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AN EXPLORATORY STUDY OF RECOVERY AND RECOVERY MAINTENANCE FOR VICTIMS OF CHILDHOOD SEXUAL ABUSE WHO COMPLETED FAITH- BASED RESIDENTIAL TREATMENT PROGRAMS by Ann Marie Kerlin Liberty University A Dissertation Presented in Partial Fulfillment Of the Requirements for the Degree Doctor of Philosophy Liberty University April 2013 AN EXPLORATORY STUDY OF RECOVERY AND RECOVERY MAINTENANCE FOR VICTIMS OF CHILDHOOD SEXUAL ABUSE WHO COMPLETED FAITH- BASED RESIDENTIAL TREATMENT PROGRAMS A Dissertation Proposal Submitted to the Faculty of Liberty University in Partial Fulfillment of the Requirements for the degree of Doctor of Philosophy by Ann Marie Kerlin April 2013 Liberty University, Lynchburg, Virginia April 2013 Dissertation Committee Approval Lisa Sosin, Ph.D., Chair date John Thomas, Ph.D., Ph.D. Committee Member date Fred Milacci, D. Ed., Committee Member date ABSTRACT AN EXPLORATORY STUDY OF RECOVERY AND RECOVERY MAINTENANCE FOR VICTIMS OF CHILDHOOD SEXUAL ABUSE WHO COMPLETED FAITH- BASED RESIDENTIAL TREATMENT PROGRAMS Ann Marie Kerlin Center for Counseling and Family Studies Liberty University, Lynchburg, Virginia Doctor of Philosophy in Counseling This interpretive phenomenological analysis of the experience of recovery and recovery maintenance for women with a history of childhood sexual abuse and its sequelae included interviews and a non-standard questionnaire. Ten women with this history who had completed a faith based treatment program for substance abuse and/or eating disorders described recovery. Themes that emerged related to the process of change included: Changes in Relationships with Others, to Self, to God, and lastly, Forgiveness as a Catalyst for Change. Six practices emerged in the exploration of maintenance recovery. This research highlighted the need for thorough bio-psycho-social-spiritual assessment and areas of concern for treatment, and illuminated an alternative path to recovery that involved a spiritually integrated treatment approach. DEDICATION This project is dedicated to my family: my husband, Gerald, and children Amanda and Austin, son-in-law Marius, and grandchildren Will and Anna Florence. For all the hours I spent with my face glued to a computer screen, please forgive me! This project is also dedicated to the memory of my mother, Florence Lydia Knisely Glass, who lost her long battle with cancer on October 24, iii ACKNOWLEDGEMENTS I would like to thank and acknowledge my long-suffering and patient family who has been with me on this long academic journey for the last decade. Their love, care, and assistance made this attempt possible. I would also like to thank my faculty chair, Dr. Sosin, and committee members, Dr. Milacci and Dr. Thomas, for their assistance and guidance during this project. The entire faculty and staff at Liberty University s Center for Counseling and Family Studies have been most helpful. I am also indebted to the faculty and staff at Luther Rice Seminary and University, who introduced me to biblical studies and counseling, and gave me my first teaching opportunity. I am also grateful to my church and community, who have allowed me to participate in many ventures and gave me support in a variety of ways. iv TABLE OF CONTENTS Page Abstract... ii Dedication....iii Acknowledgements... iv List of Tables... xi List of Figures...xii CHAPTER ONE: INTRODUCTION... 1 Background to the Problem... 1 Purpose of the Study... 3 Research Questions... 4 Assumptions and Definitions... 5 Theoretical/Conceptual Framework... 6 Locating Myself as a Researcher... 6 Organization of Remaining Chapters... 9 Summary CHAPTER TWO: REVIEW OF THE LITERATURE Introduction Sequelae Correlated with Childhood Sexual Abuse Depression Anxiety v Spiritual Problems Substance Abuse Other Issues Associated with Childhood Sexual Abuse Theoretical Constructs Correlated with Childhood Sexual Abuse Childhood Sexual Abuse and Trauma Childhood Sexual Abuse and Attachment Theory Attachment Theory Adult Attachment Relationships Attachment to God Childhood Sexual Abuse and Substance Abuse Treatment Recommendations Qualitative Research Addressing Recovery from Sequelae of CSA Summary CHAPTER THREE: METHODS Introduction Phenomenological Research Interpretive Phenomenological Research Defining the Case The Research Questions Data Collection The Sample Interviews vi Documents and Observations The Process of Analysis Assumptions and Limitations Ethical Issues Validity Summary CHAPTER FOUR: RESULTS Overview The Treatment Programs Research Participants as a Group Introductions to Individual Participants Elizabeth Erica Tina Hope Heather Leigh Grace Bella Wanda Ally The Research Questions vii Research Question One Re-Education Bonding Most Helpful Program Elements Least Favorite Program Elements Graduation Research Question Two Changes in Relationships with Others Changes in Relationship to Self Changes