Journal of Psychoactive Drugs

ISSN: 0279-1072 (Print) 2159-9777 (Online) Journal homepage: http://www.tandfonline.com/loi/ujpd20

The Role of Incest Issues in Relapse Enid B. Young To cite this article: Enid B. Young (1990) The Role of Incest Issues in Relapse, Journal of Psychoactive Drugs, 22:2, 249-258, DOI: 10.1080/02791072.1990.10472547 To link to this article: http://dx.doi.org/10.1080/02791072.1990.10472547

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in Relapse Enid B. Young, Ph.D. * Abstract - Comprehensive studies have established that relapse is the most common outcome of recovery programs treating addictive behaviors . This article examines the fact that relapse is often related to uncovering painful early childhood incest experiences that have been defended against through self-destructive addictive behaviors. Another aspect of relapse is the phenomenon of multiaddictions: withdrawal from an identified addictive behavior will often lead to the unmasking of other addictive behaviors. The phenomenon of cross-addiction is widely acknowledged in the addictions field, but the connection between cross-addiction and relapse needs to be more fully explored. This article focuses on the following points: (1) addictive behaviors may serve to defend against memories of sexual abuse; (2) unidentified incest material may precipitate relapse or result from relapse, and therefore must be considered as a possible component of treatment in recovery - indications for treatment in terms of 12-Step recovery in conjunction with therapy are explored; (3) relapse may indicate the existence of additional addictions that must be identified and explored in order for recovery to proceed; and (4) sex and love addiction is often found in conjunction with alcoholism, codependency and compulsive overeating, and often comes to light through the emergence of incest memories. The identification and treatment of this hidden addiction (i.e., sex and love addiction) will determine the extent and depth of recovery. Keywords - addiction, childhood sexual abuse, incest, recovery, relapse, sex and love addiction, 12-Step programs

[ remember asking my therapist how he could think my father hadsexually abused me when [didn't remember a thing. He said it was like walking through the woods after a snowfall and seeing thefootprints ofan animal that had passed. You don't have to see the animal to know it had been there . He said, "I can see the tracks throughout your life -the monster has been there." - Anonymous 1989

in the addiction treatment field, and more recently in the area of relapse prevention. However,the possible existence of childhood sexual abuse issues as a predisposing factor of relapse has not been explored . HISTORICAL OVERVIEW OF RELAPSE THEORY

One of the greatest unacknowledged contributors to recidivism in alcoholism and other addictions may be the failure to identify and treat underlying childhood sexual abuse issues. The occurrence of relapse - a breakdown or setback in a person's attempt to change a target behavior - has been recognized as the most common outcome of treatment in recovery programs. Traditionally, relapse has been addressed both in 12-Step recovery programs,

Why is relapseso common that it warrants defining addiction as a relapsing condition? Relapse has been studied primarilyin the fieldof alcoholism and other drug addiction. Classictheoriesof addiction(e.g., J ellinek 1952)have maintainedthat relapseis motivated and reinforcedby relief from withdrawal; that is, traditional theoryhas focusedon therole of physical withdrawal or the craving for a substance to alleviatethe unpleasantsymptomsassociatedwith withdrawal distress. Craving has also been defined in terms of the environmental cues or conditioned stimuli previously asso-

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ciated with the substance as initiating factors of craving (Ludwig, Wikler & Syark 1974). More recent theories (Marlatt & Gordon 1985; Chancy, O'Leary & Marlatt 1978; Litman, Eiser & Rawson 1977) recognize the role played by social, psychological, cultural, and situational factors in the relapse process. Such models reject theories that regard craving as the principal determinant of relapse, focusing instead on environmental, intrapersonal, and interpersonal determinants of relapse. Current relapse prevention theory (Marlatt & Gordon 1985) holds that it is the effect of high-risk situations and the individual's response to them that is most closely associated with relapse. For example, an alcoholic choosing to enter a bar or a cocaine user going to a party where cocaine is present may be placing themselves in high-risk situations for relapse. Relapse prevention draws on social learning theory and the acquisition of new cognitive-behavioral techniques that can help the individual to define high-risk situations and convert antecedents of a relapse situation (triggers), as well as to develop coping strategies for maintaining abstinent behavior (lifestyle change). Intervention strategies are designed to deal with relapse when it does occur in order to ensure an immediate return to abstinence. Common agreement among all theories has been that relapse is a highly probable, complex, multifaceted phenomenon.

terial that has contributed to the etiology of the addiction. When viewed in this way, relapse becomes an opportunity to strengthen the process of abstinence through the resolution of precipitating factors in the development of addictive behavior.

