Abstract
A qualitative metasynthesis was conducted to identify the essence of healing from sexual violence, as described by adults who experienced it as children or as adults. Based on the findings of 51 reports, four domains of healing were identified: (a) managing memories, (b) relating to important others, (c) seeking safety, and (c) reevaluating self. The ways of healing within each domain reflected opposing responses. The dialectical process identified for each of the four domains include, respectively: (a) calling forth memories, (b) regulating relationships with others, (c) constructing an “as-safe-as-possible” lifeworld, and (d) restoring a sense of self. These complex processes resulted in a new reality for the participants that was based on a greater sense of agency and provided a more satisfying life course.
Keywords: Sexual violence, healing, qualitative metasynthesis
Because sexual violence is a crime that affects the health and well-being of many men, women, and children, researchers have attempted to identify how individuals heal from the experience. According to a national telephone survey conducted between 2001 and 2003 in the United States, 1 in 59 adults had experienced unwanted sexual activity in the prior 12 months, and 1 in 15 had experienced forced sex during their lifetime (Basile, Chen, Black, & Saltzman, 2007).
Sexual violence, including adult sexual assault and childhood sexual abuse, is associated with a myriad of acute and chronic sequelae. In the immediate aftermath of an assault, individuals report a variety of psychological responses, such as acute stress reactions, emotional detachment, and sleep disturbances (Centers for Disease Control and Prevention [CDC], 2007). Physical health consequences of sexual assault may include vaginal or rectal injury, sexually-transmitted infections, and pregnancy (CDC). Common long-term psychological and social effects of sexual violence include depression, chronic post-traumatic stress symptoms, interpersonal disturbances, and revictimization (Bonomi, Anderson, Rivara, & Thompson, 2007; Dube et al., 2005; Suris, Lind, Kashner, & Borman, 2007). In addition, sexual violence is associated with lingering negative health repercussions that include gastrointestinal distress, chronic pelvic pain, health risk behaviors, substance abuse, and high utilization of health care services (Campbell, Lichty, Sturza, & Raja, 2006; CDC; Stein et al., 2004).
The estimated average cost of medical care for women who experienced an intimate partner sexual assault is over $18 million annually, and the estimated average cost of mental health care for these women is over $100 million annually (Chrisler & Ferguson, 2006). In a sample of 3,333 women who were members of a large health care delivery system, the annual health care costs for women who experienced sexual and physical abuse as children were 36% higher than for women who had not experienced child abuse, and the costs for women who experienced sexual abuse only were 16% higher than for women who had not experienced child abuse (Bonomi et al., 2008).
Despite the deleterious effects of sexual violence, the responses of individuals who experience it vary widely, and most achieve some degree of healing, as evidenced by a decrease in symptoms (Koss & Figueredo, 2004) or indications of positive life changes after the violence (Frazier, Tashiro, Berman, Steger, & Long, 2004). Research on healing from sexual violence has been focused primarily on identifying factors associated with distress and/or positive change.
Because individuals who experience sexual violence typically feel a profound loss of control over their lives, cognitions that restore perceived control facilitate healing. Beliefs that future assaults are less likely (Frazier, 2003) and perceived control over one’s recovery process (Frazier; Frazier, Mortensen, & Steward, 2005; Frazier et al., 2004) enhance recovery. Because attributing experiences of sexual violence to one’s past behaviors does not instill a sense of future control, such attributions impede recovery (Frazier et al., 2005; Littleton & Breitkopf, 2006; Steel, Sanna, Hammond, Whipple, & Cross, 2004). Maladaptive beliefs about oneself (e.g., that one has no control over what happens to self) or others (e.g., others are no good) also interfere with the healing process (Koss & Figueredo, 2004).
