ChrldAbuse & Ne&ct, Vol. 16, PP. 575-583. Printed in the U.S.A. All rights reserved.
1992 Copyright
014%2134/92 $5.00 + .OO 0 1992 Pergamon Press Ltd.
NETWORK THERAPY USING VIDEOTAPE DISCLOSURES FOR ADULT SEXUAL ABUSE SURVIVORS THOMASA.ROESLER The C. Henry Kempe National Center for the Prevention and Treatment of Child Abuse and Neglect, University of Colorado, Denver
NANCYCZECH Montlake Institute, Seattle, WA
WILLIAMCAMP Private practice, Seattle, WA
CAROLEJENNY The C. Henry Kempe National Center for the Prevention and Treatment of Child Abuse and Neglect, University of Colorado, Denver
Abstract-Treatment of childhood sexual abuse survivors may be enhanced by a technique designed to generate a therapeutic constituency for the survivor around the disclosure of childhood abuse experiences. The need for validating relationships is hypothesized as a condition for successful treatment. The videotaped disclosure process proceeds in five stages: (1) Deciding to make a tape, (2) making a videotape following a semistructured interview format, (3) the patient viewing the tape, (4) showing the tape to potential therapeutic team members, and (5) possibly using the tape for a confrontation with the abuser. The technique has been used on 27 cases. Case histories are given to illustrate the procedure. Discussion includes potential mechanisms of action and issues in treatment that arise with the use of the method described.
Key Words-Adult
survivors, Treatment, Videotape, Disclosure, Network therapy, Sexual abuse.
INTRODUCTION ADULT SURVIVORS of sexual abuse are often severely impacted by their childhood experiences (Briere, Evans, Runtz, & Wall, 1988; Briere & Runtz, 1988a, 1988b, 1990; Browne & Finkelhor, 1986; Bryer, Nelson, Miller, & Krol, 1987; Fromuth, 1986; Hooper, 1990; Jackson, Calhoun, Amick, Maddever, & Habif, 1990; Myers, 1989; Sedney & Brooks, 1984; Surrey, Swett, Michaels, & Levin, 1990; Tsai, Feldman-Summers, & Edgar, 1979). Sexual abuse is recognized as a major correlate of many types of adult psychopathology. Depression (Briere & Runtz, 1986), borderline personality disorder (Ogata et al., 1990; Shearer, Peters, Quaytman, & Ogden, 1990; Zanarini, Gunderson, Marino, Schwartz, & Frankenburg, 1989), psychogenic pain (Domino & Haber, 1987; Walker et al., 1988) sexual dysfunction (Bass & This work supported by a grant from the Van Derbur family. Received for publication February 6, I99 1; final revision received May 2, I99 1;accepted June 24, I99 1. Requests for reprints may be sent to Thomas A. Roesler, M.D., The C. Henry Kempe National Center for the Prevention and Treatment of Child Abuse and Neglect, 1205 Oneida Street, Denver, CO 80220. 575
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Davis, 1988), substance abuse (Root, 1989), dissociative disorders (Chu & Dill, 1990) and eating disorders (Root & Fallon, 1988) have all been found to be associated with a history of sexual abuse in childhood. Treatment has included individual therapy (Braun, 1989; Deblinger, Mcleer, & Henry, 1990; Stone, 1989) group therapy (Alexander, Neimeyer, Follette, Moore, & Harter, 1989; Coker, 1990; Goodwin & Taliwar, 1989; Singer, 1989) and family and community network approaches (Coker, 1990; Giarretto, 1989). In an attempt to describe how abuse suffered in childhood might result in adult psychopathology, researchers have evoked a posttraumatic stress disorder model (Chu & Dill, 1990; Coons, Bowman, Pellow, & Schneider, 1989; Lindbergh & Distad, 1985). Summit ( 1983), in his work on the child sexual abuse accommodation syndrome, outlines a phenomenological process experienced by some abused children which helps explain why adult survivors have posed such difficult problems in treatment for clinicians. He describes a “normal” process of survival which can lead to secrecy, entrapment in a web of deceit, and a sense of helplessness, self-blame, and self-hate on the part of the victim. This position of the victim is often maintained and reinforced by the immediate family, the larger community, and even societal institutions such as the court system. The videotape disclosure technique described in this paper takes into account this process. The technique is predicated on two principal ideas: (1) Mental health stems from personal relationships that validate one’s basic self-worth, and (2) abuse continues as long as the denial of its existence is maintained. These ideas dictate that any efforts to help these patients must confront denial while at the same time foster validating connections with significant people in the patient’s life. Clinicians have discussed the significance of disclosure of childhood abuse in treatment of adults (Bass & Davis, 1988; Schatzow & Herman, 1989). Network therapy has been defined as a process of assembling and using for therapeutic purposes a group of people significant for the patient which reaches beyond the immediate family (Speck & Attneave, 1973). To our knowledge the literature does not describe the use of videotape in the process of disclosure for the purpose of generating a therapeutic network.
