannot attend daytime meetings. When a resident begins to function outside the facility, usually after 9 to 12 months of residence, she is referred to an outside psychotherapist, who can deal with any appropriate subject including continuation of what was begun in the incest group. The relationship with the outside therapist helps to give the woman an extra support system and lessens her dependence on Odyssey House. Knowing that participation in the group will be replaced by working with an individual therapist makes it easier for group members to handle the issues of termination, coping with loss and abandonment, and their additional guilt and shame. The group therapist is sensitive to the group members’ inability to talk about the details of the incest experience until they have been in the group for long enough to accept the other participants and be candid about what happened. Often, giving the details eases access to the affect associated with the event. Survivors may bring up material from the incest group in other therapy groups, including those that include men. There are no explicit instructions on whether or not to do so. The other residents generally know who the survivors are by observing who goes to the group sessions. Some incest survivors raise the subject in other groups during their stay, but others never do so in any mixed group. This seems to be independent of whether the leader is male or female.

C. Winick et al.

314 SOME GROUP THEMES

Among the topics covered in the group are how the survivors feel about their mothers and significant others, experiences in having tried to tell others about the experience, how lifestyle and orientation and interpersonal relationships have been affected, how sexual behavior has been influenced, relationships with and fears for children, marital relationships, body image, fear of loss of control, shame, guilt, discomfort with fantasy, and circumstances of the multiple episodes experienced by most women. Many mothers are concerned that their own children will become incest victims and overreact when they see their children touching siblings, or other children, while playing. Because the mothers are distrustful of men, their daughters are often similarly distrustful. Whether to have more children, because of incest fears, is often discussed. The women’s ability to develop healthy sexual relationships with men is usually undermined by the residues of incest. They have often either become withdrawn or have engaged in precocious sexuality and promiscuity. The incest experience provides an additional complication for those women who have earned money for drugs by prostitution. Trust of others is a key concern and perhaps one of the two or three most important themes. One reason that the incest group meets weekly is that the issue of trust is so significant in the residents’ overall recovery. If the relatives who ought to be the most trustworthy sexually exploit a young girl, whom can she trust subsequently? As a result, she may engage in pseudoindependent acting out. Denial is another centra1 consideration that is found in the group. Up to the time of admission to Odyssey House, most women have engaged in denial of the incest experience. One reason that the members of the group are so ambivalent and hostile about the group is that it compels them to confront their denial. Denial is so common because the women have often tried to dissociate themselves from what happened because it is so difficult to deal with the violation and powerlessness represented by incest. The passivity that many of the women have integrated into their character structure has made them candidates for subsequent victimization. Guilt and shame represent yet another major issue. Most incest survivors were told or threatened not to tell anyone about the incest. In many cases, they were told that they were to blame, either because they were “bad” or so pretty. In incest with the father, they often became father’s favorite child and were given special gifts or treats that their siblings did not receive. Since they enjoyed this feeling of “specialness,” it led to further guilt and shame. Yet another reason for guilt and shame is that many of the survivors experi-

enced sexual arousal when touched in the right places by the incest perpetrators. With the therapist’s help, they can begin to see that being special is an appropriate desire for any child. The issue of biological responses being normal is also raised and explored. There is emphasis on the role of the perpetrator as the person who is responsible for what happened, since a child does not know enough to give informed consent in a sexual situation. The adult knows what represents the boundary of appropriate behavior, even though the child does not. Many of the women experienced a depressive reaction upon realizing how they lost a part of their childhood and grieve for the change in perception of their parents. After working through such feelings, they can overcome their feelings of loss and move toward more mature assertive behavior patterns. A small number of women experience concern about their ability to control aggressive feelings toward their parents; their doing so in the group provides experience in coping with such effect. Sometimes, a group member has more anger than can be communicated during the session and the leader will encourage her, in the company of another group member, to punch a mattress in the basement later in the day. Such punching seems to permit constructive ventilation of her anger. TRANSFERENCE/COUNTERTRANSFERENCE ISSUES

The survivors group offers intense bonding with other women, which provides a powerful therapeutic dimension Not only is the intermember relationship strong; the transference to the group leader is also intense. Transference issues with the therapist are usually displayed in exaggerated feelings of anger and/or idealization. If the group therapist has to cancel a session for any reason, the group members are furious and express great hostility, far beyond what is usually experienced in analogous circumstances at the facility. At other times, the group may feel pushed to talk about intense feelings. The therapist is often then seen as the sadistic mother who was not available to give the nurturing that a child so desperately needs. This is often displayed in either body language, silence, or angry scowls. The therapist will ask the group what is going on and encourage the participants to express their feelings. The reticence to discuss these feelings openly in the group is diminished by the therapist telling the group that any issues relating to the group must be discussed in the group, rather than by using other program tools. The hesitation to explore what the group members are feeling is further lessened by the therapist’s openness to hearing what is being said. This enables an exploration of what is being felt in the transference.