CESSATION OF ADDICTIVE ACTIVITY INVOLVES MORE THAN ABSTINENCE Alcoholics Anonymous (AA) and other 12-Step programs for addictive behaviors all emphasize that while abstinence is essential to relapse prevention, it is not the only issue. Recovery can be achieved only when the attitudes and behaviors that led to and/or were associated with the addictive behavior are changed. In other words, while relapse has usually been defined in terms of abstinence or the total cessation of addictive behavior (Washton 1988; Marlatt & Gordon 1985; Litman, Eisel' & Rawson 1977), it is important to understand that cessation of an addictive activity involves more than abstinence. As Washton (1988) asserted: Abst inenc e is mer ely a prerequisite to recovery, because only during sustained abstinence can a chemically dependent person make the psychological, behavioral and attitudinal changes that are necessary to initiate and continue recovery from the addictive illness. If patients manage to stay abstinent for a while by sheer willpower and dogged determinism . . . but do not make fundamental changes in their way of living and behaving,they often continue to act in the same self-defeating and maladaptive manner as when they were actively using drugs . Moreover, their relapse potential remains extraordinarily high. In alcoholism treatment, this phenomenon is known as the "dry drunk,"

THE ROLE OF CHILDHOOD SEXUAL ABUSE ISSUES IN RELAPSE Classic theories of dependence and current theories of relapse prevention have not addressed the high potential for relapse associated with internally generated phenomena, such as the effects of early childhood sexual abuse. The association between addictive behaviors, such as alcoholism , other drug abuse and eating disorders, and the incidence of childhood sexual abuse is increasingly being documented (Courtois 1988; Gil 1988; Finkelhor & Browne 1986). However, because denial is a principal defense mechanism in handling the effects of childhood sexual abuse, these experiences and the resultant symptoms are frequently masked. Thus they remain untreated and become a high-potential risk for relapse in recovery from addiction. Therefore, relapse prevention must explore the possible existence of childhood sexual abuse as a precipitating factor of relapse. The present article proposes that many of the relapses that may appear to be stimulus contingent. as current theory proposes, may in fact turn out to be internally generated. This would help to explain the persistent, repetitive occurrence of relapse when attempting to abstain from addictive behavior. Relapse should be viewed not only as a regression in terms of a defined goal of abstinence, but more importantly, as an indication of the existence of underlying maJOUFlUJI

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When indicating the presence of unresolved traumatic experiences, relapse may be viewed not as a failure but rather as an opportunity to understand and thereby resolve psychological, behavioral, attitudinal, and spiritual material that has contributed to the addictive behavior. The resolution of this previously unresolved material strengthens the recovery process and is a critical factor in the prevention of further relapse.

THE PHENOMENON OF MULTIADDICTIONS Another factor that may contribute to the persistence of relapse is the phenomenon of multiaddictions. The prevalence of multiaddictions has become increasingly apparent. The recognition this phenomenon is receiving is evident in the proliferation of 12-Step programs that address a variety of addictive behaviors, such as compulsive eating, gambling, relationship addiction, and sex and love addiction. Clinical observation has shown that abstinence from one addictive behavior often leads to the substitution of a different addictive behavior. For example, the alcoholic who stops drinking may start eating compulsively. To better un250

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tics on sexual abuse among men have been more difficult to document, in part because the taboo against men reporting such abuse is even greater than for women, it is beginning to be reported as significant (Crewdson 1988).

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derstand how multiaddictions surface, one must recognize that the factors predisposing an individual to addictive behavior,such as childhood sexualabuse, result in an impairment of the self that predisposes an individual to addictive behaviors in many arenas. Relapse in the context of an abstinence program of recovery from an identified addictive behaviormay in fact stem from an underlying addictionthat has not yet been identified. The prevalence of multiaddictions will be exploredlateras an acknowledged contributing factor to relapse. In particular, an often unrecognized addiction, sex and love addiction, will be discussed.

HOW DOES CIDLDHOOD SEXUAL ABUSE PREDISPOSE ONE TO THE DEVELOPMENT OF ADDICTIVE BEHAVIORS High Correlation Between a History of Sexual Abuse and the Subsequent Manifestation of Addiction Does the experience of childhood sexual abuse predispose an individual to the development of addictive behaviors? The etiology of addiction hasbeen and continues to be studied extensively. It is clear that addiction is multidetermined: biological, social, and psychological factors all contribute to the development of addictions. In the present article, childhood sexual abuse will be explored as a contributing factor in the development of addictive behavior, and thereby a possible risk factor in relapse. Increasingevidence revealsa high correlationbetween a history of sexual abuse and the subsequent manifestation of addictive behavior. For example, recent studies have indicated that early sexual trauma may lead to alcohol problems in women (Nielsen 1984; Kovach 1983). In areview of the sexuality of female alcoholics, Covington (1986) pointed out that early sexual abuse appears to predispose women toward alcoholism. When asked about experienceswith incestor rape, 12% to over 50% of alcoholic women stated that they experienced incest and other childhood sexualabuse, andup to 74% reported all types of sexual abuse combined (Russell 1983). In a survey of 78 eating-disordered patients, Oppenheimer and colleagues (1985) reported that 66% revealed a history of adverse sexual experience, 80% of which occurred in childhood. Kearney-Cooke (In press) reported a 90% reduction in binge-purge frequency in bulimic women whose treatment included a focus on the aftereffects of childhoodsexual abuse. Kearney-Cooke also asserted that "abusive sexual experiences, as well as the feelings of powerlessness which result from them, can be importantcontributingfactors in the developmentof an eating disorder and require specific treatment." Odyssey House, a well-established residential drug abuse treatment program, has reported that 44% of its female drug addicts were sexually abused as children . John Siverson, a Minneapolis therapist specializing in treating teenage drug addicts, estimated that figure to be closer to 70% (Forward & Buck 1978). Furthermore, a strong relationship between self-destructive behaviors (e.g., alcohol and other drug abuse, gambling,compulsive spending, eating disorders, and sexual disorders) and childhood sexual abuse among adults