A VIDEOTAPED
DISCLOSURE
INTERVIEW
TECHNIQUE
A videotape interview process consists of five stages. First, the survivor of sexual abuse decides to make the tape. Second, a videotape is made with the help of the therapist. Third, the patient watches the tape with the therapist. Fourth, the patient decides which people in his or her life might constitute a “therapeutic team” and shows the videotape to them. As an optional fifth step, the patient shows the videotape to the offender in the presence ofthe “team.” We believe it is important that the patient be in control of each stage of the process. It can be interrupted at any stage. Therapy never progresses faster than the patient deems reasonable and appropriate. Stage
One
The decision to make the videotape is made by the patient after the entire process is explained, and the patient understands clearly that he/she is in control of the process. This requires a significant level of trust in the therapist. The patient must also have sufficient confidence in the memory of the abuse experience so it can be stated coherently during the interview. Survivors of sexual abuse have extremely good reasons for not revealing the nature and extent of the abuse, or, sometimes, not even allowing themselves access to their own
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memories. Often the abuse was accompanied by overt threats of harm for revealing the secret. Even when threats were covert, the consequences of speaking about the abuse experience can be catastrophic. Because patients vary in the time required to recover buried memories or build trust in the therapist, stage one may take from one week to several years. Stage Two Before proceeding with the interview, we believe it to be extremely important to obtain informed consent from the patient, preferably on videotape as well as in writing. The interview itself consists of variations on three questions: 1. What happened to you as a child? 2. What have the consequences been in your life? 3. What do you expect will happen when this tape is shown to significant people in your life? The first part is a straightforward recounting of the abuse experience. It is important that the patient be encouraged to give as much detail as possible. Questions such as, “When you say your father had you masturbate him, do you mean once or more than once? How many times? Where did this take place?” The therapist must be careful not to “lead’ the patient. The interviewer should not ask questions in a way that might be construed as putting words into the patient’s mouth. Detailed and explicit information is more believable than vague statements, both for the patient in stage three, and for the network and abuser in stages four and five. We have noted that disclosure is often more limited by the therapist’s own discomfort with the material than the patient’s willingness to proceed. The second part of the interview deals with the effects of the abuse. Questions are asked about suicidal feelings and attempts, psychotherapy experiences, dissociative experiences, sexual dysfunction, chronic pain, eating disorders, depression, and substance abuse. In our experience, it is not necessary to establish a direct connection between childhood abuse and adult functioning for people viewing the tape to understand the patient’s experience. Rather, it is sufficient to elicit a picture of the patient’s life over the last few years prior to the taping. The last part of the interview concerns the patient’s perception of the effect the tape will have on the significant people in his/her life. The questions in this part include, “Let’s take a minute to imagine what response people will have to seeing this interview. How will your sister react? Your best friend? Your father? Your stepfather?’ This part of the interview becomes extremely important in stage four in establishing the patient’s credibility and overcoming denial. Stage two, the actual videotaping of the disclosure, is the least stressful part of the process. Typically the interviewer relies on well-established skills. The interviewee will often respond in a cognitive, rational manner. It may take a few minutes to overcome anxiety about the videotape equipment. The equipment itself need only provide a clear picture of the patient and a clearly audible sound track. If another person is to be present for the interviewing, he or she must be someone the patient trusts implicitly. Examples might be a spouse or best friend. A typical disclosure interview may last from 45 to 75 minutes. Stage Three While stage two is the least stressful, stage three is the most stressful and potentially dangerous part of the treatment technique. Immediately after the taping the patient may experience a flood of painful memories or second thoughts over breaking long-established taboos concerning disclosure. In many of our cases the patient had suicidal ideation during this phase, and one suicide attempt occurred the same day the videotape was made. For this reason we recommend strongly that stages two and three be done either in a hospital setting or with
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immediate access to a secure hospital environment. Stage three represents the patient coming to terms with what is on the videotape. The patient needs to feel secure that what was said correctly represents his/her experiences. To do this, the tape is viewed by the therapist and patient together. It can be turned off at any time the patient desires. Once again, consistent with the patient being in control of the process, the patient is told the tape belongs to him/her, and can be destroyed if desired. This idea, to destroy the tape, may become powerful as the patient realizes the family secret is revealed on the tape. Watching the tape may be an extremely emotional experience. It may take several days or weeks to get through the tape completely. Several viewings of the tape may be required before the patient is able to accept the tape as accurate. This stage may take from a few days to months. The medium of videotape makes it possible for the patient and therapist to rework the tape until the patient feels comfortable. Usually, any changes will be relatively minor. It is important for the patient to accept the tape before attempting stage four. Stage Four
Once the tape has been made and accepted, work can begin to assemble a therapeutic constituency or “team” for the patient, who is told that although there may be family and friends the patient feels close to, he/she may have felt that if they “really knew the truth” the patient would face abandonment. Indeed, in the authors’ experience, this fear has frequently been voiced during the videotaping. The only way to find out if this is so is to allow them the opportunity to see the tape. The therapist and patient make a list of possible team members, avoiding anyone who might be expected to be discounting or antagonistic to the disclosure. The patient then invites the possible team members to a showing of the video. The patient may get help in this from a supportive friend or relative or from the therapist. The therapist may be present for each viewing although this is not always necessary or possible. Once again, the patient controls who is invited and how it is done. The people invited to view the tape are told the purpose of the viewing, and what they will be asked to see. The therapist reviews with the patient the potential effect on each viewer, and may speak to the invitees prior to viewing to assess whether it seems reasonable to include that person as a potential team member. The team can be assembled in stages with each new group viewing the tape in the presence of already established team members. At no time is the patient exposed to charges of revealing the family secret without someone from the therapeutic team present for support. Ten to 15 people consitute an effective “team.” Stage four may take from a few weeks to 6 months. Stage Five Only after the therapeutic support network has been assembled should a confrontation with the offender be attempted. Even then, the patient should be encouraged to consider whether a confrontation should occur at all. Stopping at any stage is the prerogative of the patient. The confrontation is made by showing the tape to the offender in the presence of as many members of the therapeutic team as can be assembled, all of whom have previously viewed the tape and voiced validation for the patient. If the offender can view the tape and allow its contents to be accepted as a baseline for all subsequent family transactions around the abuse, then therapy involving the abuser can proceed.