in Relationship to God Forgiveness as a Catalyst for Change Research Question Three Self-imposed Barriers Spiritual Practices Participation in Recovery Groups Continuing Mental Health Care Sharing the Story Connections Instead of Isolation Summary Final Summary CHAPTER FIVE: DISCUSSION Overview viii Significance of the Research Findings Symptoms and Conditions of Interest Biological Symptoms Psychological Symptoms Social Symptoms Spiritual Symptoms Differences Between Participants and the Literature Comparison of Programs to the Literature Program Structure and Design Program Elements Comparison with Evidence Based Practices Symptom Improvements Summary Implications for Treatment Treating Co-occurring Disorders Intrapersonal Focus Interpersonal Focus Summary Recovery Maintenance Practices Summary Spiritual Integration Forgiveness ix Summary of Implications for Treatment Summary Suggestions for Further Research More Quantitative and Qualitative Research on this Population Program Evaluation for Faith Based Residential Care Eating Disorders as CSA Sequelae Prospective Rather than Retrospective Research Summary Strengths of Present Research Limitations of the Research Locating the Research in Reference to the Findings Summary Final Summary REFERENCES Appendixes Appendix A: Abstract Appendix B: Consent Form Appendix C: Questionnaire Appendix D: Semi-Structured Interview Protocol x List of Tables Table 4.1: Comparison of Residential Treatment Programs Table 4.2: Comparison of Participants and Symptoms Reported at Program Entry Table 4.3: Frequencies of Themes Mentioned by Participants Table 4.4: Changes Reported by Participants Table 4.5: Three Most Important Changes as Identified by Participants Table 4.6: The Role of Forgiveness in Recovery Table 4.7: Summary of Changes Reported by Participants Table 4.8: Recovery Maintenance Practices Table 4.9: Summary of Research Questions and Resultant Themes Table 5.1: Similarities of Symptoms between the Sample And The Literature Table 5.2: Differences between Symptoms and the Literature Table 5.3: Composite Program Structure and Design Table 5.4: Evidence Based Practice Approaches Table 5.5: Summary of Implications for Diagnosis Table 5.6: Summary of Implications for Treatment Planning xi List of Figures Figure 4.1: Emotional States and Behaviors Connected to Negative Self-esteem Figure 5.1: Composite Model of Faith Based Treatment Programs Figure 5.2: Recovery Maintenance Practices xii CHAPTER ONE: INTRODUCTION Childhood sexual abuse (CSA) is a very negative event, and may leave emotional, physical, or spiritual scars that can last a lifetime. It occurs in both female and male children, and unfortunately occurs much too often. In the United States, prevalence rates are estimated to be as high as 36% (Draucker & Martsolf, 2006). About twenty years ago, some groundbreaking research began with this population (Finkelhor, 1991). Both professional counselors and pastoral counselors have become more aware of the nature of the problem and its frequent occurrence. Treatment models that are effective are still needed (Taylor & Harvey, 2010). CSA is a very individualized experience, and adults who seek treatment have spent at least a few years coping with these memories in their own unique way (Draucker & Martsolf, 2006). This chapter describes issues related to CSA. It begins with the background of the problem, the purpose of the study, the research questions, the assumptions and definitions used by the researcher, and the theoretical and conceptual framework of the research. It concludes with the section describing the interest and location of the researcher. Background of the Problem One of the most devastating experiences a person can endure is to be sexually violated in childhood. When a child endures repeated episodes of abuse, the term complex trauma is used as a descriptor (Briere & Spinazzola, 2005). This experience can lead to a range of difficulties because it may affect so many aspects of the person. Research on childhood sexual abuse (CSA) has shown a negative impact on attachment 1 style (Cook, Hoffman, Powell, & Marvin, 2005; Fonagy & Bateman, 2007), affect regulation (Walker, Holman, & Busby, 2009), overall mental health (Chunis, 2009; Fergusson, Boden & Horwood, 2008; Lundqvist, Hansson, & Svedin, 2004; Sachs- Ericsson, Medley, Kendall-Tackett, & Taylor, 2011; Zink, Klesges, Stevens, & Decker, 2009), the biological system (Sachs-Ericsson, Blazer, Plant, & Arnow, 2005; Wilson, 2010), neurological and neurocognitive processes (Minzenberg, Poole, & Vinogradov, 2008; Pierrehumbert et al., 2009; Shenk, Noll, Putnam, & Trickett, 2010), dissociative propensity (Briere & Runtz, 1989; Thomas, 2005; Murthi, Servaty-Seib, & Elliott, 2010) and self-concept (Cook et al., 2005). CSA has been linked to early sexual contact and prostitution (Wilson & Widom, 2008), sexual dysfunctions (Blake, 2007; Cobia, Sobansky, & Ingram, 