Incest Survivors’ Therapy Group

Idealization of the therapist usually comes in the form of seeing her as the perfect mother and the perfect therapist to the exclusion of all their other group leaders. Survivors often complain about their other therapists, try to get extra time with the survivors’group therapist, and do special things for her (i.e., offering coffee every morning when she comes into the facility). This is explored in the group. This group has special meaning for its members, but they are asked to look at what they get from other groups. The members are helped to see that the therapist is neither the sadistic mother nor the most perfect mother, but a human being with certain faults and attributes. Transference between group members often occurs when there are feelings that what happened to one woman was worse than what happened to another, so the latter questions her right to be damaged by her own incest experience. This is explored and the members are helped to see that whatever happened to them was wrong and that they are entitled to their own pain. Countertransference by the therapist usually reflects the desire to make things better and/or easier for these group members. The therapist often wants to “fix” things. At times, the extreme needs of the members are felt very strongly with varying degrees of emotion on the part of the therapist. The therapist knows that she cannot take away the pain but can only help the group members to work through their feelings. Countertransference in a therapeutic community, where the members of the group are seen every day, often leads to staff members’ feeling closer to the group participants than to other people in the facility. As long as the therapist is aware of this tendency and tempers such feelings, it diminishes the chances of her acting on them. SOME GROUP

DIMENSIONS

The typical group member remains in the group for from 8 to 10 months. Regular attendance for such a period provides enough time to explore key aspects of the incest experience. Because of the many other therapeutic groups and treatment activities at the facility, the survivors group can concentrate on incest-related matters. From 70% to 80% of the content of the sessions is devoted to ramifications of incest. Because the composition of the group varies from month to month, it is not possible to describe any schematic unfolding of a sequence of themes. More than 15 members are difficult to accommodate in the group. If there are more than 15 candidates for the group, the new residents are not admitted until a senior survivor begins to function outside the facility, in Level III, and her space becomes available. The intensity of the group discussions sometimes makes it important that the therapist physically express

315

support for a group member. However, the therapist never touches or hugs a group member without asking her if it is all right to do so. Sometimes, one member may manifest discomfort if another woman puts her arm around the member’s shoulders. In such a case, the therapist might ask, “Jane, are you uncomfortable when Helen puts her arm around you?” Since physical relations are so central in incest, some survivors become unusually sensitive to issues of touching and embracing. In this group, it is more than usually important that the members address their communications to each other rather than to the therapist. The therapist encourages the group dynamics process to operate, at all times. However, a member of the group who requested a private session with the leader, because of something that was triggered during the group but that was best handled in private, is able to arrange such a session. Women who have had more frequent and violent experiences of incest tend to require the longest periods of therapy, because they have been more damaged by the incest. One woman, for example, took many months before she could come to terms with her father’s having inserted a baseball bat in her vagina, over a period of years. She had been terrified of mentioning it to anyone, before coming to the program. Once the subject was broached, she could begin to come to terms with it. Sometimes it is therapeutically valuable for a woman to share the incest experience with a relative in a faceto-face situation. In such cases, a special one-meeting group is arranged, with the therapist, the patient, a peer of the patient, and the relative. In one case, Mary, a 24-year-old whose daughter was staying with her parents, became worried that her uncle, who had had an incestuous relationship with her, would also do so with her daughter. The therapist telephoned the father and asked him to visit the facility. He had not known of the incest. At the session, the therapist asked Mary, “Do you have something to tell your father?” Mary told her father what had happened. He was very supportive and indicated that he would be careful about leaving Mary’s daughter with the uncle. The peer is included in such a minigroup because it is important for the survivor to have support and be able to share, and thus dilute, the impact of the experience. After this meeting, Mary made dramatic progress in the group. Talking to her father was a breakthrough experience that helped to purge her of the weight of the incest experience and its associated guilt and shame. Twenty-seven year old Connie had sworn to her brother that she would never tell anyone that he had forced her to have sexual intercourse with him. While she was at the program, Connie received word that her brother had died of AIDS. Since the brother was dead, Connie felt that she could violate her pledge and dis-