WHAT IS CHILDHOOD SEXUAL ABUSE? Childhood sexual abuse may be defined as "contacts or interactions between a child and an adult when the child is being used as an object of gratification for adult sexual needs or desires" (De Vine 1980). When this contact happens within the family system (e.g., father, mother, brother, sister,cousin, stepfather), it is defmed as incest. Childhood sexual abuse occurs on a continuum, from covert to overt. Overt sexual abuse involves actual sexual contact, while covert sexual abuse includes more subtle sexual behaviors, such as exhibitionism, sexualized language, and lack of appropriate privacy. It is a traumatic experience that interfereswith a child's normal, healthydevelopment While the focus of the present article is childhood sexual abuse within the family system (i.e., incest), the theorizing is not limited to abuse within the family alone. Childhood sexual abuse often happens outside the family with similar dynamics, such as denial, repetitiveness, and trauma. Therefore,for the purposesof this article, the terms "incest" and"childhood sexual abuse" will be used interchangeably. Historically, sexual abuse in childhood had been characterizedby one of the most common reactionsto the abuse experience itself; that is, denial. As early as 1896, Freud speculatedin "The Aetiologyof Hysteria"thatsexualabuse during childhood might be a causal factor in the subsequent development of emotional problems in women. When he retracted his "seduction theory" and replaced it with the theory of the Oedipus complex, the belief that his patient's hysterical symptoms reflected sexual fantasies rather than actual sexual abuse, the aclcnowledgment of childhoodsexual abuse was repudiated. During the past decade, however, the prevalence of all forms of child sexual abuse, including incest, has been discovered and has received unprecedentedsocietal recognition (Courtois 1988; Covington & Beckett 1988; Finkelhor & Browne 1986; Butler 1985; Russell 1983). It is now accepted that a substantial percentage of women have experienced childhood sexual abuse; the prevalence rates for all forms of childhood sexual abuse among females in the United States has been reported to be 54% by Russell (1983) and 53% by Wyatt (1985). While the statisJOIl17UJI ofPsychoactive Drugs

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has been described (Gil 1988; Miller 1984). Bass and Davis (1988), experts in the field of incest recovery, stated that addictions are common ways of coping with the pain of sexual abuse. For example, they suggested that eating disorders as well as alcohol and other drugs are often used to numb feelings, suppress memories, and escape from the pain of sexual abuse, In Conspiracy of Silence, Butler (1985) quoted an incest survivor: "We create our own denial system. We erect a wall between us and what has happened, There are lots of ways to build that wall - drugs, alcohol, whatever brings immediate oblivion will serve. If people could only find a way to look past that wall they might understand that many of our choices are the only ways we know to survive."

integrity and life itself. Confrontations with violen ce challenge on e's mo st basi c assumptions about the self as invulnerable and intrinsically worthy, and about the world as order! y and just. After abuse, the victim's view of self and world can never be the same a.gain: it must be reconstructed to in corporate the abuse expenence. In an effort to reduce the inevitable feelings of helplessn.es.s.and vulnerability. victims frequently tend to assume responsibility for the abuse. thereby restoring an illusion of control; altemati~ely. th~y may redefine and minimize the event. thereby protectmg a VIeW of the world as ju st and ord e rly,

The secondary symptoms, including various addictive behaviors, are manifestations of the underlying selfimpairmenL Therefore, the occurrence of sexual abuse and the resultant damage to the self are often hidden behind the secondary symptoms. It is not until the secondary symptoms are treated that the recogni tion and repair of the original trauma becomes possible. For example, in the recovery process, abstinence may lead to the emergence of sexual abuse memories previously masked by the addiction. In the following passage, Brown (1985) described a recovering alcoholic: "When she started, Brenda had few memories of her childhood. During the course of her thecapeutic work, the uncovering of her denial was of key significance. , .. As she progressed in recovery, she felt a continuing threat of impending disaster and a terror of uncovering her feelings and acknowledging their reality and strength. Abstinence created a clarity that made denial impossible... ." The emergence of these childhood memories may become a high-risk precipitating factor for relapse. As previously stated, addressing this possibility is essential for effective relapse prevention. It may initiate a process of the restoration of the self that has been impaired by the abuse. The specific ways in which addressing these childhood memories will assist the prevention of relapse and the reparation of the self will be discussed later in this article.