RESULTS The videotape disclosure process has been used in 27 cases by five different therapists. The small number of cases precludes any results from being interpreted as other than clinical
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impressions at this time. It has been used with both male and female victims, and with people who experienced extrafamilial as well as intrafamilial abuse. Because the technique was employed in the context of ongoing therapy, results must be interpreted on a case-by-case basis. In every case, the technique was employed as an adjunct to established, ongoing individual therapy. Some of the patients were also engaged in group treatment. The therapists worked primarily in a private practice setting although no contradiction exists for using the technique in a mental health center environment if the proper backup is in place. Accessibility to a secure inpatient setting is advised. The therapists were all experienced family therapists, which may have influenced issues of timing, and the question of whom to invite to join the therapeutic network. The decision to make a tape was often made in the context of an impasse in therapy, or a crisis in the life of the patient. One woman decided to make a tape, a year after the process was first described to her, when she became pregnant. Morning sickness became a triggering event for flashbacks to childhood memories. A woman who had a pattern of binge drinking resulting in suicidal behavior followed by psychiatric hospitalization, entered drug and alcohol treatment 2 months after making a tape. Her sobriety made her much more amenable to treatment even though her suicidal thoughts continued. The longest follow-up available at this writing is 3 years. Among adverse effects must be noted the increased access to repressed memories and concomitant suicidal thinking immediately after making the tape and watching it. This increased vulnerability was transient but did result in hospitalization in several cases. Two patients with histories of dissociative behavior dissociated during the taping, and subsequently while watching the tape. In each case, after continued individual treatment, the patient was eventually able to watch and process the material on the tape. In a subgroup of 10 cases treated by one of the authors (TR), all 10 individuals progressed through stage four of the process. The number of people to whom the tape was shown varied from 6 to 18. While almost all tape viewers expressed initial support for the victim, the victim was usually correct in identifying who would not be able to continue to be supportive over time. Three of the 10 patients used the tape to confront the abuser. In two cases, the abuser was a deceased grandfather, and in three others the whereabouts of the abuser was unknown. Case History 1 Susan was 20 years old when referred for treatment of chronic anxiety and depression. She had had a major depressive episode while attempting to leave home to attend college. Since that time she had been in therapy with minimal progress. She thought about suicide daily, had cigarette burn scars and numerous healed cuts on her arms, had frequent accidents, abused alcohol, marijuana, and cocaine, had dysfunctional relationships with male friends, and could not live away from her parents’ home. During the initial evaluation she denied sexual abuse but admitted she had had to fend off her senile paternal granfather’s advances while taking care of him before he died. During the next 9 months she received antidepressant medication and psychotherapy. She was able to work part time and maintain herself in an apartment close to her parents’ home. However, while attempting to return to college in another city, she experienced crippling anxiety with suicidal ideation and was admitted to a psychiatric hospital. While there, she revealed that her grandfather had systematically fondled her and penetrated her digitally from her earliest memory until he died when she was 16 years old. Shortly after her discharge, the video interview procedure was presented to her. She decided to make a tape because, “I’m going to die if I don’t do something.” During the interview she described her abuse experiences in detail for the first time. She talked about her suicidal feelings, and concluded that her worst fear was that after everyone saw the tape she would “be dropped off on a sidewalk somewhere and forgotten.” Earlier she has described how her parents would leave her on the sidewalk in front of her grandparents’ home as a preschool child each morning as they left for work. When asked how the tape would affect those who viewed it, she first felt her parents would reject her, but then reconsidered. She maintained that, despite being close for many years to her aunts and uncles on the abuser’s side of the family, she was certain they and their children would disown her. Susan took almost a month to view the tape completely three times. During the first viewing, she turned off the tape several times and walked out of the office. She reported suicidal thoughts. During the month after taping she contem-
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plated “blowing up grandpa’s grave” or spray painting obscenities on the house where he used to live, unthinkable prior to the taping as Susan was previously known throughout the family as “grandpa’s little nurse.” When it came time to assemble a team to see the tape, Susan included an aunt and two cousins from her grandfather’s family, her parents and brother, and two friends. Subsequently she showed the tape to her minister. Her father, with Susan’s approval, made the tape required viewing for his brothers before he would join them in a family reunion. Susan had successfully predicted her aunt and cousins could not remain sympathetic team members. They were replaced over the next few months with people from church and school. Within 6 months after the team was assembled, Susan was drug and alcohol free, was attending college successfully, and was free of suicidal ideation and self-mutilation. Two years postintervention she remained in therapy working on issues around self-worth and struggling to become self-supporting.
Case History 2 Mary, a 42-year-old biologist, was referred for hospitalization by her outpatient therapist for persistent suicidal ideation. She had spent months awakening every night at 3:00 a.m. and contemplating killing herself by injecting air into her veins. She had been in therapy for 8 years with several therapists after disclosing that her father had frequent intercourse with her for 9 years beginning when she was 13. She had written a letter to him several years before her hospitalization stating she was in therapy for the abuse. Her father responded by paying for her therapy. She had disclosed the abuse to her husband without going into detail. Mary had no idea how much her mother knew of the abuse. She had confided somewhat to one sister but not to another who had also been molested by their father. Mary took a year to decide to make a videotape. In the interim she joined a group for adult survivors of incest. While her group offered support. as did her husband, she still did not feel she could visit with her family without pretending everything was fine. She asked to be admitted to the hospital to make the tape. During the interview she gave a painfully articulate description of her incestuous relationship, the sexual dysfunction in her marriage, and the depth of her suicidal thinking. She related she was afraid her parents would stop loving her and have nothing to do with her after seeing the tape. Her husband was present during the taping and stayed with her in the hospital that night while she experienced waves of anxiety and feelings of worthlessness. She watched the tape twice before going home, and concluded that not only was the interview accurate, but that her actual experience was “twice as bad” as depicted on the tape. Over the next few months she composed a letter to her family. who lived in another state, inviting parents and siblings to come see the tape and talk about it. She decided she did not want to show the tape to nonfamily members, partially because she felt her therapy group already constituted a “team” she could fall back on, and that at least one sister would provide a strong support during her confrontation with her parents. Mother, father, and supportive sister accepted the invitation. The tape was shown and 5 hours of family therapy ensued over a 3-day period. Father reluctantly accepted responsibility for the abuse. Mother reaffirmed support for Mary while stating she had known nothing. Mary asked questions that had been plaguing her since childhood; for example, “Mother, when you walked in on us that time, when we were having intercourse, why did you just turn your back and walk out?” After her parents left, Mary experienced a feeling of profound emptiness. She reviewed the videotapes ofthe family meetings and concluded the incest experience held little emotional importance for either mother or father compared to the effect it had had on her life. Within weeks she felt an emotional release as she distanced herself from her family of origin, and became much more invested in being a wife and mother with a network of friends and ties to her community. Her suicidal thinking diminished dramatically, and she began using her support team actively. Several months later, a brother independently asked to see the tape and became a strong member of the support network.