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cuss what had happened with her mother. The therapist asked the mother to visit the program, without specifying the reason for the visit. A group consisting of Connie, a peer who was also in the survivors’ group, the mother, and the group therapist met and permitted Connie to unburden herself. Although the session was difficult, it was much more tolerable than if Connie had presented the situation to her mother privately. The minigroup represented a dramatic increase in Connie’s progress. RELATIONS WITH FAMILY MEMBERS The role of the mother in father-daughter incest varies. In some cases, the mother was in bed with the father and daughter when the activity occurred. In another situation, ‘I-year-old Georgette would be regularly fondled by her father and several of his friends. When her mother brought coffee and cake to her husband and his friends in the husband’s den, she saw the men fondling her daughter. Yet, the mother punished her daughter when the daughter complained. In a rare situation, in which the mother complained to the police after her daughter reported the father’s sexual advances, the daughter told the police that her mother was lying in order to protect the father. Typically, daughters generally attempt to avoid denunciation of the father. A key issue is what happened when the victim tried to tell a relative, usually the mother, about the incest situation. If the mother or other confidante was supportive, the impact of the experience is less traumatic than if the report is treated derisively or denied. If the father is the perpetrator, a significant consideration is the mother’s role. Very few mothers accept the child’s report. Many a woman will deny that her father engaged in sexual activity with her, because she does not want to cause trouble for the father. “I want to be a good enough girl to be loved by my father, and if I keep quiet, my father will love me more,” is the symbolic statement being made. Since many of these women are second and third generation addicts, their family relations are likely to be strained, so that whatever fosters love is likely to be prized. The group participants are encouraged to discuss what happened with other family members as one way of reestablishing relationships with those members. They may sometimes be assisted in working toward confronting the offender, if such a confrontation has therapeutic merit. Survivors often have difficulties in considering such matters because of feelings of loyalty and their sense that their silence may have helped the family to stay together. One technique that has been found helpful in encouraging incest survivors to approach the possibility of discussing the incest with significant others is to ask

the woman, for the next session, to prepare a letter to an appropriate relative about the incest. The letter is not mailed, but is read to the group. The content of the letter usually provides a significant springboard for subsequent examination of a thorny subject. REPRESENTATIVE

CASE

Gloria was a 37-year-old black lesbian mother in the program. She was extremely intelligent and independent. She tried to hide her insecurity by distancing herself from others. Gloria was an overprotective mother who hated people who said that her daughter was pretty. Gloria had been a resident for about 8 months and had previously denied that she was an incest survivor. In her other groups, Gloria had expressed anger at her father for deserting the family when she was about 5 years old. She had been his favorite, and her siblings teased her about not being special anymore. In a group where incest had been mentioned, Gloria began to remember her father bouncing her up and down on his lap. She recalled feeling something hard (his erection) against her bottom. Other memories emerged, such as being in her parents’ bed, lying against her father and feeling his penis get hard. She became distraught at these recollections and the therapist of the Survivors’ Group met with her three times before she came to her first meeting. The other participants were extremely supportive and recognized that Gloria had dissociated her incest for such a long time that it was difficult for her to accept being an incest survivor. During her first session, Gloria stared at the wall and would not look at anyone. She held a roll of paper and during the entire session, she squeezed it and tore it to pieces. A group member or the therapist periodically asked if she was all right or if they could do anything for her. Her response was an angry “No.” As the first month passed, she began to listen more closely to other members. The therapist suggested that she go to the basement with a few group members and beat on a mattress in order to express some of her anger. Because Gloria’s condition was so fragile, the therapist continued to see her in individual sessions for this month. She became more calm, but remained extremely angry. During the fifth session, Gloria began to talk about her recollections. She recalled her father masturbating into a glass and making her drink his semen. The “balloon game” involved the father putting his penis in her mouth and it getting bigger, “just like a balloon.” She was horrified at these recollections. Over the next few weeks, she became more empathetic to the others in the group. When the group talked about mothers, she became very angry at her own mother. She remembered that

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after her father left, her mother insisted that Gloria sleep in her bed with her. There was a memory of seeing her mother masturbate in bed. Someone in the group suggested that she write, but not mail, a letter to her mother so she could release her real feelings. Gloria read the letter in the next session and for the first time, was able to cry about how both her mother and her father had let her down. She expressed her greatest fear: “I don’t remember if my father penetrated me.” Everyone was silent. The therapist asked Gloria what she felt. She responded that if it had happened, it would be the worst thing she could imagine. Over time, Gloria learned to deal with the shame of being her father’s favorite child. She began to understand her previous need to dissociate these terrible memories and forgive herself for enjoying the fact that she was his most “loved” child. As the time came for Gloria to go into individual therapy outside the program, she wanted to continue working on the incest experience. During her last survivors’group (before leaving the facility), she said she was sad to leave the group after 8 months, but realized that she could continue growing on the basis of what she had learned. She had been a big asset to the group and the other members told her how they felt about her leaving and how much they would miss her. EFFECTS