Children Victimized by Sexual Abuse Are at High Risk for the Development of Negative Aftereffects It has been increasingly documented that children victimized by sexual abuse are at high risk for the development of negative aftereffects both immediately and in adulthood (Courtois 1988; Finkelhor & Browne 1986; Butler 1985; Gelinas 1983; Russell 1983). The range of problems most commonly includes such difficulties as low self-esteem low functioning or driven functioning, depression, anxiety: alienation and the inability to sustain relationships, the repetition of abusive relationships, sexual dysfunctions, and dependence on alcohol and other drugs, as well as other addictions. While the immediate and long-term negative effects of childhood sexual abuse have been documented they have not been systematized into a coherent model until recently.

TRAUMA AND CHILDHOOD SEXUAL ABUSE Why does childhood sexual abuse predispose one to the development of addictive behaviors? Current models conceptualize the impact of childhood sexual abuse in terms of the relation of trauma 10 the development of men tal health problems (Finkelhor & Browne 1986; Figley 1985; Lindberg & Distad 1985; Gelinas 1983; Green 1983; Herman 1981). It has been asserted that at the time of abuse victims develop symptomatology associated with acute posttraumatic stress disorder (Courtois 1988; Briere & ~unlZ 1987; Conte & Schuerman 1987). Because the origmal effects of the trauma generally remain untreated, they become chronic and appear in delayed fashion, disguised in such secondary symptoms as depression, anxiety dis orders, substance abuse, sexual difficulties, sleep disturbances, revictimization, and dissociative disorders. The direct result of the trauma is an assault to the self. As Rieker and Carmen (1986) stated:

What Are the Traumatic Effects of Childhood Sexual Abuse on the Developing Child's Sense of Self In 'The Phenomenology of Self," Meissner (1986) addressed the issue of the self as an integrating and organizing principle in a child's development. This self organization is expressed in the capacity for trust, autonomy and initiative, as well as in the ability to set meaningful goals and undertake to achieve them (Erikson 1980; Kohut 1977). An individual's sense of self (perception of self) and functioning self (expression of self) will determine his or her ability to live a productive and creative life and to form fulfilling relationships with others. The child victim of sexual abuse is deprived of the experience of separateness and an environment that facilitates the development of a sense of self as valuable in its own right. The ability to define one's own feelings, needs and perceptions, and one's growing capacity to interact with

Victims of physical and sexual abuse are faced with a formidable and complex series of social, emotional, and cognitive tasks in trying to make sense of experiences that threaten bodily

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When the effects and defenses associated with the trauma of childhood sexual abuse are left untreated. secondary symptoms will develop that mask them. Addictive behaviors may serve such a function. They keep the self impaired by covering over the trauma and maintaining the lies and denial that have surrounded the abuse. At the same time, they allow the impaired self to function more or less with its restrictions for a certain period of time. (The impaired self, for example.has been cut off from learninghow to care for itself. A person in psychological pain, therefore. may take a drink or overeat to soothe the pain. A healthy person would be capable of addressing the pain directly.) Eventually, throughthe progressiveandpathologicaleffects of the addictive behavior, the impairment of the self will increase. Addictive behaviors develop and become serious problems in themselves. Indeed, in their manifestations, they recreate many elements of the repressed trauma. such as denial, secrecy, numbness. shame. powerlessness, and pain. They become one possible "disguised presentation" (Gelinas 1983) of childhood sexual abuse that keeps the individual and others in denial about the abuse. When the addictions themselves are treated, the hidden trauma will often be revealed .

