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CBT for Survivors of Childhood Sexual Abuse
6 CEUs It Wasn't Your Fault- Diagnosis & Treatment of Sexual Abuse in Children & Adults

Section 10
The Adult Survivor Therapeutic Rationale

Question 10 | Test | Table of Contents | Child Abuse CEU Courses
Social Worker CEU, Psychologist CE, Counselor CEU, & MFT CEU

In the adult survivor rationale, the "healing" or "recovery" process is conceptualized as an identity change, a transition from being a victim to being a survivor and then beyond. As previously noted, some adults molested as children began to call themselves "survivors" in the late 1970s, rejecting the label "victim" which they saw to have negative connotations. In the survivor rationale, however, not all victims are survivors. The term survivor has a more specific meaning. It connotes a present state of being and of under standing. To be an "adult survivor" is to be a victim but one who has come to understand her childhood experience as sexual abuse, who recognizes its effects on her life, and who is working to overcome the powerlessness of "being a victim" by making particular personal changes. The survivor rationale provides the interpretive framework of new understandings and accompanying emotion norms that define this identity change and its requirements.

The survivor rationale is underwritten by the trauma model, which is the basic framework in the treatment literature for ordering and explaining the long-term psychological harm correlated with childhood sexual abuse. This harm is organized into four general categories. Childhood sexual abuse, therapists argue, can undermine the victim's self-esteem, inhibit her from establishing clear personal boundaries, cause her to have a fragmented identity, and prevent her from developing appropriate social skills. Over time, such disabilities are incorporated into the victim's identity and shape how she interacts with others. They are expressed in and account for a wide range of symptoms-troublesome thoughts, emotions, behaviors, and relational dynamics-that therapists encounter when adults molested as children finally come for help. Therapists do not necessarily view every distress or disability observed in adult survivors as arising from an accommodation to childhood sexual contact. In her early formulation, Gelinas (1983), for instance, argued that victims also show the effects of "relational imbalances" that exist within incestuous families, and these effects are in part distinct from and even prior to the effects of the incest. Similarly, other writers have argued that some disturbances and assumptions deemed problematic (for example, about the role of women in the family) are not the result of sexual contact but of other factors, including the family system in which the victim was raised (e.g., Courtois 1988; Meiselman 1990). Following the trauma model, however, all agree that the long-term effects of childhood sexual contact are serious and manifold, and the principal textbooks include symptom lists that cover a wide range of problems. Given the pathogenic power of the sexual experience, therapists argue that it must be made the "central core" around which treatment is organized.

In the survivor rationale, child sexual abuse is an act of domination that deprives the victim of agency in broad areas of her personal life. The paradigm case is repeated sexual acts between a father and young daughter, but sexual abuse refers to sexual or sexualized activity of any kind between a minor (up to age eighteen) and anyone possessing greater power. Those with greater power include adults, but also include children who are older, physically stronger, or otherwise can dominate another child. Given a power differential, sexual or sexualized activity is by definition coercive and harmful. All experiences take their pathogenic implications from the father-daughter paradigm, but in the survivor rationale, the types and intensity of victim distresses or disabilities need have no correlation with the circumstances or intrusiveness of the sexual experiences. Even multiple personality, the limit case, could theoretically arise from a single incident. Discovering if any sexual abuse occurred, therefore, is essential. It is not the therapist's task, however, to judge whether childhood incidents constitute abuse or trauma if the client believes they do. As one therapist writes: "The adult survivor's perception of the experience as traumatic and a determination of the impact it has had on his or her life are of greatest interest to counselors in defining an abusive childhood sexual experience" (Draucker 1992: 3).

In the survivor rationale, however, victims' perception of their experience is neither necessarily given nor fixed. Experiences or key aspects of the trauma may not be remembered. According to the trauma model, victim efforts to cope with the trauma may mean that they are consciously unaware that it happened. "At more extreme levels of preservation," according to one textbook, "the sexual abuse remains dissociated from the everyday consciousness of the patient, thus constituting a secret even from the victim herself" (Davies and Frawley 1994: 86). If the experience itself is a secret, then the meaning must be as well. Even if aware of other aspects of the abuse, victims, through defenses of denial, repression, or dissociation, may partially or wholly block off their emotional responses. "Without the consensual validation she needs to honor and accept her real feelings, the survivor is forced to choose another route. She betrays her authentic self and becomes false." (Kirschner, Kirschner, and Rappaport 1993: 55). The victim, in other words, has given her experience meaning, but it is false, shaped by a "desperate attempt to maintain internal stability" rather than her true feelings. Further, on exposure to new meanings, adult survivors may decide that their previous perceptions were inaccurate. "It must be noted that a client's perception of the intrusiveness of any specific sexual activity is subjective. His perceptions may change as he redefines his childhood experience through his adult understanding." (Crowder 1993: io) In the survivor rationale, victim interpretations of and labels for experience can change; indeed they almost always need to change. Healing requires true meanings, the meanings that the rationale provides. Memory deficits and resistance to new meanings in the form of defenses or old coping strategies must be overcome. Buried feelings must be drawn out and expressed.