The strategies that individuals use to cope with sexual violence also affect healing. Active approach-oriented coping strategies, for example, facilitate recovery. Such strategies include engaging with others, cognitive restructuring, and expressing emotions (Frazier et al., 2005; Frazier et al., 2004). Avoidance-oriented coping strategies, however, hinder recovery. Individuals who engage in social withdrawal or who repress or deny thoughts and feelings about the sexual violence experience greater distress (Frazier et al., 2005; Rosenthal, Hall, Palm, Batten, & Follette, 2005; Whiffen & MacIntosh, 2005).
Recovery is also facilitated by social support. Individuals who perceive others as being helpful following sexual violence experience more positive life changes and less psychological distress (Frazier et al., 2004; Steel et al., 2004). Negative social reactions to disclosures of sexual violence, such as disbelief or blame, however, have deleterious effects on recovery (Littleton & Breitkopf 2006).
The identification of cognitive, coping, and social support variables associated with negative or positive outcomes has contributed substantially to the understanding of healing from sexual violence and provides the foundation for the development of interventions. Psychotherapy approaches that address problematic cognitions, for example, have proved to be effective in the treatment of sexual violence (Koss & Figueredo, 2004). Yet, the focus on specific, measurable variables does not fully capture the dynamic and complex processes through which adults heal from sexual violence. Although such processes have been described in many qualitative studies, no attempt has been made to integrate the findings of these studies. This research, therefore, has been of limited use in advancing theory regarding healing from sexual violence. An integration of the findings of these studies could facilitate the development of therapies that both target factors that impede healing (e.g., self-blame) and also address the variations and nuances of healing from sexual violence as described by those who have experienced it. Such an integration could reveal essential elements of the healing process.
The purpose of this qualitative metasynthesis (Sandelowski & Barroso, 2007) was to identify the essences of healing as described by adults who experienced sexual violence as children or as adults. This metasynthesis was one component of a larger project entitled Women’s and Men’s Responses to Sexual Violence, the purpose of which was to develop a midrange theory explaining women’s and men’s responses to sexual violence. Whereas the aim of the larger project was to identify the processes by which individuals respond to sexual violence, this study was focused on describing the fundamental nature – or essence - of healing from sexual violence.
Method
Qualitative metasynthesis is a systematic procedure for integrating and interpreting the findings of qualitative reports on a similar topic. We conducted this metasynthesis study using the procedures Sandelowski and Barroso (2007) described. The research team included four nurse researchers and two doctoral students in nursing.
Searching for/Retrieving Relevant Reports of Studies
The reports eligible for inclusion were of qualitative studies (a) conducted with participants of any race, ethnicity, nationality, or class conducted in the United States or Canada, (b) published in refereed venues prior to January 1, 2009, and (c) focused on adults’ responses to sexual violence of any type experienced at any point in the lifespan. We used the definition of sexual violence proposed by the CDC (Saltzman, Fanslow, McMahon, & Shelley, 1999):
The use of physical force to compel a person to engage in a sexual act against his or her own will, whether or not the act is completed; an attempted or completed sex act involving a person who is unable to understand the nature or condition of the act, to decline participation, or to communicate unwillingness to engage in the sexual act (e.g., because of illness, disability, or the influence of alcohol or other drugs, or due to intimidation or pressure); and/or abusive sexual contact. (p. 12)
We defined qualitative studies as reports derived from “empirical research with human participants conducted in any research paradigm that used what are commonly viewed as qualitative techniques for sampling, data collection, data analysis, and interpretation” (Sandelowski & Barroso, 2003a, p. 154). Reports were excluded if (a) participants had not experienced sexual violence themselves (e.g., mothers of children who experienced childhood sexual violence), (b) participants were children at the time of the study, (c) qualitative findings could not be separated from quantitative findings in mixed-methods studies, and if (d) findings about sexual violence and other types of abuse or life challenges (e.g., non-sexual child abuse, domestic violence) participants experienced could not be distinguished from each other.