the environment- an ability that is dependenton the caretaking adult's capacity to provide such an environment (Wmnicott 1965)- is superseded by the necessity to conform to the adult's needs andrequirements. Therefore.maturational development is halted and the child is forced to conform to another's reality (needs. expectations. perceptions) rather than to engage in the developmental process of defining his or her own reality (sense of self). The sexually abused child leamsfusion (powerlessness and subjugation). which entails responding to other's needs. expectations. andrequirementsas a way of relating to oneself and others. rather than individuation (separateness).which means trust in one 's own perceptions. expectations. and requirements. The child victim is abused twice: the cessation of the development of the self is a result of (1) the actual event of the abuse (both singular and repeated). and (2) the conditionsof secrecy anddenial within whichtheabuseoccurs. The child is told to keep the abuse a secret. This is often at the risk of severe punishment if the event is disclosed. The meaning of abuse is also distorted by the adult abuser. who frequently tells the child that the abuse is "good" for the child. The abuser often asserts that the child must "like" it If the child does disclose the abuse. he or she is usually met with disbelief. criticism. and hostility(Courtois 1988). This dual aspect of the assault on the self was expressed by one victim(Anonymous 1989): "We were victimswhen. as trusting and dependent children. someone we loved and believed in used us for his own devices. First. we felt our bodies were taken from us. Then. when our pain and anguish were met with denial. we felt our minds were taken: 'No. that never happened. How dare you say such a thing about your father (or brother. or uncle. or grandfather) ... so we gave up possession of our thoughts and feelings to others.·.. The sacrrifice of self and the enforced denial of the abuse and its effects evoke overwhelming terror,rage, and despair in the child. The sacrifice and denial are required by the adult figure on whom the child is dependent. The powerlesschild is forced to comply in order to accomodate the adult. According to Rieker and Carmen (1986), "the child's task is to accomodate to a family in which exploitation, invasiveness, and the betrayal of trust are normal and in which loyalty, secrecy, and self-sacrifice form the core of the family's value system. In a sense. the victim's survival is dependent on adjusting to a psychotic world where abusive behavior is acceptable but telling the truth about it is sinful." The terror, rage and despair, which are intolerable to a child, force the child to form maladaptive defense mechanisms to survive. 1 These defenses deny both the powerlessness of the child to stop the abuse and the terror, rage, anddespairassociatedwith that powerlessness. They allow the self, impaired by the trauma of abuse, to survive. JOIITNJ/

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TREATMENT

Withdrawal The incest survivor who enters treatment for addictive behaviors will in most cases be unaware of the childhood trauma underlying his or her behavior. The addictive behavior is at this time the primary pathology. A disease in itself,it must be addressedas such. Following a progressive course of destruction to the physical, emotional, social and spiritual well-being of the individual. the addictive disease has become the preoccupyingfocus of the addict's life. The addict's ability to function has increasingly deteriorated and. if left untreated, the addiction would lead to death. AA and the many addiction recovery programs that follow the 12-Stepprogram model emphasize that total abstinence from the addictive behavior is a prerequisite for recovery from addictive disease (Washton 1988; Maxwell 1984; Alcoholics Anonymous 1976; Johnson 1973). Abstinenceis the conditionthat allows the tasks of recovery to take place, including the development of a new way of life and the reparation of the impaired self. In each stage of abstinence - early, middle, and long-term - there is a potential for relapse to addictive behavior. Relapse is viewed as a "return to the former coping style in a context of recovery" (Rankin 1989). As stated previously, relapse may be a tool in strengthening abstinence when the underlying state of the addictive behavior is revealed and a pr0gram of relief is initiated for it (Brown 1989). Abstinence, the first task in the treatment process, be253

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gins a period of withdrawal from the addictive behavior. which initially involves "cleaning out" the effects of the addictive behavior as well as a strong pull back toward the addictive behavior. In later stages of abstinence. withdrawal will involve the emergence of underlying material and will reveal deeper characteristics of the addictive behavior. At each stage, withdrawal presents a risk for relapse as new material emerges. new addictive behaviors are revealed. and a new lifestyle is developed. Withdrawal is viewed here as the movement from a lifestyle dependent on addictive behaviors (impaired self) to a lifestyle based on healthy. self-determined. and creative choices (restored self). The incest survivor in addiction recovery will be at ris k for relapse in four major areas: (I) memories are unknown or begin to surface; (2) affects associated with the incest begin to emerge as well as feeling in general; (3) life experiences are met without the aid of addictive behaviors; and (4) addictive behaviors surface other than the identified addiction. These risk factors do not occur sequentially. but they are all present throughout recovery. How can this issue of relapse best be addressed as recovery proceeds?

the recovery program will need to suppo rt the individual in returning to abstinence . This will mean increased use of the tools of the program. including additional meetings. phone calls. and 12-Step work. Second. uncovering the sexual abuse material und erlying the addictive beh avior will need to be specifically addres sed. This will involve participation in a self-help group that focuses on incest recovery. such as Incest Survivors Anonymous or other groups that focu s on incest recovery. At this point. ind ividual therapy is also indicated in order to sy stematically deal with the intensity of affects that begin to surface as well as working through the incest experience . It is important to understand that the treatment program for the originally identified add ictive behavio r is a crucial . ongoing support for recove ry re lated to th e c hild hoo d trauma. Abstinence is supported by this treatment The original treatment setting provides a consistent. reliable base as the exploration of and working through the trauma proceed. The new atti tudes and beh av ior s learned in the treat ment group will become even more impo rtan t in es tablishing a new orientation as the old co ping mechanisms instituted to deal with the trauma are lifted. Furthermore, when difficult transference material arises in individual treatment - as the survivor reenacts past relationships in order to resolve them - the treatment group provides a neutral en vironment and reality feedback . Th erefore, as tran sference and trauma issu es are addressed and worked through, recovery from the originally ide ntified addiction will take on new meaning and will be strengthened. In brief. the se xual abuse treatment will entail identification of the memories. processing the memories wi th their attendant affects, placing the abuse in the proper con text. and undertaking the wo rk of self-development that has been halted by th e abuse. Ricker and Carmen (1986) summarized thi s process nic el y :