DISCUSSION One can speculate that a certain aspect of the treatment technique is crucial with the other effects being secondary. Perhaps having the patient feel safe enough to make the tape in the first place is the most significant step. Obviously, this represents the establishment of the first relationship with enough trust to bring the core abuse experience to light. In all the interviews done by the authors, the patient revealed significant new information about the abuse experience. As with Mary, some of the patients had been in therapy for many years prior to the taping. The second stage, making the tape, can also be viewed as the essential step. Several of the
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participants commented how reassuring it was to have their story “in that little box” which could then be locked in their therapist’s office. There is a security in knowing they have told their story and may not have to tell it again. Therapists working with survivors tell how the story gets diluted with each repetition if the survivor needs to disclose to a series of people. The tape serves as a baseline source of information which the patient and family can return to as needed. A strong case can be made for stage three, viewing the tape, as the salient feature of the process. Certainly, watching oneself describe one’s life experience provides the patient with an element of objectivity with which to process the experience. Mary’s response, “It was twice as bad,” represented a major paradigm shift for her, away from seeing herself as responsible for her family’s problems, and toward seeing herself as the recipient of terrible treatment. As the warning above about emerging suicidal ideation at this stage would indicate, the survivors have an intense emotional response to the viewing. Perhaps matching this affect with cognitive memories is the major therapeutic effect. The authors feel that stage four, using the tape to create an informed, supportive constituency, is the most significant aspect of the process. It has the potential to impact the therapy process in a major way. It represents a reversal of the usual mode of operation of the family and associated social network around the patient. Where previously the patient and her personal environment ignored, minimized, or denied the survivor’s core abuse experience and the effect it has had on her life, after watching the tape that experience can become a central organizing feature of the social network. Only then can the abuse experience be incorporated into a view of reality consistent with the adult needs and expectations of the survivor. When Susan was asked her worst fear, she described abandonment as an adult by her family in terms which duplicated her daily experience as a toddler of being “dropped off on a sidewalk” to be abused by her caretaker. Because she lacked a constituency of people to help her redefine reality using adult perceptions, in her internal world she reverted to experiencing the world as she did as a toddler. Her present-day reality still included the experience of abuse with an immediacy that justified her self-mutilation and other symptoms. Once she had a validating, accepting, therapeutic network of relationships acknowledging the truth of her core experience, she could reinterpret the childhood experience. This network is provided partially by a relationship with an individual therapist, or with an adult survivor group. These relationships, however, are competing with the long-standing presence in the survivor’s life of parents, siblings, friends, and others whom the survivor may perceive as having a conflicting judgment. The procedure offers the opportunity to enlist the help of as many of these people as possible to reconstitute the personal environment of the patient. And if the patient discovers people in this network who cannot be validating given information about the abuse, this can be dealt with openly with the help of others who remain supportive. The caveat, of course, is that a therapist must not expose the survivor to the prospect of losing part of the network without providing the means to guarantee that others will be there to provide support. We feel that stage five, confrontation of the perpetrator, is probably the least significant part of the process. It is important to note, however, that should such a confrontation take place, the existence of a large group of significant people confirming the reality of the abuse minimizes the potential of the perpetrator recreating the abuse experience by denial or minimization. In the case of Mary, her husband, sister, and therapist provided the therapeutic system when she confronted her mother and father. The major therapeutic effect came as she viewed the videotape of the confrontation in the ensuing weeks with her “team.” This technique is in the early stages of development and controlled clinical studies have not been done. While the results have been encouraging from a clinical standpoint, work is
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required to establish parameters for its use and to understand the mechanism of efficacy. The questions raised about the salient aspects of the disclosure technique call for ongoing prospective clinical studies which are currently in process. Acknowledgement-This climbing accident.
paper is dedicated to Nancy Czech who died July 8, 1991, from injuries sustained in a
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Sedney, M. A., & Brooks, B. (1984). Factors associated with a history of childhood sexual experience in a nonclinical female population. Journal ofthe American Academy of Child Psychiatry, 23, 2 15-2 18. Shearer, S. L., Peters, C. P., Quaytman, M. S., & Ogden, R. L. (1990). Frequency and correlates of childhood sexual and physical abuse histories in adult female borderline inpatients. American Journal of Psychiatry, 147,2 14-2 16. Singer, K. I. (1989). Group work with men who experienced incest in childhood. American Journal of Orthopsychiatry, 59, 468-482. Speck, R., & Attneave, C. (1973). Family networks. New York: Pantheon. Stone, M. H. (1989). Individual psychotherapy with victims of incest. Psychiatric Clinics of North America, 12, 237-255. Summit, R. C. (1983). The Child Sexual Abuse Accommodation syndrome. Child Abuse & Neglect, 7, 177-193. Surrev. J.. Swett, C.. Michaels. A.. & Levin. S. (1990). Reported historv of phvsical and sexual abuse and severity of symptomatology in women’psychiatric outpatients. American Journal oj‘drthopsychiatry, 60,412-4 17. _ Tsai, M., Feldman-Summers, S., & Edgar, M. (1979). Childhood molestation: Variables related to differential impacts on psychosexual functioning in adult women. Journal of Abnormal Psychology, 88,407-4 17. Walker, E., Katon, W., Harrop-Griffiths, J., Helm, L., Russo, J., & Hickok, L. R. (1988). Relationship of chronic pelvic pain to psychiatric diagnoses and childhood sexual abuse. American Journal of Psychiatry, 145, 75-80. Zanarini, M. C., Gunderson, J. G., Marino, M. F., Schwartz, R. O., & Frankenburg, F. R. (1989). Childhood experiences of borderline patients. Comprehensive Psychiatry, 30, 18-25.
R&une-Le traitement des victimes d’abus sexuel pourrait Ctre amtliore par une technique destinte a g6ntrer une composante thtrapeutique lors de la r&elation des s&ices sexuels au cours de I’enfance. L’hypothtse formulee est qu’il est necessaire de prendre en consideration les relations pour que le traitement puisse &treun succts. La revelation par cassettes vidto pro&de en cinq &apes: (1) D&cider de faire une cassette (2) realiser la cassette en suivant le format dun entretien semi-structure (3) faire visioner la cassette au patient (4) montrer la cassette aux membres de l’equipe therapeutique et (5) utiliser eventuellement la cassette pour une confrontation avec I’abuseur. La technique a etC utilisee dans 27 cas. Des histoires de cas sont presentees pour illustrer la procedure. La discussion inclus les mecanismes potentiels d’action et les elements utilisables dans le traitement. Resumen-El tratamiento de 10s sobrevivientes del abuso sexual puede mejorarse con el uso de una tecnica disefiada para generar una estructura terap6utica en el sobreviviente en la comunicacibn de las experiencias infantiles de abuso sexual al crear la hipbtesis de que la necesidad de validar sus relaciones son una condici6n para que el tratamiento tenga Cxito. Se describe el uso de1 videotape durante el proceso de la comunicaci6n de la experiencia con el fin de crear una red terap6utica. La entrevista grabada en video de1 paciente pasa por cinco etapas. Primero, el sobreviviente del abuso sexual decide hater la grabacibn. Segundo, se graba el video con la ayuda del terapista. Tercero, el paciente observa el video con el terapista. Cuarto, el paciente decide que personas en su vida podrian formar un “equip0 terap&ttico” y les ensefia el video tape a ellos. Como una quinta etapa optional, el paciente le muestra el video tape al ofensor, en presencia del “equipo”. (El paciente esta en control de cada una de las etapas de1 proceso. Puede interrumpirse en cualquier etapa). Esta ttcnica ha sido utilizada en veintisiete cases. Se ofrecen 10s historiales de cada case para ilustrar el proceso. La discus& in&ye mecanismos potenciales de accibn y aspectos en el tratamiento que surgen con el use de1 metodo descrito.