With the assistance of a reference librarian, the team searched four electronic data bases (CINAHL, PsychInfo, Medline, Sociological Abstracts) and used a variety of search strategies (e.g., footnote chasing, citation searching, author searching, subject searching) to produce the citation list. Two members of the research team reviewed the titles on the list, the abstracts, and the full articles to determine relevance. Eighty-two full-text articles were selected for further appraisal. The search results were saved in the reference management program RefWorks©. The tasks of the metasynthesis process, including a record of substantive decisions, were managed with the Excel© and MS Word© software programs.
Appraising the Reports
Each of the 82 articles was appraised by two research team members using the 14-item reading guide in Sandelowski and Barroso (2007). The reports were discussed in weekly team meetings to determine whether they met inclusion criteria and to acquaint team members with the content, method, form, and style of each report. A table was constructed to display information for each report on all 14 items. Several reports were rejected at this stage because a close reading revealed that they did not meet study criteria or did not contain any findings (e.g., case descriptions with no systematic interpretation of data). Reports were also eliminated if they offered no discussion of how data were used to derive the findings or no evidence that the findings were empirically-based (e.g., summary of data, participant quotes). After this process, 55 articles remained in the sample.
Classifying the Findings
In order to determine the appropriate techniques for integrating the findings, a classification system was used to identify the types of data transformation used in each study (Sandelowski & Barroso, 2007). Two team members read each report and identified the level of transformation of the findings. These classifications were reviewed, consensus was reached in cases of disagreement, and the final classification placed in a cross-case comparison table.
Extracting the Findings
The 55 reports in the final sample were divided among the team members who extracted the findings related to men and women’s responses to sexual violence from the reports. The findings were then edited into complete sentences to make them accessible to anyone who had not read the original reports. The first or second author validated each of the edited sentences with the original report and in some cases provided further editing to improve accessibility.
In team meetings, the 1,087 edited statements of findings from the 55 reports were grouped into 12 topical domains. One of these topical domains, called healing responses, was made up of statements about how individuals heal, recover, or in some way “get better” from an experience of sexual violence. Of the 55 total reports, 51 contributed to 514 edited statements on the topic of healing responses. These 51 reports (marked with an asterisk in the reference list) constituted the data set for the analysis that follows. Fifteen of the 51 reports had duplicate or overlapping samples as they were derived from common parent projects.
Profile of 51 Reports
The 51 reports that contributed to the findings featured here are characterized by a variety of disciplinary affiliations and methodological approaches. The disciplinary affiliations of the primary authors (excluding reports with common or overlapping samples) included nursing (n = 17), psychology (n = 12), social work/counseling (n = 4), sociology (n = 2), human development (n = 1), criminology (n = 1), education (n = 1), health sciences (n = 1), mental health (n = 1), and psychiatry (n = 1); 2 affiliations were not stated. In only 12 of the 51 reports was the stated purpose of the study to describe how individuals heal, adapt, or recover from sexual violence. In the remaining 39 reports, studies were focused on the “lived experience” of sexual violence or its aftermath, or on specific types of responses, such as disclosure or memory of the event. The stated methodology of the 51 reports were: phenomenology (n=15), grounded theory (n=13), qualitative descriptive or content analysis (n=12), narrative/discourse (n=3), and ethnography (n=2); in 6 reports, no methodology was specified. In 21 of the reports, authors identified a guiding theoretical framework, including social constructivisim (n = 5), trauma (n = 4), sociocultural or ecological (n = 4), feminism (n = 3), identity formation (n = 2), symbolic interactionism (n = 1), and cognitive/social learning (n = 2).
The sample sizes of the 51 reports ranged from 5 to 251, with a mean sample size of 28. The total sample across all reports (excluding participants from duplicate or overlapping samples) was 1,219. The number of women in the total sample was 1,093, and the number of men was 126. In 38 of the reports, authors identified the ethnicity or race of 1,016 of the participants as 893 White/Caucasian, 56 Black/African American, 26 Asian American, 17 Hispanic/Latino, 17 Native American or Canadian Aboriginal, and 7 multiracial or of another race.