OF THE SURVIVORS

GROUP

It is difficult to distinguish the unique effect of the survivors’ group from the therapeutic impact of the other groups and activities at Odyssey House. It is a plausible assumption that women who are incest survivors are more impaired than other women in the program, who are generally similar in age, ethnicity, socioeconomic status, drug history, and related variables. Being more impaired, we would expect that they would be less likely to remain in the program and have successful outcomes. A key indicator of outcome is how long the program member remains in the therapeutic community. The longer the stay, the more favorable the outcome (Simpson&Sells, 1982). The 15 women who were in the survivors’ group in June, 1989, had averaged 13 months in the program. The 79 other women who were at Odyssey House at the same time, whose characteristics were otherwise similar to those of the survivors, averaged only a 5-month stay. By comparison, none of the incest survivors left the program in less than 5 months. The significance of the 13-month mean retention period for the survivors can be best understood in terms of the average of 14 months in the program of graduates in 1989. Another measure of effect is provided by graduation rates. Of the 46 women in the survivors’ group during 1987-89, 13 or 28% graduated. By comparison, 6 or 4% of the 163 other women in the program at the

same time graduated. The populations are too small for statistical analysis but the difference is suggestive. Why do the members of the survivors’group do well, not only in terms of clinical impressions, but also as measured by objective criteria such as retention and graduation, even though they are probably more impaired than other women in the program? The intense bonds they develop with the other group members provide an additional therapeutic dimension. They can deal with guilt and shame and focus on intrafamilial relationships in a supportive setting. The women realize that they are not alone and that incest has been experienced by other women. For the first time, they can focus their energies on functioning in the world of work and their own roles as parents. They are less likely to blame or scapegoat others and more likely to feel accepted and behave in a less passive manner. On the basis of the process observations of the group therapist and of the staff persons who observe the residents, there is no doubt that practically all the survivors are substantially helped by the group. Over 15 years, in which several hundred women have participated, only 5 have not improved in their ability to cope with their incest experiences and, collaterally, their general psychological growth and adaptational abilities. Sometimes the group has an extraordinary therapeutic effect on a member. Barbara was a 40-year-old woman who had not done well in the program and who had an extremely negative reaction to her first session. As she discussed her incest experiences with a brother and an uncle, she cried and rocked back and forth in her chair. Her crying continued over 2 months. At later sessions, she explained how her mother had beaten her and called her a liar when she reported what had happened. Over months of meetings, Barbara became more at home in the group and manifested a previously hidden sense of humor. She developed a more realistic perception of her mother, who had repeatedly told her, “I wish you were never born.” Barbara was able to shed her self-blame as her demeanor and appearance slowly but steadily were transformed. At graduation, she said, “The survivors’ group was the most important part of the program for me-it has completely changed my life. The group made my progress much easier. I expect it has made it easier for me to remain drug free.” There is clear evidence that the group provided a major therapeutic dimension for its participants. Residents’ self-report, staff observations of the residents, and assessment of survivors by the group therapist all indicate the importance of the group. The disparity between the retention rate (21: 1) and the graduation rate (7: 1) of incest survivors, compared with other women residents, who are otherwise demographically similar, provides compelling evidence of the therapeutic impact of the survivors’ program.