Memories Are Unknown or Begin to Surface Relapse may occur at any time in the withdrawal process , without any awareness of the traumatic events. In this case, relapse may be used as a signal to investigate the possibility of childhood sexual abuse. This investigation may lead to uncovering sexual trauma. Or childhood sexual abuse memories may surface at once in the abstinence process . Abstinence from the addictive behavior will initiate withdrawal from the effects of the addiction, one of which ha s been to effectively block sexual abuse memories. As one incest survivor stated (Brown 1985): "At the point I decided to put down drinking. I had to start feeling. The connection to the abuse was almost immediate. And I watched other people come to AA and do the same thing. They have just enough time to get through the initial shakes and you watch them start going through the memories. And you know what's coming. But they don't" Thus, memories may surface immediately or at any point along the recovery continuum. An attempt to once again block these painful. often overwhelming memories may lead to relapse. When relapse occurs in connection with these memories. a treatment process focusing on the abuse must be initiated. The initial task: is to disclose the abuse. If the clues are missed or the abuse is dismissed as unimportant. the individual may return to the silence and secrecy surrounding the original abuse. At the same time. it is important to assess the readiness of the survivor to face these issues and to proceed sensitively with the exploration. Forced or rushed exploration could itself lead to relapse. From the point at which childhood sexual abuse issues have been identified as a precipitant of relapse. the recovery process must continually proceed along two axes. First. Jo urnal ofPsychoactive Drugs

The core of treatm ent m ust be 10 hel p the victim, in a safe and controlled way, to recall the abuse and its original affects and to restore the accurate meanings attached to the abu se; that is, to recontexualizc the trauma . As Miller noted , the turning point for the patient occurs when her or his rag e is expe rienced not as meaningless, but as a response to cruelty. The patient needs to und erstand that nothin g will erase the past Th e work of therapy is, rather, to reclaim that t raum ati c past as pan of one 's history and identity. With this kind of understanding, the abused patient will be able to grieve and to let go of both the trauma and the distortions in memo ry and affec ts tha t once were necessary foc surviva l.

Gil (1988) des cr ibed " positive resolution" of the trauma, which is achi eved wh en the trauma is processed in a realistic way. and the affects associated with the memories of the abuse are experienced. Responsibility for the abuse is attributed to the abuser rather than the self. The abuse is understood as being in the past, not a danger in the present. There is no co mpuls ion to repeat the trauma because it has been faced and dealt w ith. 254

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as a resourcerather than a liability. Feelings become a tool for defmingoneselfas distinct from others. The likelihood of relapse is gradually reduced.

Defining the incest experience and forming connections with others who have had similarexperiencescan be an enormousrelief to the survivor. Understandingthat one is neither crazy (i.e., his or her difficulties have a source in reality) nor alone (i.e., others have sufferedin the same way and with similar effects) breaks the forced isolation, secrecy, and shame of the original abuse conditions. Uncovering theincest materialis a majorstep forward in recoveryfrom addiction. As Courtois (1988)remarked: "... some problems are not responsive to treatment until theirfunctions and secondarygainsare uncovered. ... selfdestructive behaviors, and addictions ... may all be resistant to treatment until such underlying dynamics as selfhatred, theneed for self-punishment, and identification with the aggressor are uncovered...."