Abstracting Findings and Calculating Effect Sizes
The 514 edited statements related to healing were further abstracted as redundant statements were eliminated and the remaining statements were refined. The statements were examined for commonalities, and 12 abstracted statements related to healing were constructed. Manifest frequency effects were calculated to assess the relative magnitude of abstracted findings by taking the number of reports that contributed to each abstract finding (minus those with common or overlapping samples) and dividing it by the reports that had contributed to healing findings (minus those with common or overlapping samples). The 11 statements with frequency effect sizes over .15 are shown in Table 1.
Table 1.
Abstracted Findings of Healing Statements
Finding | Reports1 | Effect Size2 |
---|---|---|
1. Adults who have experienced sexual violence describe responses aimed at healing, recovering, managing their lives, or moving beyond the effects of the violence they have experienced. | 43 | 1.00 |
2. Adults who have experienced sexual violence heal by regulating their relationships with others through tightening/relaxing boundaries, breaking off/reestablishing contact with families/perpetrators, disclosing/not disclosing the violence, and seeking forgiveness/obtaining justice. | 27 | .63 |
3. Adults who have experienced sexual violence heal by making sense of the violence by labeling it, understanding it, reframing it, and finding purpose; this is done by distancing from it/dwelling with it, remembering it/not remembering it, and abdicating blame/maintaining responsibility. | 25 | .58 |
4. Adults who experience sexual violence heal by establishing a sense of self that spares what is essential about their natures while recovering aspects of themselves that were damaged by the abuse through therapy, getting psychological treatment, receiving the support of others, or acquiring missing skills. | 19 | .44 |
5. The process of healing is never complete but life after healing has a different quality than life prior to healing as individuals describe feeling alive, having a voice, fitting in and being normal, being renewed and reawakened, feeling free, and being empowered. | 15 | .35 |
6. Adults who have experienced sexual violence heal by seeking peace and safety and creating a safe place for themselves in a world they know to be inherently dangerous. | 14 | .33 |
7. The process of healing from sexual violence is described as a long, challenging, tedious, and non-linear process that is fraught with many obstacles and takes much effort; this stage, in which survivors have an inherent sense how to navigate, has been referred to as journeying to free soil, constructing the residence, and regenerating the buried self. | 13 | .30 |
8. The process of healing from sexual violence often begins with a turning point that includes a poignant memory, a meaningful disclosure, a significant life change (marriage), or a motivating event (the birth of a child) that is often associated with intense emotions; this stage has been referred to as breaking free from the dungeon, and reappearing the buried self. | 11 | .26 |
9. The process of healing from sexual violence includes a period of preparation for a break with the past that includes getting tired of living with the effects of violence daily, attributing these effects to the violence, getting ready to face the violence by letting go of negative relationships and forming positive ones, and making a choice to heal; this stage has been referred to as preparing for the break, deciding to build, arriving at readiness, and resuscitating and renovating the buried self. | 9 | .21 |
10. The process of healing from sexual violence often culminates in actions to help others who were oppressed, abused, or victimized by warning others of danger, stopping perpetrators, appreciating the pain of others, making things better for others, and passing on lessons learned. | 8 | .19 |
11. The process of healing from the effects of violence has been described as escaping the dungeon, forging ahead in a dangerous world, constructing a personal residence, resurrecting the buried self, rebelling, finding refuge, being determined, and resurging. | 6 | .14 |
The number of reports that contributed to the finding, minus those with common or overlapping samples
The number of reports that contributed to the finding, minus those with common or overlapping samples, divided by the number of total reports that contributed to the healing findings, minus those with common or overlapping samples
Creating a Taxonomy
In order to display the full conceptual range of the findings related to healing, we conducted a taxonomic analysis whereby items that shared a semantic relationship to a category were grouped together. Moving between the edited statements, the abstracted statements, and the original reports, the team determined that the data could be categorized into four key domains of healing: managing memories, relating to important others, seeking safety, and reevaluating the self. We noted striking variations in the ways individuals responded to sexual violence within each domain. Each domain consisted of healing responses that seemed to be conflicting (e.g., escaping and being drawn to memories). We, therefore, divided each domain into two categories that reflected these conflicting healing responses. Items reflecting specific types of behaviors or strategies that constituted each type of response became subcategories in the taxonomy. The taxonomy consisting of the four domains of healing, the two types of healing responses within each domain, and the healing behaviors or strategies constituting each response are displayed in Table 2.