1992 Copyright
014%2134/92 $5.00 + .OO 0 1992 Pergamon Press Ltd.
NETWORK THERAPY USING VIDEOTAPE DISCLOSURES FOR ADULT SEXUAL ABUSE SURVIVORS THOMASA.ROESLER The C. Henry Kempe National Center for the Prevention and Treatment of Child Abuse and Neglect, University of Colorado, Denver
NANCYCZECH Montlake Institute, Seattle, WA
WILLIAMCAMP Private practice, Seattle, WA
CAROLEJENNY The C. Henry Kempe National Center for the Prevention and Treatment of Child Abuse and Neglect, University of Colorado, Denver
Abstract-Treatment of childhood sexual abuse survivors may be enhanced by a technique designed to generate a therapeutic constituency for the survivor around the disclosure of childhood abuse experiences. The need for validating relationships is hypothesized as a condition for successful treatment. The videotaped disclosure process proceeds in five stages: (1) Deciding to make a tape, (2) making a videotape following a semistructured interview format, (3) the patient viewing the tape, (4) showing the tape to potential therapeutic team members, and (5) possibly using the tape for a confrontation with the abuser. The technique has been used on 27 cases. Case histories are given to illustrate the procedure. Discussion includes potential mechanisms of action and issues in treatment that arise with the use of the method described.
Key Words-Adult
survivors, Treatment, Videotape, Disclosure, Network therapy, Sexual abuse.
INTRODUCTION ADULT SURVIVORS of sexual abuse are often severely impacted by their childhood experiences (Briere, Evans, Runtz, & Wall, 1988; Briere & Runtz, 1988a, 1988b, 1990; Browne & Finkelhor, 1986; Bryer, Nelson, Miller, & Krol, 1987; Fromuth, 1986; Hooper, 1990; Jackson, Calhoun, Amick, Maddever, & Habif, 1990; Myers, 1989; Sedney & Brooks, 1984; Surrey, Swett, Michaels, & Levin, 1990; Tsai, Feldman-Summers, & Edgar, 1979). Sexual abuse is recognized as a major correlate of many types of adult psychopathology. Depression (Briere & Runtz, 1986), borderline personality disorder (Ogata et al., 1990; Shearer, Peters, Quaytman, & Ogden, 1990; Zanarini, Gunderson, Marino, Schwartz, & Frankenburg, 1989), psychogenic pain (Domino & Haber, 1987; Walker et al., 1988) sexual dysfunction (Bass & This work supported by a grant from the Van Derbur family. Received for publication February 6, I99 1; final revision received May 2, I99 1;accepted June 24, I99 1. Requests for reprints may be sent to Thomas A. Roesler, M.D., The C. Henry Kempe National Center for the Prevention and Treatment of Child Abuse and Neglect, 1205 Oneida Street, Denver, CO 80220. 575
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Davis, 1988), substance abuse (Root, 1989), dissociative disorders (Chu & Dill, 1990) and eating disorders (Root & Fallon, 1988) have all been found to be associated with a history of sexual abuse in childhood. Treatment has included individual therapy (Braun, 1989; Deblinger, Mcleer, & Henry, 1990; Stone, 1989) group therapy (Alexander, Neimeyer, Follette, Moore, & Harter, 1989; Coker, 1990; Goodwin & Taliwar, 1989; Singer, 1989) and family and community network approaches (Coker, 1990; Giarretto, 1989). In an attempt to describe how abuse suffered in childhood might result in adult psychopathology, researchers have evoked a posttraumatic stress disorder model (Chu & Dill, 1990; Coons, Bowman, Pellow, & Schneider, 1989; Lindbergh & Distad, 1985). Summit ( 1983), in his work on the child sexual abuse accommodation syndrome, outlines a phenomenological process experienced by some abused children which helps explain why adult survivors have posed such difficult problems in treatment for clinicians. He describes a “normal” process of survival which can lead to secrecy, entrapment in a web of deceit, and a sense of helplessness, self-blame, and self-hate on the part of the victim. This position of the victim is often maintained and reinforced by the immediate family, the larger community, and even societal institutions such as the court system. The videotape disclosure technique described in this paper takes into account this process. The technique is predicated on two principal ideas: (1) Mental health stems from personal relationships that validate one’s basic self-worth, and (2) abuse continues as long as the denial of its existence is maintained. These ideas dictate that any efforts to help these patients must confront denial while at the same time foster validating connections with significant people in the patient’s life. Clinicians have discussed the significance of disclosure of childhood abuse in treatment of adults (Bass & Davis, 1988; Schatzow & Herman, 1989). Network therapy has been defined as a process of assembling and using for therapeutic purposes a group of people significant for the patient which reaches beyond the immediate family (Speck & Attneave, 1973). To our knowledge the literature does not describe the use of videotape in the process of disclosure for the purpose of generating a therapeutic network.