Life Experiences Are Met Without the Aid of Addictive Behaviors The third possiblerisk for relapsefacingtherecovering incest survivor is that ordinary life experiences and life challengesare likely to trigger the underlying negative effects of the incest. Because the self is impaired, the incest survivor is unequipped to deal with life processes without the mediating effects of the addictive behavior. Courtois (1988) indicated that "many of the survivors that I interviewed ... told me that they felt the incest irreparably changed them and that they did not develop as they might have.... Survivors described themselves as feeling as though they have holes in themselves and in their development, as though they don't know where other people leave off and where they begin, and as so burdened with the demands of others that their own needs remain undefined." As the incestsurvivorattempts to meetlife experiences that he or she is developmentally unprepared to handle, there may be a reversion to the addictive behavior that has substitutedfor adequatedevelopment Developmental triggers, or any normal developmental occurrence that calls into playa new area of functioning impaired or disordered because of the incest (Gelinas 1983), will be a factor throughout therecoveryprocess. This will involveattempts to assert needs and desires, and to actualize creative endeavors.Each step may trigger the fear of reprisal for selfassertion that characterized the survivor's childhood experience. Relapse may be a response to this fear. To deal with the issue of developmental triggers, relapse prevention will involve a maturational process. Because incest survivors have had their development affected and modified,treatment will involve reworking the tasks of maturationthat were either missed or experienced prematurely (Courtois & Sprei 1988; Rist 1979). The addictionrecoverygroupprovidesfunctionsthat wereabsent or distorted in the original family that are necessary for healthy development. The recovery group supports individuation rather than fusion. The concept of boundaries is introduced through sharing one's own experience without cross-talk- judgments or advice-givingfrom others. The 12-Steps articulatea new set of attitudes andbehaviorsthat provide a framework for relating to oneself and others. Modeling is provided by members of the group who are in sustained recovery. Breaking the silence by sharing experiences (identification) allows acceptance of the individual's uniqueselfas it is revealedto the group (mirroring) and affirms the individual's steps in the recovery process (validating). The group provides the tools that were unavailablein the originalfamilysystem. Maladaptivemech-

The Emergence of Affects Associated with Incest and Other Feelings The second risk for relapse facing the incest survivor is the emergenceof feelings. Addictivebehaviors maskthe effects of the original trauma. Feelings have either been repressed or never experienced at all. Therefore, at all stagesof abstinence,withdrawal will involvethe surfacing of feelings. The emergence of feelings will bring discomfort to the incest survivorwhose survival has dependedon not feeling. He or she will experienceboth the painful feelings associated with the trauma and newly experienced feelings of joy and excitement as life begins to be well lived. Relapse will be a possible defense in relation to the emergence of these feelings. All feelingsare associatedwith the intolerableaffects of trauma. The recovering incestsurvivorwill needto learn thatfeelings are not dangerous or destructive. The addiction treatment groupprovidesa contextforrelearning the meaning of feelings. The spiritual orientation of the group, the belief in a power greater than oneself that offers unconditionalacceptanceand love,and the unconditional acceptance offered by group members provide a safety net for the incestsurvivorwho risks experiencing both painfuland joyful feelings. At the same time, as warded-off feelings are experiencedand new feelings emerge, individual and incestgroup treatment provide a setting within which feelings can be safely explored.The therapist and group memberswill be utilizedas alter egos who offer informationabout feelings and reality feedback. This assists the survivor in distinguishing past traumatic feelings from present appropriate feelings. Rather than fearing and avoiding feelings, the incest survivor learns to identify,experience, and trust his or her own feelings, and learns to use feelingsas guidesfor defining needs, desires, and perceptions. As feelings become familiarand helpful,the necessity to mask themis reduced. Self-determination is strengthened by experiencing feelings J0lU7U11 ofPsychoactive Drugs

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of a compulsive avoidance of sexuality and of relationships because of a fear of fusion (Schaef 1989). What characterizes sex and love addiction is fusion: defining oneself through others, rather than through oneself. As one person characterized it (Anonymous 1989): ''Whereas Noelle compulsively sought out sexual relationships, hoping they would meet her overwhelming needs, Megan withdrew from sexual involvement, afraid of he r overwhelming needs. They are both manifestations of the same problem - a distorted model of love and sex. Sometimes we ex perience both types of behavior in the form of on again/off again sexual activity." Sex and love addiction has it s roo ts in incestuous abuse. It is a generationally transmitted addiction, usually hidden and unidentified. The perpetrator of childhood sexual abuse is a sex and love addict who uses the child for his or her own sexual and emotional needs. For the child, early relationships are sexualized: the child learns that sex and affection arc synonymous and that sexuality is involved in all close interpersonal interactions. The child who is used in this manner learns fusion as a survival coping mechanism. One way this manifests is in fusion with the perpetrator. In order to accommodate the adult abuser and to maintain a relationship with the abuser on whom the child is dependent, the child incorporates the perpetrator's worldview a s part of his or her identity. Separation from the "abuser within" is a major aspect of recovery for the incest survivor. The patterns that are learned in the incestuous abuse experience, when left unrecognized and untreated, will repeat themselves in adult relationships. Thus the sur vivor acts out these patterns in sex and love addiction in adulthood. Furthermore, sex and love addiction may be viewed as one aspect of posttraumatic stress . On the one hand, compulsive inappropriate sexual relationships are engaged in, repeating the dynamics of fusion in the original sexual abuse (e.g., using and being used by another person). This is done in an attempt to master the original situation as well as in the hope that the outcome might, this time, be different (Norwood 1985). On the other hand, relationships arc compulsively avoided in an effort to ward off triggers of affects related to the original abuse. Sex and love addiction is often hidden by other addictions and is not revealed until abstinence from the identified addiction is initiated. One recovering alcoholic commented: "I sec now that my alcoholism developed to support my sex and love addiction. n This is becoming clear in the area of cocaine addiction, where it has been observed clinically that cocaine is very often used to support sexual compulsivity. In this case, it is only when one abstains from the originally defined addiction that the manifestations of the sex and love addiction, which it has been supporting, appear. (This may also be true for codependency, where codependent patterns of behavior support sex and love addiction.) If left unrec-