Table 2.
Taxonomy of Healing Responses from Sexual Violence
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Importing the Concept of the Dialectic
Our interpretation of the conflicting responses within the four domains provided the basis for apprehending the essence of healing. As shown in Table 2, managing memories involved both escaping and being drawn to memories. Relating to important others involved keeping others out of one’s life and seeking them out. Seeking safety involved constricting and reforming one’s surroundings. Reevaluating the self involved repairing damaged aspects of the self and protecting one’s identity. Analysis revealed that these healing responses were not necessarily sequential (e.g., first escaping from memories and then being drawn to them), mutually exclusive (e.g., keeping others out or in), or uni-directional (e.g., repairing aspects of oneself facilitating healing, protecting one’s identity hindering healing). Instead, people who experienced sexual violence engaged in opposing types of responses simultaneously, evaluated the same response differently at different times, and showed elements of a variety of responses.
We, therefore, imported into our metasynthesis the philosophical concept of the dialectic (Lavine, 1984; Stokes, 2003; Tarnas, 1991) to advance analysis. Dialectic is a Greek term reflecting an interpretive method in which contradictions between a thesis and antithesis are merged in such a way that elements of each opposing view are retained, thereby creating a synthesis (Stokes). Hegel viewed human reality as pervaded by contradictions that, rather than being logically exclusive, are elements of a larger truth. Opposites, thus, render higher states of being possible (Tarnas). Lavine argued that the three functions of dialectical synthesis are that it (a) cancels the conflict between the thesis and antithesis, (b) preserves elements of truth from both the thesis and antithesis, and (c) transcends the opposition to reveal a higher truth.
We used the concept of the dialectic to refer to the process by which people transcend two contradictory responses to a life experience and move into a third state that is fundamentally new, but retains elements of both responses. Like the philosophers who espouse the dialectic, we suggest that change occurs in response to the tensions that underlie the way people respond to the sexual violence they have endured. Engaging in the dialectical process moves them toward a more satisfying way of being. We propose, therefore, that it is the synthesis of the co-occurring tensions between the types of responses within each domain that best explains the essence of healing. In a few reports, the notion of synthesis is explicitly addressed (although not labeled as such); in most cases, the descriptions of the dialectical processes are based on our reciprocal translation of concepts we interpreted as addressing this synthesis. To understand how the dialectic was manifested within each domain, we constantly compared the in vivo concepts from the qualitative reports and explored how the synthesis of the seemingly opposing responses provided the foundations for healing.
The Essence of Healing From Sexual Violence
The four domains of healing, the opposing responses that comprise them, and the process that results from the synthesis of the opposing responses, are depicted in Figure 1. The arrows between the opposing responses (e.g., keeping others out/seeking out others) reflect the synthesis of these responses.
Figure 1.
Domains of healing, healing responses, and dialectics of healing from sexual violence
Managing Memories of the Sexual Violence
The sexual violence participants experienced created frightening memories that were associated with a myriad of disturbing emotions and reactions (e.g., rage, shame, anxiety, helplessness). To avoid this emotional distress, they found a variety of ways to escape these memories. They avoided thoughts or reminders of sexual violence, blocked out memories of the event with psychological mechanisms (e.g., repression, dissociation) or substances, and/or convinced themselves that the sexual violence was not important, victimizing, or harmful and, therefore, not worth remembering.
Yet, participants were also drawn to their memories of the sexual violence. They experienced flashbacks, nightmares, and intrusive thoughts over which they had no control. They felt compelled to seek out missing memories of the event because they were disturbed that their memories and their life histories were incomplete. They actively worked to fill in the gaps of their memories, even if they had to think about the sexual violence or talk with those who could provide missing information, including, in some cases, the perpetrator. They also dwelt on their experience of sexual violence because they were plagued by not understanding what had happened and why it had happened to them.