318 A follow-up study in order to determine whether the women in the survivors group have sustained their gains after leaving the program, in comparison with a control group, is contemplated. Also under consideration is the use of a male co-therapist, in order to provide incest victims with a therapeutic relationship with a supportive and nonexploitive male. IMPLICATIONS FOR SUBSTANCE ABUSE TREATMENT PROGRAMS There is growing awareness of the vast number of women incest survivors, especially among those who abuse drugs and alcohol. It is important for drug and alcohol programs to deal with this issue as one approach to reducing recidivism. The first step in identifying the incest survivor is to insure that she will not feel stigmatized for revealing her secret. Therefore, staff should be trained to be sensitive to this problem and desensitized to over-reacting when a woman reveals her secret, especially where it has not previously been disclosed. Many survivors will not reveal their secret the first time they are asked. A person who is believed to be an undisclosed incest survivor should be given some time to volunteer the information and then the question can be asked again. The door should be left open so that she feels that it will be possible to reveal the secret at some future time. Generally, if a survivor knows that the program is open to such knowledge and that there is a survivors’ group, she is much more prone to be open about herself. There are a number of characteristics shared by persons with histories of sexual abuse. They find it very hard to trust others, that is, a person will not enter a room before everyone else has done so. Other abuse victims have a need to sit against a wall so that they can watch persons already in the room and those entering through the door. Such attitudes are often expressed subtly. Persons with anorexia, bulimia, or obesity problems may engender suspicion of having an incest history. Some survivors have a history of being promiscuous. Others seem almost asexual. Clothes may be either very baggy or very revealing. An inability to have any kind of long-term significant relationship is another signal, as is overprotectiveness of their children. Incest survivors tend to be very protective of their abusers. Thus, if someone tends to be overly defensive about a family member while being able to look objectively at others, incest could be the reason. Other characteristics may include phobias, insomnia, anger when touched or hugged without permission. Incest survivors often continue playing the victim role even as adults. Since it is probably easier to talk about rape than incest, if a woman reports a history of multiple rapes it is quite possible that she is also carrying an incest se-

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cret. Survivors have very low self-esteem, are either very aggressive or withdrawn and self-protective. In initiating a survivors group, a program should talk openly with its members so that they will know the program is starting. Ideally, a therapist with some experience in dealing with incest survivors should lead the group. An initial interview with each potential member is essential. The group should start off slowly and gently, so that its members can become familiar with each other and with the therapist. Once word gets around that such a group exists, it is likely that other survivors will come forward. While the number of female incest survivors may be larger than that of male survivors, the latter do exist. Men who have been sexually abused generally have different problems than females, but their problems are probably less harmful to their ability to live in a healthy drug- and alcohol-free environment.

REFERENCES Benward, J., & Densen-Gerber, J. (1975). Incest as a causative factor in antisocial behavior: An exploratory study. Contemporary Drug Problems, 4, 323-340. Blake-White, J., &Kline, C. (1985). Treating the dissociative process in adult victims of childhood incest. Social Casework, 66, 394-402. Cole, C.H., &Barney, E.E. (1987). Safeguards and the therapeutic window: A group treatment strategy for adult incest survivors. American Journal of Orthopsychiatry, 51, 601-609. Coleman, E. (1982). Family intimacy and chemical abuse: The connection. Journal of Psychoactive Drugs, 14, 153-158. Gebhard, P-H., Gagnon, J.H., Pomeroy, W.B., Christenson, C.V. (1965). Sex offenders: An analysis of types. New York: Harper and Row. Geiser, R.L. (1979). Hidden victims. Boston: Beacon. Goodman, B., & Nowak-Scibelli, D. (1985). Group treatment for women incestuously abused as children. Infernational Journaiof Group Psychotherapy, 35, 531-544. Hailer, O.L., &Alter-Reid, M.A. (1986). Secretiveness and guardedness: A comparison of two incest survivor samples. American Journal of Psychotherapy, 4, 554-563. Herman, J., & Hirschman, L. (1981). Families at risk for fatherdaughter incest. American Journal of Psychiatry, 138967-970. Meisselman, K. (1978). Incesf. San Francisco: Jossey-Bass. Rada, R., Kellner, D., & Winslow, W. (1978). Drinking, alcoholism and the mentally disordered sex offender. Bulletin of the American Academy of Psychiatry and Law, 6, 296-300. Rosenfeld, A.A. (1979). Incidence of a history of incest among 18 female psychiatric patients. American Journal of Psychiatry, 136, 791-795. Russell, D. (1983). The incidence and prevalence of intrafamilial and extrafamilial sexual abuse of female children. Child Abuse and Neglect, 7, 133-146. Simpson, D.D., &Sells, S.B. (1982). Effectiveness of treatment for drug abuse: An overview of the DARP research program. Advances in Alcoholism and Substance Abuse, 2, 7-29. Virkkunen, M. (1974). Incest offenses and alcoholism. Medical&ience and Law, 14, 124-128. Walker, B., Jr. (1988). Odyssey House of New York. Journalof Substance Abuse Treatment, 5, 113-115. Yeary, J. (1982). Incest and chemical dependency. Journal of Psychoactive Drugs, 14, 133-135.

An incest survivors' therapy group.

A weekly therapy group for women who have been incest victims and are residents of Odyssey House, a therapeutic community for drug abusers, is describ...
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