2004; Rellini & Meston, 2011; Testa, VanZile-Tamsen, & Livingtons, 2005), relationship dysfunctions (Rumstein-McKean & Hunsley, 2001; Walker, Sheffield, Larson, & Holman, 2011); and revictimization (Barnes, Noll, Putnam, & Trickett, 2009; Ericksen, 2010). CSA has also been correlated with spiritual disruptions (Gall, Basque, Damasceno-Scott, & Vardy, 2007; Houg, 2008; Ryssel, 2010). A history of CSA has been correlated with substance use disorders, particularly alcohol (Boles, Joshi, Grella, & Wellisch, 2005; Briere & Scott, 2006; Draucker & Marsoff, 2006; Khoury, Tang, Bradley, Cubells, & Ressler, 2010; Sartor, Agrawal, McCutcheon, Duncan, & Lynskey, 2008; Seifert, Polusny, Murdoch, & Maureen, 2011). Gilbert et al. (2009) conducted a meta-review of the literature in high income countries, and connected all forms of child maltreatment to negative consequences in adulthood, including suicide attempts based upon retrospective and prospective studies. 2 Unfortunately, CSA is very common. The Fourth National Incidence Study of Child Abuse and Neglect is based on data reported by 50 states (Sedlak, Mettenburg, Basena, Petta, McPherson, Greene, & Li, 2010). According to this report, 135,300 children were sexually abused in the years These statistics do not reflect the unreported cases which may never make it into the light of the judicial system; this report suggested that about one third of all cases are actually reported. Other estimates regarding the rates of sexual abuse are based on sampling and extrapolated to the general population, and range from 3% to 36% (Draucker & Martsolf, 2006). Outcome research on treatments for this population is in its infancy. Martsolf and Draucker (2005) conducted a meta-analysis of research studies in the literature that included participants with a history of CSA, as did Taylor and Harvey in However, there was no research study on residential, faith-based treatment programs included in either meta-analysis. These analyses did not mention alcohol or substance use as a comorbid disorder. Each research study targeted only one mental health issue. Purpose of the Study The purpose of this study was to add to the exploration of the nature of recovery from the sequelae related to a history of CSA, including substance abuse/use. The quantitative studies mentioned in the previous section did not address treatment programs that integrated spirituality with professional counseling. There are no studies that explore the phenomenon of recovery from the sequelae of CSA that include conservative Christianity. And as an auxiliary purpose, there is also a need for phenomenological exploration of recovery from substance abuse and mental health issues. According to the 3 Institute of Research, Education and Training in Addictions (IRETA, 2009) there is a need to explore the elements of sustained recovery, through phenomenological research that explores the changes themselves and the mechanisms of change. This is directly related to the substance abuse issue. The goal of defining and measuring recovery and resiliency was also adopted by the Substance Abuse and Mental Health Services Administration (SAMHSA) for SAMHSA is also advocating for exploration of paths to recovery in both mental health issues and substance abuse. Specifically mentioned are those that combine religion and spirituality, professional treatment models, and those with a variety of alternative approaches. Research Questions Because recovery is an anomalous term, the intention of this study was to explore the experience of recovery. This will be done by interviewing women with a history of CSA who have completed a residential treatment center designed for women and having them complete a non-standard questionnaire. The research questions were: 1. What is the experience of recovery from the sequelae of CSA, including alcohol or substance abuse, in a faith based residential treatment center? 2. What changes do participants recognize as part of healing or recovery? 3. How are graduates of this program functioning post treatment? 4 Assumptions and Definitions An assumption made by the researcher is that her understanding of conservative evangelical Christianity will parallel that of the participants when they speak about how their spirituality or faith affects recovery. A definition of this and other key terms follows. Religion and spirituality and/or faith. Religion has been defined in recent years as a search for the sacred within institutions, while spirituality is more of an independent venture and based on experiences rather than dogma. Many people understand these two definitions as overlapping (Worthington & Sandage, 2001). In this study, both will refer to Christianity, as rooted in a conservative, biblical, Protestant tradition. Faith will refer to belief in a Trinitarian view of God. Child abuse. The Federal Child Abuse Prevention and Treatment Act (CAPTA), (42 U.S.C.A. 5106g), as amended by the Keeping Children and Families Safe Act of 2003, defines child abuse and neglect as: Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or An act or failure to act which presents an imminent risk of serious harm (p. 44). Sexual abuse of children. This is defined as: The employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct; or the rape, and in cases of caretaker or inter-familial relationships, statutory rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children (CAPTA, 2003, p. 44). 