We labeled the synthesis of these responses calling forth memories. This is a dialectical process because individuals who experienced healing incorporated elements of escaping and being drawn to the memories, but also transcended these responses by gaining the ability to evoke or reject the memories at will. People accessed their memories of sexual violence in order to process them, but did not allow them to intrude on their day-to-day lives. Processing the memories included labeling the violence (i.e., calling it rape or abuse), contextualizing it (e.g., considering the roles of society/community/family in the sexual violence), explaining it (e.g., assigning culpability to the perpetrator or others), understanding how it contributed to their present distress (e.g., emotional concerns, troubled relationships), and attributing meaning to it (e.g., finding positive outcomes, embracing lessons learned). Fivush and Edwards (2004, p. 14) explicitly described this dialectic; they indicated that women who had experienced childhood sexual abuse expressed “a very complex and subtle process of simultaneous remembering and not remembering, forgetting and not forgetting.” Kondora (1993, p. 13) used the term “coming of what has been” when memories of childhood sexual abuse informed individuals’ present and opened up “new possibilities” for their future.
Relating to Important Others
Sexual violence for the studies’ participants involved a betrayal of basic trust. To protect themselves, individuals who experienced it often kept others out of their lives. They broke off contact with those who had hurt them or failed to protect them (e.g., perpetrators, non-protecting parent), steered clear of new relationships, and/or avoided intimate and sexual relationships. They kept others at a distance by keeping the violence a secret due to fear of negative or hurtful responses.
Yet, participants also sought out interactions with others as a way to deal with the hurt they experienced. They maintained or resumed contact with important others, even those who were responsible for the violence; formed new relationships, particularly with others who had also experienced violence; and sought out intimate or sexual relationships, often so they could feel loved. They discussed their violence with others to not feel alone, despite the risk of negative or hurtful responses.
We labeled the synthesis of these responses regulating relationships with others. This is a dialectical process because participants who experienced healing incorporated elements of keeping and seeking others out, but also transcended these responses by making deliberate choices about how they interacted with others. They established boundaries that allowed, but limited, the access others had to their time, affections, and bodies, and set limits on the behaviors of others that they construed to be intrusive, harmful, or exploitive. They disclosed the violence to others, but in a cautious, reasoned, and selective manner. Their experience of violence, therefore, caused them to be more mindful of their relationship needs, but did not determine their social network. For example, they engaged in intimate and sexual relationships, not in reaction to their victimization, but because they were ready to move on with their lives.
Seeking Safety
Because participants learned that the world was inherently dangerous, they strove to recreate a sense of security. We use the phenomenological term lifeworld to refer to the surroundings they sought to keep safe. A “lifeworld” is the world in which individuals carry out “their day-to-day practical affairs” (Guignon, 1993, p. 6). Participants constricted the sphere of their normal activities in order to stay safe. Initially, some would not leave their homes. When they did venture out, they became hyper-vigilant, continually looking for signs of danger. They avoided social situations that resembled the setting of the sexual violence (e.g., social gatherings in which there was alcohol) and exercised extreme caution in situations in which they felt vulnerable (e.g., being out at night). If the violence occurred within the context of a relationship, they developed a sensitivity for signs that the relationship might become dangerous or abusive. Sexual violence left those who had experienced it feeling wiser about the dangers lurking in their lifeworlds even as their lifeworlds became narrower. The precautions they took could impede their travels, hinder their activities, and limit their educational or occupational opportunities.
Yet, participants also became preoccupied with reforming their lifeworlds by making them safe for themselves or others. They engaged in new activities to create a safe lifeworld. They became focused on obtaining justice (e.g., reporting the violence, testifying at the perpetrator’s trial), seeking revenge against the perpetrator, warning others of the dangers of a shared lifeworld (e.g., a college campus, a family environment), and speaking out publicly about violence. When their attempts to create a safe lifeworld were not successful (e.g., the perpetrator was not convicted, others did not heed their warnings), they experienced frustration and disillusionment.