A VIDEOTAPED
DISCLOSURE
INTERVIEW
TECHNIQUE
A videotape interview process consists of five stages. First, the survivor of sexual abuse decides to make the tape. Second, a videotape is made with the help of the therapist. Third, the patient watches the tape with the therapist. Fourth, the patient decides which people in his or her life might constitute a “therapeutic team” and shows the videotape to them. As an optional fifth step, the patient shows the videotape to the offender in the presence ofthe “team.” We believe it is important that the patient be in control of each stage of the process. It can be interrupted at any stage. Therapy never progresses faster than the patient deems reasonable and appropriate. Stage
One
The decision to make the videotape is made by the patient after the entire process is explained, and the patient understands clearly that he/she is in control of the process. This requires a significant level of trust in the therapist. The patient must also have sufficient confidence in the memory of the abuse experience so it can be stated coherently during the interview. Survivors of sexual abuse have extremely good reasons for not revealing the nature and extent of the abuse, or, sometimes, not even allowing themselves access to their own
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memories. Often the abuse was accompanied by overt threats of harm for revealing the secret. Even when threats were covert, the consequences of speaking about the abuse experience can be catastrophic. Because patients vary in the time required to recover buried memories or build trust in the therapist, stage one may take from one week to several years. Stage Two Before proceeding with the interview, we believe it to be extremely important to obtain informed consent from the patient, preferably on videotape as well as in writing. The interview itself consists of variations on three questions: 1. What happened to you as a child? 2. What have the consequences been in your life? 3. What do you expect will happen when this tape is shown to significant people in your life? The first part is a straightforward recounting of the abuse experience. It is important that the patient be encouraged to give as much detail as possible. Questions such as, “When you say your father had you masturbate him, do you mean once or more than once? How many times? Where did this take place?” The therapist must be careful not to “lead’ the patient. The interviewer should not ask questions in a way that might be construed as putting words into the patient’s mouth. Detailed and explicit information is more believable than vague statements, both for the patient in stage three, and for the network and abuser in stages four and five. We have noted that disclosure is often more limited by the therapist’s own discomfort with the material than the patient’s willingness to proceed. The second part of the interview deals with the effects of the abuse. Questions are asked about suicidal feelings and attempts, psychotherapy experiences, dissociative experiences, sexual dysfunction, chronic pain, eating disorders, depression, and substance abuse. In our experience, it is not necessary to establish a direct connection between childhood abuse and adult functioning for people viewing the tape to understand the patient’s experience. Rather, it is sufficient to elicit a picture of the patient’s life over the last few years prior to the taping. The last part of the interview concerns the patient’s perception of the effect the tape will have on the significant people in his/her life. The questions in this part include, “Let’s take a minute to imagine what response people will have to seeing this interview. How will your sister react? Your best friend? Your father? Your stepfather?’ This part of the interview becomes extremely important in stage four in establishing the patient’s credibility and overcoming denial. Stage two, the actual videotaping of the disclosure, is the least stressful part of the process. Typically the interviewer relies on well-established skills. The interviewee will often respond in a cognitive, rational manner. It may take a few minutes to overcome anxiety about the videotape equipment. The equipment itself need only provide a clear picture of the patient and a clearly audible sound track. If another person is to be present for the interviewing, he or she must be someone the patient trusts implicitly. Examples might be a spouse or best friend. A typical disclosure interview may last from 45 to 75 minutes. Stage Three While stage two is the least stressful, stage three is the most stressful and potentially dangerous part of the treatment technique. Immediately after the taping the patient may experience a flood of painful memories or second thoughts over breaking long-established taboos concerning disclosure. In many of our cases the patient had suicidal ideation during this phase, and one suicide attempt occurred the same day the videotape was made. For this reason we recommend strongly that stages two and three be done either in a hospital setting or with
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immediate access to a secure hospital environment. Stage three represents the patient coming to terms with what is on the videotape. The patient needs to feel secure that what was said correctly represents his/her experiences. To do this, the tape is viewed by the therapist and patient together. It can be turned off at any time the patient desires. Once again, consistent with the patient being in control of the process, the patient is told the tape belongs to him/her, and can be destroyed if desired. This idea, to destroy the tape, may become powerful as the patient realizes the family secret is revealed on the tape. Watching the tape may be an extremely emotional experience. It may take several days or weeks to get through the tape completely. Several viewings of the tape may be required before the patient is able to accept the tape as accurate. This stage may take from a few days to months. The medium of videotape makes it possible for the patient and therapist to rework the tape until the patient feels comfortable. Usually, any changes will be relatively minor. It is important for the patient to accept the tape before attempting stage four. Stage Four
Once the tape has been made and accepted, work can begin to assemble a therapeutic constituency or “team” for the patient, who is told that although there may be family and friends the patient feels close to, he/she may have felt that if they “really knew the truth” the patient would face abandonment. Indeed, in the authors’ experience, this fear has frequently been voiced during the videotaping. The only way to find out if this is so is to allow them the opportunity to see the tape. The therapist and patient make a list of possible team members, avoiding anyone who might be expected to be discounting or antagonistic to the disclosure. The patient then invites the possible team members to a showing of the video. The patient may get help in this from a supportive friend or relative or from the therapist. The therapist may be present for each viewing although this is not always necessary or possible. Once again, the patient controls who is invited and how it is done. The people invited to view the tape are told the purpose of the viewing, and what they will be asked to see. The therapist reviews with the patient the potential effect on each viewer, and may speak to the invitees prior to viewing to assess whether it seems reasonable to include that person as a potential team member. The team can be assembled in stages with each new group viewing the tape in the presence of already established team members. At no time is the patient exposed to charges of revealing the family secret without someone from the therapeutic team present for support. Ten to 15 people consitute an effective “team.” Stage four may take from a few weeks to 6 months. Stage Five Only after the therapeutic support network has been assembled should a confrontation with the offender be attempted. Even then, the patient should be encouraged to consider whether a confrontation should occur at all. Stopping at any stage is the prerogative of the patient. The confrontation is made by showing the tape to the offender in the presence of as many members of the therapeutic team as can be assembled, all of whom have previously viewed the tape and voiced validation for the patient. If the offender can view the tape and allow its contents to be accepted as a baseline for all subsequent family transactions around the abuse, then therapy involving the abuser can proceed.