In the survivor rationale, the correct assignment of blame is pivotal. Because sexual abuse is always an act of domination, nothing the child victim did or did not do, before, during, or after sexual contact, has any bearing on the question of responsibility. While victims, therapists argue, often interpret their experience as involving some responsibility and experience guilt accordingly, self-blame in any manner is always wrong. It is an impediment to the understandings and accompanying emotions that are central to healing. The moral meanings that underlie self-blame must be reframed. People besides the abuser are not to blame either. To be sure, therapists note, other "non-protecting" adults, such as the mother, who deny the abuse may fail child victims. Their denial can take the form of not doing anything to stop the sexual activity once they know about it. In cases where the child attempts to disclose the abuse, it can take the form of refusing to discuss it or accusing her of making it up. To blame others for the abuse, however, even if they failed to help, would, according to the rationale, be to misdirect responsibility. They did not sexually abuse the child: the abuser did. Besides, therapists argue, people who could potentially protect child victims are frequently powerless, economically and emotionally bound to abusers, and often victims themselves. The abuser alone bears complete moral blame. Healing, in the survivor rationale, requires that this attribution not be watered down or deflected to the self or others.

In the survivor rationale, the matter of responsibility extends from the sexual contact itself to its effects on the victim. Given the efficient domination that abuse represents, victim defenses and coping are necessary for psychic survival. Without such internal operations, the victim's self would be overwhelmed. With them, she is able to achieve a measure, perhaps a large measure, of psychological balance and personal success. In this sense, the victim's responses are a personal strength, even if they might lead to various dysfunctions later in life. In the survivor rationale, abuse causes enduring psychological harm, but it does not cause survival. Survival is an accomplishment of the victim and signifies an internal strength that is the basis for further empowerment. At the same time, defenses and coping mechanisms arise in response to an imposed condition. Hence, the victim is not responsible for the long-term psychological problems that these defenses and mechanisms can eventually create. In the survivor rationale, healing requires recognition of both "survivor strength" and non-responsibility for the effects that abuse has wrought.

In indicating symptoms of disorder and the change that healing requires, the adult survivor therapeutic rationale also indicates a model of health. This model has two aspects. One aspect, implicit in the trauma model, is the mirroring of the collective story in the definition of individual health. Individual health, as with social health, means no denial or forgetting; it means disclosing rather than remaining silent; it means believing and affirming rather than doubting or blaming the victim; it means empowerment rather than dependency; and it means wholeness not fragmentation. A second aspect of the health model is a deeper level of implicit assumptions about the self, about society, and about the proper ordering of the relationship between the two. Such assumptions necessarily formed the foundation on which the new definitions of victim psychological harm were formulated, since disorder is, by definition, a deviation from a conceptually prior standard of health. In the trauma model, and therefore in the survivor rationale, the standard of health is drawn from a therapeutic ethic of personal liberation. In much of the clinical and research literature, the assumptions that inform this standard are so taken-for-granted that they go virtually unexpressed.
- Davis, J. E. (2005). Therapeutic Rationale and Therapeutic Persuasion. In Accounts of innocence sexual abuse, trauma, and the self (pp. 145-149). Chicago: University of Chicago Press.
The box directly below contains references for the above article.


Personal Reflection Exercise #3
The preceding section contained information about the adult survivor therapeutic rationale. Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Pulverman, C. S., & Meston, C. M. (2020). Sexual dysfunction in women with a history of childhood sexual abuse: The role of sexual shame. Psychological Trauma: Theory, Research, Practice, and Policy, 12(3), 291–299.

Shevlin, M., Murphy, S., Elklit, A., Murphy, J., & Hyland, P. (2018). Typologies of child sexual abuse: An analysis of multiple abuse acts among a large sample of Danish treatment-seeking survivors of childhood sexual abuse. Psychological Trauma: Theory, Research, Practice, and Policy, 10(3), 263–269.

Tener, D., Lusky, E., Tarshish, N., & Turjeman, S. (2018). Parental attitudes following disclosure of sibling sexual abuse: A child advocacy center intervention study. American Journal of Orthopsychiatry, 88(6), 661–669.

In the survivor rationale what is the basis for the statement that "the correct assignment of blame is pivotal?" Record the letter of the correct answer the Test.

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