Recent research has indicated that the rate of childhood sexual abuse appears to be substantially higher for persons in substance abuse treatment facilities than for those in the general population. In the general population, its incidence has been estimated to be about 7% for men and 38% for women (Covington, 1986); however, Finkelhor (1984) and Peters, Wyatt, and Finkelhor (1986) have estimated that up to 22% of men and 45% of women who were receiving substance abuse treatment had been victims of sexual assault. According to Russell (1988) men and women who report histories of childhood sexual abuse, sexual assault, and other forms of family violence are at a high risk for subsequent development of chemical dependency. In a review of the literature discussing male incest cases, Pearce (1987) stated that males constituted between 12% and 33% of the sexually abused children who are reported. Of these cases, between 6% and 50% were abused by parents or step-parents. Parents United, a self- help group for victims of incest and their families estimates that 25 % of all women and nearly the same percentage of men in the United States will be sexually molested before age eighteen. They further stated that more than 70% of these molestations are committed by a family member of close family friend, thus constituting an incestuous contact (Yearly, 1982). Recently researchers have begun to examine the adult consequences of having experienced an incestuous assault. Hyde and Kaufman (1984) referred to incest as a “psychological nightmare that continues into adulthood requiring some kind of behavioral and psychological adaptation” (p.148). When the effects of the sexual traumatization are not treated, psychological dysfunction may emerge, including amnesia, phobias, anxiety states, low self-esteem, and guilt (Hyde and Kaufman, 1984). Given the strong and lasting impact that sexual victimization has on adult emotional and social functioning, it is not unreasonable to expect victims to turn to alcohol or other drugs because of these negative effects (Rohsenow, Corbett, and Devine, 1988)
In recent years, researchers have suggested that clients with dual diagnoses for substance abuse and sexual abuse be simultaneously treated for both conditions in order to maximize the treatment effectiveness and decrease the potential for substance abuse relapse (Sullivan and Evans, 1994; Wadsworth, Spampneto and Halbrook, 1995.). Despite the current thinking regarding integrated treatment, however, service delivery frequently focuses solely upon the “primary problem” of chemical dependency. Prioritizing and dealing with one problem at a time may be seen as the most manageable and least overwhelming approach in terms of time management and available resources. However, Evans and Sullivan, 1995 argued that “not only does treatment need to address both issues simultaneously, it must weave the treatment together in order to address the intertwined reality of these two fused conditions” (p. 13). Further, they stated that “… a coordinated model also takes into account the need to blend elements of mental health and chemical dependence treatment approaches …” (Evans and Sullivan, 1995, p. 15). Several authors have suggested that a failure to receive treatment for sexual abuse issues may lead to the premature withdrawal from substance abuse treatment (Nielsen, 1984) and relapse (Barnard, 1989; Evans, and Schaefer, 1980; Rohsenow et al., 1988). Relapse rates appear higher among persons in substance abuse treatment who have experienced sexual abuse (Brown, 1991; Kasl, 1989; Rohsenow et al., 1988). Data reported (Glover et al., 1996) indicated that while 40% of the clients surveyed made their therapist aware of their past incest abuse; only 15% were receiving counseling specific to the sexual abuse. However, it may be necessary to resolve past sexual abuse issues in order to reduce the risk of relapse (Brown, 1991; Rohsenow et al., 1988; Rose, 1991) because as memories of past sexual abuse surface or persist untreated, relapse potential increases (Harrison, Hoffman, and Edwall, 1989). Miller (1994) reported that clients in treatment who had a history of sexual abuse used alcohol and drugs for the reduction of emotional pain and tension.
Substance abuse counselors are not typically trained in sexual abuse treatment; however, clients with sexual abuse issues routinely appear in substance abuse treatment. In a review of literature Daley (1989) reported that over 75% of clients treated for substance abuse will relapse within a fist year after treatment. Although many clients are helped, many others return to use of addictive substances. If a major contributing factor to addition, such as incest, is not addressed in current modes of treatment, relapse rates may be exacerbated (Rohsenow et al., 1988; Wadworth et al., 1995). Substance abuse, in fact, may be a survival response to a past history of incest and symptomatic of underlying personal dysfunction (Gelinas, 1983; Lindberg and Distad, 1985). Relapse should be viewed not only as a return to substance abuse, but as a possible indicator of the existence of underlying emotional issues that are a part of the etiology of addiction. For this reason, treatment professionals should become aware of the ways in which substance abuse and incest may overlap as treatment issues.