RESULTS The videotape disclosure process has been used in 27 cases by five different therapists. The small number of cases precludes any results from being interpreted as other than clinical
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impressions at this time. It has been used with both male and female victims, and with people who experienced extrafamilial as well as intrafamilial abuse. Because the technique was employed in the context of ongoing therapy, results must be interpreted on a case-by-case basis. In every case, the technique was employed as an adjunct to established, ongoing individual therapy. Some of the patients were also engaged in group treatment. The therapists worked primarily in a private practice setting although no contradiction exists for using the technique in a mental health center environment if the proper backup is in place. Accessibility to a secure inpatient setting is advised. The therapists were all experienced family therapists, which may have influenced issues of timing, and the question of whom to invite to join the therapeutic network. The decision to make a tape was often made in the context of an impasse in therapy, or a crisis in the life of the patient. One woman decided to make a tape, a year after the process was first described to her, when she became pregnant. Morning sickness became a triggering event for flashbacks to childhood memories. A woman who had a pattern of binge drinking resulting in suicidal behavior followed by psychiatric hospitalization, entered drug and alcohol treatment 2 months after making a tape. Her sobriety made her much more amenable to treatment even though her suicidal thoughts continued. The longest follow-up available at this writing is 3 years. Among adverse effects must be noted the increased access to repressed memories and concomitant suicidal thinking immediately after making the tape and watching it. This increased vulnerability was transient but did result in hospitalization in several cases. Two patients with histories of dissociative behavior dissociated during the taping, and subsequently while watching the tape. In each case, after continued individual treatment, the patient was eventually able to watch and process the material on the tape. In a subgroup of 10 cases treated by one of the authors (TR), all 10 individuals progressed through stage four of the process. The number of people to whom the tape was shown varied from 6 to 18. While almost all tape viewers expressed initial support for the victim, the victim was usually correct in identifying who would not be able to continue to be supportive over time. Three of the 10 patients used the tape to confront the abuser. In two cases, the abuser was a deceased grandfather, and in three others the whereabouts of the abuser was unknown. Case History 1 Susan was 20 years old when referred for treatment of chronic anxiety and depression. She had had a major depressive episode while attempting to leave home to attend college. Since that time she had been in therapy with minimal progress. She thought about suicide daily, had cigarette burn scars and numerous healed cuts on her arms, had frequent accidents, abused alcohol, marijuana, and cocaine, had dysfunctional relationships with male friends, and could not live away from her parents’ home. During the initial evaluation she denied sexual abuse but admitted she had had to fend off her senile paternal granfather’s advances while taking care of him before he died. During the next 9 months she received antidepressant medication and psychotherapy. She was able to work part time and maintain herself in an apartment close to her parents’ home. However, while attempting to return to college in another city, she experienced crippling anxiety with suicidal ideation and was admitted to a psychiatric hospital. While there, she revealed that her grandfather had systematically fondled her and penetrated her digitally from her earliest memory until he died when she was 16 years old. Shortly after her discharge, the video interview procedure was presented to her. She decided to make a tape because, “I’m going to die if I don’t do something.” During the interview she described her abuse experiences in detail for the first time. She talked about her suicidal feelings, and concluded that her worst fear was that after everyone saw the tape she would “be dropped off on a sidewalk somewhere and forgotten.” Earlier she has described how her parents would leave her on the sidewalk in front of her grandparents’ home as a preschool child each morning as they left for work. When asked how the tape would affect those who viewed it, she first felt her parents would reject her, but then reconsidered. She maintained that, despite being close for many years to her aunts and uncles on the abuser’s side of the family, she was certain they and their children would disown her. Susan took almost a month to view the tape completely three times. During the first viewing, she turned off the tape several times and walked out of the office. She reported suicidal thoughts. During the month after taping she contem-
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plated “blowing up grandpa’s grave” or spray painting obscenities on the house where he used to live, unthinkable prior to the taping as Susan was previously known throughout the family as “grandpa’s little nurse.” When it came time to assemble a team to see the tape, Susan included an aunt and two cousins from her grandfather’s family, her parents and brother, and two friends. Subsequently she showed the tape to her minister. Her father, with Susan’s approval, made the tape required viewing for his brothers before he would join them in a family reunion. Susan had successfully predicted her aunt and cousins could not remain sympathetic team members. They were replaced over the next few months with people from church and school. Within 6 months after the team was assembled, Susan was drug and alcohol free, was attending college successfully, and was free of suicidal ideation and self-mutilation. Two years postintervention she remained in therapy working on issues around self-worth and struggling to become self-supporting.
Case History 2 Mary, a 42-year-old biologist, was referred for hospitalization by her outpatient therapist for persistent suicidal ideation. She had spent months awakening every night at 3:00 a.m. and contemplating killing herself by injecting air into her veins. She had been in therapy for 8 years with several therapists after disclosing that her father had frequent intercourse with her for 9 years beginning when she was 13. She had written a letter to him several years before her hospitalization stating she was in therapy for the abuse. Her father responded by paying for her therapy. She had disclosed the abuse to her husband without going into detail. Mary had no idea how much her mother knew of the abuse. She had confided somewhat to one sister but not to another who had also been molested by their father. Mary took a year to decide to make a videotape. In the interim she joined a group for adult survivors of incest. While her group offered support. as did her husband, she still did not feel she could visit with her family without pretending everything was fine. She asked to be admitted to the hospital to make the tape. During the interview she gave a painfully articulate description of her incestuous relationship, the sexual dysfunction in her marriage, and the depth of her suicidal thinking. She related she was afraid her parents would stop loving her and have nothing to do with her after seeing the tape. Her husband was present during the taping and stayed with her in the hospital that night while she experienced waves of anxiety and feelings of worthlessness. She watched the tape twice before going home, and concluded that not only was the interview accurate, but that her actual experience was “twice as bad” as depicted on the tape. Over the next few months she composed a letter to her family. who lived in another state, inviting parents and siblings to come see the tape and talk about it. She decided she did not want to show the tape to nonfamily members, partially because she felt her therapy group already constituted a “team” she could fall back on, and that at least one sister would provide a strong support during her confrontation with her parents. Mother, father, and supportive sister accepted the invitation. The tape was shown and 5 hours of family therapy ensued over a 3-day period. Father reluctantly accepted responsibility for the abuse. Mother reaffirmed support for Mary while stating she had known nothing. Mary asked questions that had been plaguing her since childhood; for example, “Mother, when you walked in on us that time, when we were having intercourse, why did you just turn your back and walk out?” After her parents left, Mary experienced a feeling of profound emptiness. She reviewed the videotapes ofthe family meetings and concluded the incest experience held little emotional importance for either mother or father compared to the effect it had had on her life. Within weeks she felt an emotional release as she distanced herself from her family of origin, and became much more invested in being a wife and mother with a network of friends and ties to her community. Her suicidal thinking diminished dramatically, and she began using her support team actively. Several months later, a brother independently asked to see the tape and became a strong member of the support network.