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anisms are replaced with healthier and more appropriate ones, and a positive feeling toward oneself replaces defeatist, destructive attitudes. As treatment provides an opportunity to move through maturational levels and to develop at one's own pace, acknowledgment of the "child within" will emerge. The therapeutic relationship and the incest recovery support group provide the context within which this difficult work can take place (Courtois 1988): In the context of the supportive relationship and environment, the survivor reconnects with the abused child and reex periences the trauma and the feelings of childhood, in particular responsibility, guilt, confusion, ambivalence, shame, anger, sadness, and loss .... Since this work is often the most intensive of the therapy involving affective and autonomic arousal, the therapist must closely monitor the process and help the survivor "dose" and contain her reactions . She should be assisted in man aging both her denial and her intrusive symptoms to make them as tolerable as possible. The support of the therapist and of others, such as therapy group members, .. . assists the survivor to resurface and face cutoff memories and emotions.

The goal of treatment is to ameliorate the developmental deficits and arrest that have resulted from sexual abuse. Both the addiction recovery group and specific incest recovery work help the survivor to replace patterns of behavior motivated by fear, anxiety, and helplessness with new behaviors determined by his or her own needs, desires, and perceptions. Creative and healthful living becomes possible as the self, which was impaired and thereby dependent on addictive behaviors, is reconstructed and restored. Multiaddictions The fourth factor creating a high risk for relapse throughout abstinence and withdrawal is when addictions surface other than the identified addiction: individuals may relapse into an unidentified addiction. A recovering alcoholic successfully withdrawing from the effects of alcoholism, for example, may discover codependency issues (e.g., the compulsion to control people, places, and things). Or, after the effects of an eating disorder have been treated, a compulsive eater may discover a craving for other substances, such as alcohol. As with the primary addiction, these hidden addictions arise out of the self-impairment caused by the incest trauma. The awareness of the interconnectedness of addictions is cmcial to relapse prevention. Sex and Love Addiction There is one hidden addiction, often underlying other addictions, that the incest survivor is likely to display: sex and love addiction - the compulsive fusion with others or, as one sex and love addict put it, "involuntary enmeshment." Sex and love addiction may manifest in a compulsive engagement in sexual relationships, compulsive sexual fantasies and/or compulsive solitary sexual activity (Carnes 1983). On the other hand, the addiction may take the form JOUTNJI ofPsychoactive Drugs

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will be infinite unless we grab it, tum it around, and face it. We are victims while we endure it. We are survivors when we face it. And we can face it. In the process of recovery, we face the 'monster.' We examine it, we come to terms with it, and we dispose of it once and for all. We regain our self-possession and we are free, no longer victims, no longer survivors, just ourselves at last."

ognized and untreated, sex and love addiction remains a high -risk factor of relapse during recovery, and it is an area that must be addressed in relapse prevention.

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CONCLUSION As memories appear, as the feelings associated with the original trauma resurface, as feelings in general are experienced' and as the challenge is faced of living a lifestyle free of addictive behaviors that have both maintained and further destroyed the impaired self, relapse will be both a risk (diminishing over time as the self is strengthened) and a tool. Relapse may be a bridge between repressed childhood sexual abuse issues and disclosing and working through material necessary for a successful recovery. In this respect, a successful recovery is defined as the restoration and healing of the impaired self. Indeed, it is the restored self that is the ultimate prevention of relapse to addictive behaviors. As one anonymous (1989) individual stated: "In the end, we may lose our souls to alcohol, drugs, damaging relationships, or other destructive behavior, unless we get angry enough to say, 'Enough!' Sometimes we have to reach the bottom of the pit of despair to realize that our pain

NOTES 1. Among the defenses most commonly documented as responses to the trauma of sexual abuse are the following: (1) assuming responsibility for the abuse in order to protect the adult on whom the child is dependent as well as the child's feelings for the adult; (2) the numbing of affect in relation to the abuse as well as general affect; (3) turning the rage at the abuser toward the self instead; (4) preoccupation with the abuser in the repeated attempt to ward off further abuse; (5) compulsion to repeat the trauma as well as to avoid the return of the traumatic state; (6) dissociation during the experience ofabuse; (7) repressing the memory of the abuse; and (8) adaption through the assumption of various roles in relation to others based on fusion.

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