Because incest is prevalent among substance abuse treatment clients, treatment facilities should regularly screen all clients for incest histories as a part of their facility-intake procedure. Substance abuse treatment staff should become prepare to deal with problem of incest that is and will continue to show up on their case loads. Substance abuse counselors should be undergoing cross-training in substance abuse and sexual abuse issues. If the facility staff is unqualified to deal with incest as a counseling issue, they should establish formal referral relationships with incest treatment professionals. McFarley, and Korbin (1983) insist that an important beginning step to address problems of incest in substance abuse counseling is the institutionalization of routine screening for past sexual victimization that in non-threatening, nonjudgmental, and non-malicious. Many clients will be hesitant, however, to reveal past incest during intake screening. Consequently, facilitating self-disclosure during treatment, both through routine questioning and creation of an accepting atmosphere, is equally important. Utilization of therapeutic approaches such as art, play, and experiential therapy, that focuses on free expression in a non-threatening environment. At Vince Carter Sanctuary Substance Abuse Treatment Center non traditional therapy is used as a regular part of the treatment program. It allows clients to express their emotions and become in touch with their inner selves through different creative venues in safe and healing ways. Along well trained therapist and supportive staff clients can process their emotions and begin the journey of transformation from the victim to the survival of their traumas.
Anna Freud (1955) believed that negative and maladaptive behaviors were likely to result from traumatic events if the individual did not express the emotions associated with the traumatic occurrence. Treatment for adults included the expression of the repressed emotions in order to assist in release from those emotions. Likewise, Nichols and Efran (1985) believe that catharsis is a way of defining emotions that may otherwise block persons from effective functioning because negative emotions may build up internal tensions that block personal goals. By releasing the interfering emotions, the client is better able to work toward personal mastery. Play, art, and experiential therapy can provide a non-threatening atmosphere for such a catharsis to occur, specific play or art therapy techniques can provide a protective shield of sorts. At Vince Carter Sanctuary the process of play, art and experiential therapy is extended to adults who have experienced sexual abuse and others who present with emotional traumas, because it can provide some of the same cathartic benefits. It allow for free expression of feelings and events without the consequence of societal stigmatization. It provides the opportunity for adults to release the feelings of shame associated with the past traumas and/or abuse. Adults may also find experiential and art therapy as a vehicle for internal conflict resolution. Play and art therapy can be used to safely work through “emotional memories,” thus revealing anxieties and fears because play and art are a stabilizing experience, offering the comfort of a nonthreatening environment.
It is becoming increasingly clear that the substance abuse treatment needs of incest clients cannot be accommodated fully by applying universal treatment techniques used in standardized substance abuse treatment programs. Clients in treatment may use substances for a variety of reasons and purposes. It appears that a substantial number of clients in treatment for substance abuse also have a history of incest that may require specific, highly individualized treatment. Shame, self-blame, feelings of worthlessness, stigma, low self-esteem, and a lack of trust in others may stand as barriers to entering into therapy that is highly focused upon verbal interactions between clients and therapists. Furthermore, talk therapy may not be the most effective form of treatment because, due to dissociation, the client may not have previously verbally processed the experience and associated emotions. Moreover the traditional male role orientation of substance abuse treatment, is highly confrontational, and is focused exclusively on powerlessness over the chemical usage and the singular importance of abstinence (Wadsworth et al., 1995). “These approaches may encourage a client who has a history of sexual abuse to deny or be silent about the abuse” (Wadswarth et al., 1995, p.402). These memories of incest may exist primarily as visual and emotive memories similar to those of a child. By utilizing therapy that is focused on play or visualization though art and experiential therapy the adult client may process and work toward resolution.
In an atmosphere that allows one to draw upon childhood memories, haunting secrets and repressed feelings may at last surface so that the client may at last come to terms with the past and be empowered to make positive changes. Similar to childhood cognitive processing, traumatic events are frequently reexperienced in fragmented and multidimensional forms. A therapy that allows an individual access to all of those dimensions is more holistic and effective than merely treating the symptoms of substance abuse. At a Vince Carter Sanctuary focus on individualized approach to treatment and diversity of care allows clients to process their traumatic memories and painful emotions in as safe way with unique approach to each person entering Vince Carter Sanctuary’s care.
By Anna Temple, MS, RMHCI