DISCUSSION One can speculate that a certain aspect of the treatment technique is crucial with the other effects being secondary. Perhaps having the patient feel safe enough to make the tape in the first place is the most significant step. Obviously, this represents the establishment of the first relationship with enough trust to bring the core abuse experience to light. In all the interviews done by the authors, the patient revealed significant new information about the abuse experience. As with Mary, some of the patients had been in therapy for many years prior to the taping. The second stage, making the tape, can also be viewed as the essential step. Several of the
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participants commented how reassuring it was to have their story “in that little box” which could then be locked in their therapist’s office. There is a security in knowing they have told their story and may not have to tell it again. Therapists working with survivors tell how the story gets diluted with each repetition if the survivor needs to disclose to a series of people. The tape serves as a baseline source of information which the patient and family can return to as needed. A strong case can be made for stage three, viewing the tape, as the salient feature of the process. Certainly, watching oneself describe one’s life experience provides the patient with an element of objectivity with which to process the experience. Mary’s response, “It was twice as bad,” represented a major paradigm shift for her, away from seeing herself as responsible for her family’s problems, and toward seeing herself as the recipient of terrible treatment. As the warning above about emerging suicidal ideation at this stage would indicate, the survivors have an intense emotional response to the viewing. Perhaps matching this affect with cognitive memories is the major therapeutic effect. The authors feel that stage four, using the tape to create an informed, supportive constituency, is the most significant aspect of the process. It has the potential to impact the therapy process in a major way. It represents a reversal of the usual mode of operation of the family and associated social network around the patient. Where previously the patient and her personal environment ignored, minimized, or denied the survivor’s core abuse experience and the effect it has had on her life, after watching the tape that experience can become a central organizing feature of the social network. Only then can the abuse experience be incorporated into a view of reality consistent with the adult needs and expectations of the survivor. When Susan was asked her worst fear, she described abandonment as an adult by her family in terms which duplicated her daily experience as a toddler of being “dropped off on a sidewalk” to be abused by her caretaker. Because she lacked a constituency of people to help her redefine reality using adult perceptions, in her internal world she reverted to experiencing the world as she did as a toddler. Her present-day reality still included the experience of abuse with an immediacy that justified her self-mutilation and other symptoms. Once she had a validating, accepting, therapeutic network of relationships acknowledging the truth of her core experience, she could reinterpret the childhood experience. This network is provided partially by a relationship with an individual therapist, or with an adult survivor group. These relationships, however, are competing with the long-standing presence in the survivor’s life of parents, siblings, friends, and others whom the survivor may perceive as having a conflicting judgment. The procedure offers the opportunity to enlist the help of as many of these people as possible to reconstitute the personal environment of the patient. And if the patient discovers people in this network who cannot be validating given information about the abuse, this can be dealt with openly with the help of others who remain supportive. The caveat, of course, is that a therapist must not expose the survivor to the prospect of losing part of the network without providing the means to guarantee that others will be there to provide support. We feel that stage five, confrontation of the perpetrator, is probably the least significant part of the process. It is important to note, however, that should such a confrontation take place, the existence of a large group of significant people confirming the reality of the abuse minimizes the potential of the perpetrator recreating the abuse experience by denial or minimization. In the case of Mary, her husband, sister, and therapist provided the therapeutic system when she confronted her mother and father. The major therapeutic effect came as she viewed the videotape of the confrontation in the ensuing weeks with her “team.” This technique is in the early stages of development and controlled clinical studies have not been done. While the results have been encouraging from a clinical standpoint, work is
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required to establish parameters for its use and to understand the mechanism of efficacy. The questions raised about the salient aspects of the disclosure technique call for ongoing prospective clinical studies which are currently in process. Acknowledgement-This climbing accident.
paper is dedicated to Nancy Czech who died July 8, 1991, from injuries sustained in a
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R&une-Le traitement des victimes d’abus sexuel pourrait Ctre amtliore par une technique destinte a g6ntrer une composante thtrapeutique lors de la r&elation des s&ices sexuels au cours de I’enfance. L’hypothtse formulee est qu’il est necessaire de prendre en consideration les relations pour que le traitement puisse &treun succts. La revelation par cassettes vidto pro&de en cinq &apes: (1) D&cider de faire une cassette (2) realiser la cassette en suivant le format dun entretien semi-structure (3) faire visioner la cassette au patient (4) montrer la cassette aux membres de l’equipe therapeutique et (5) utiliser eventuellement la cassette pour une confrontation avec I’abuseur. La technique a etC utilisee dans 27 cas. Des histoires de cas sont presentees pour illustrer la procedure. La discussion inclus les mecanismes potentiels d’action et les elements utilisables dans le traitement. Resumen-El tratamiento de 10s sobrevivientes del abuso sexual puede mejorarse con el uso de una tecnica disefiada para generar una estructura terap6utica en el sobreviviente en la comunicacibn de las experiencias infantiles de abuso sexual al crear la hipbtesis de que la necesidad de validar sus relaciones son una condici6n para que el tratamiento tenga Cxito. Se describe el uso de1 videotape durante el proceso de la comunicaci6n de la experiencia con el fin de crear una red terap6utica. La entrevista grabada en video de1 paciente pasa por cinco etapas. Primero, el sobreviviente del abuso sexual decide hater la grabacibn. Segundo, se graba el video con la ayuda del terapista. Tercero, el paciente observa el video con el terapista. Cuarto, el paciente decide que personas en su vida podrian formar un “equip0 terap&ttico” y les ensefia el video tape a ellos. Como una quinta etapa optional, el paciente le muestra el video tape al ofensor, en presencia del “equipo”. (El paciente esta en control de cada una de las etapas de1 proceso. Puede interrumpirse en cualquier etapa). Esta ttcnica ha sido utilizada en veintisiete cases. Se ofrecen 10s historiales de cada case para ilustrar el proceso. La discus& in&ye mecanismos potenciales de accibn y aspectos en el tratamiento que surgen con el use de1 metodo descrito.
