CHRISTINE A. COURTOIS, Ph.D.*
This article provides an updated treatment model for adults who report having experienced incestuous abuse in childhood. It integrates psychodynamic, traumatic stress, developmental and feminist formulations, accords greater emphasis to object relations and self-psychology perspectives, includes more attention to dissociative reactions, and utilizes more cognitivebehavioral interventions. It is also responsive to issues raised in the recovered/false memory controversy. This holistic model is sequenced, paced, and titrated according to the patient's characterological structure, ego strength, and needs as well as the range and severity of presenting problems and life difficulties. Special consideration is given to issues pertaining to memory and the maintenance of a neutral stance by the therapist, especially in the case of recovered rather than continuous memories and/or suspicions rather than actual knowledge of abuse. Contemporary perspectives regarding some of the unique transference, countertransference, and vicarious traumatization issues with this population and their potential impact on treatment are also discussed.
Throughout the 1970s and 80s, research on incest/child sexual abuse documented an alarmingly high prevalence rate in North America. This research was given extensive media coverage with the result that child sexual abuse was publicly acknowledged as never before in human history. The research also documented the potentially dire personal, interpersonal, and societal consequences of abuse, prompting researchers to call for the development of prevention and intervention initiatives. In response, social service and child welfare professionals developed new models for intervening in contemporaneous sexual abuse and treating child victims and their families. Mental health professionals simultaneously developed models for the treatment of adults who reported a history of sexual abuse.
One of the first comprehensive models for the retrospective treatment of adults reporting a history of incestuous abuse was published in Healing the Incest Wound: Adult Survivors in Therapy.l Several other treatment models were also published from the mid-80s to the early 90s, making up a preliminary expert consensus or "first generation" of treatment for past incest/sexual abuse.2-11 In general, these models were posttraumatic in perspective and emphasized abuse as an important, although not exclusive, focus of treatment. This orientation was in marked contrast to the predominant therapeutic perspective of the day that dismissed or minimized reports of abuse as either unimportant or as wish or fantasy on the part of the victimized child.
Since that time, considerable refinement has occurred, spurred by increased clinical experience with the population, more sophisticated diagnostic formulations that include an increased recognition of characterological deformations and dissociative responses associated with chronic traumatization during childhood, and the integration of the early models with additional therapeutic orientations. The model has also been significantly shaped, influenced, and buffeted by a number of societal events and issues. Foremost among them: the widespread publicity accorded the new research findings on abuse and other forms of family dysfunction during the 1980s in the print media and in radio and TV reporting (and the "tabloidization" of abuse in some cases); the resultant influx of individuals who sought treatment for "adult child" and abuse related issues, some with trained therapists, others with uncredentialed treaters, and some in selfhelp programs; the noninclusion of abuse and trauma in professional training programs, a situation that put therapists in the difficult position of "learning by doing" when working with abuse issues; the resurgence of interest in psychological dissociation, Multiple Personality Disorder in particular, and the latter's association with sexual abuse and other major forms of childhood trauma; the acceptance and dissemination of the concept of traumatic memory, including the likelihood of amnesia and delayed/recovered memories of abuse and other trauma; the rise in allegations of ritual forms of abuse, especially among patients diagnosed with multiple personality; the legislative extension of statutes of limitations to allow for delayed discovery of damage from past abuse that opened the option of civil lawsuits; the development of a countermovement spearheaded by the False Memory Syndrome Foundation and academic memory researchers, some of whom were members of the Foundation's professional advisory board, that challenged the concept of recovered memories and charged that therapists were creating false memories of abuse through the use of suggestive techniques; and, last but not least, the rising influence of managed care. …