5 Complex trauma. This is defined as: Complex psychological trauma as resulting from exposure to severe stressors that are (1) repetitive or prolonged (2) involve harm or abandonment by caregivers or other ostensibly responsible adults and (3) occur at developmentally vulnerable times in the victim s life, such as early childhood or adolescence (when critical periods of brain development are rapidly occurring or being consolidated. (Ford & Courtois, 2009, p. 13) Theoretical/Conceptual Framework This research was an interpretive phenomenological analysis. By exploring the process of recovery and recovery maintenance through the recollections of participants, the researcher hoped to learn more about changes these women experienced and possibly some information on how they occurred. The possibility of the reduction of trauma symptoms, depression, anxiety, and any possible improvements in attachment styles, whether with God or with other adults have important implications for treatment. Recovery from substance abuse and how these women explained their continued abstinence is also of value for treatment planning. Recovery maintenance includes not only abstinence from alcohol or substance use, but overall healthy living which may or may not differ from the participants self-described patterns before entering treatment. Locating Myself as a Researcher I set out to find myself, but got lost! Since I constantly get lost in a more grounded sense, I am not too terribly surprised when I consider this in retrospect. I am an Excel oriented, financial calculator, accounting type of person at heart. Numbers are nice; they do not get arrested, commit suicide, hoard things, or get diseases, and they are pretty passive entities. And money is nice! Despite my love for things financial, I ended 6 up doing phenomenological research in an aspect of counseling and its integration with religion, as expressed in conservative Christianity. I am not sure I could explain clearly how I ended up in this position; even to myself! I was engaged in a career in which I was well-paid but not challenged. Life happened and I re-started down an academic path, uncertain of my direction. I enjoyed the pursuit of knowledge for its own sake; just as I enjoyed the pursuit of God. I seem to recall complaining a little bit during this diversion from an undergraduate degree in accounting to a master of divinity. But during my study in seminary, I got an inkling of the importance of hermeneutics. According to Fry (2009): Hermeneutics is the art and principles of interpretation. Proper interpretation of Scripture is vital, especially if you hold those words to be sacred. The way one interprets the Bible is based on more than just the definition of individual words; context is critical. Context refers to individual word placement, sentence structure, paragraphs, sections, chapters, books, and the other literature and/or records from the same time period (McQuilkin, 1992). You have to know a bit about who was doing the writing and what was happening when he was writing. I chose counseling as my area of concentration in seminary because it involved the application of theology, which seemed very practical. Context in literature parallels context in life. People are situated in particular contexts. Family systems theory became my favorite counseling approach because it accounted for the circles of influence in a person s life (Bowen, 1992). Counseling is interpretation. It is a beautiful process in the abstract; helping people as they work at discovering how they are embedded in life, and 7 helping them unfold, uncover, and reveal where they are and where or how they want to be. I seemed to have a little trouble with the application of all this knowledge I was chasing, and became engulfed in reading existentialism, the integration of spirituality and health, philosophy of mind, trauma and posttraumatic stress disorder (PTSD), attachment theory, and developmental psychopathology. I also wanted some sort of anthropology of man that I could really agree with! When it was time to complete my doctorate in counseling, I was thinking about some sort of medical-psychological-spiritual experiment, but life intervened again. During internships, I was back with the real world and struck by the long lasting effects of childhood
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