We labeled the synthesis of these responses constructing an “as-safe-as-possible” lifeworld. This is a dialectical process because participants who experienced healing incorporated elements of constricting and reforming their lifeworlds, but transcended these responses by learning to take reasonable precautions while confronting the inevitability of danger. This allowed them to achieve some sense of security as they went about their lives. The intense focus on making their lifeworlds safe dissipated over time, although they often continued to engage in everyday actions to contribute to the safety of their communities (e.g., supporting agencies that work to prevent violence). They accepted that their lifeworlds would never be completely safe, but did what they could to create a safe spot for themselves and a safer lifeworld for others. Phillips and Daniluk (2004, p. 181) referred to this process as assuming “a more present- and future-oriented worldview, rather than being focused on and constrained by … history.”
Reevaluating the Self
The experience of sexual violence almost inevitably affected the participants’ sense of self. For individuals who experienced it, feelings of low self-worth, a sense of vulnerability, decreased self-confidence, and feeling damaged were often rooted in a sense of being responsible for the violence or powerless to prevent it. After experiencing the sexual violence, they reevaluated how they viewed themselves and sought to repair aspects of themselves that they believed had been damaged. They attempted to rid themselves of the psychological or physical consequences of the violence by a variety of means (e.g., seeking treatment for psychiatric symptoms, entering substance abuse programs, making lifestyle changes). They also sought to acquire skills that were not developed because of the violence or its aftermath (e.g., social skills, work or educational competencies). Godbey and Hutchinson (1996, p. 308) referred to these strategies as “renovating the self.”
Yet, participants also rejected the notion that the sexual violence had damaged them and, therefore, resisted the need to change or receive help. The violence threatened the way they were accustomed to seeing themselves, and they were most concerned with protecting their established identities. They asserted that their core identity, soul, or “essential nature” (Draucker & Madsen, 1999, p. 330) had not been touched by violence. They viewed help-seeking as an indication that they were harmed by sexual violence and rejected any imposed identity such as victim or survivor. At times, they engaged in behaviors that countered their sense of victimization, such as risk taking and aggression toward others.
We labeled the synthesis of these responses restoring a sense of self. This is a dialectical process because participants who experienced healing incorporated elements of repairing damaged aspects of their selves and protecting their identity, but also transcended these responses by deciding they could fix what was wrong without losing who they were. They confronted the physical, psychological, and social consequences of the sexual violence and came to believe that these healing activities did not threaten their identity, but, in fact, made them stronger. A number of terms have been used to describe this process: “reincarnating the buried self” (Godbey & Hutchinson, 1996, p. 309), “reconstituting a sense of me” (Kondora, 1993, p. 14), “transforming self” (Wing & Oertle, 1999, p. 582), and “redefining self” (Smith & Kelly, 2001, p. 346). We chose the translation restoration because it implies the preservation of the essence of an entity by repairing damage done by the environment.
Example of a Dialectical Process
In a report of their study of eight women who had experienced date rape, Wood and Rennie (1994) provided a clear example of a dialectical synthesis, although it is not presented in these terms. Their findings demonstrate that these women used complex discourse strategies to formulate the rape experience and to “negotiate victim/non-victim identities for … themselves and villain/non-villain identities for the men who had raped them” (p. 125).
Wood and Rennie (1994) noted that when women are raped, society labels them as victims. Women, however, do not readily assume this identity; rather, they negotiate and construct their own identities. Formulating the rape and constructing an identity following a rape is problematic for women due to the dichotomy commonly used to define such experiences. Wood and Rennie argued that if a situation is defined as rape, a woman must assume the role of victim, the man is given the role of criminal, and the proper response for the woman is to go to the police, testify against the rapist, avoid the rapist, and possibly obtain therapy. In contrast, if the event is defined as a date, the woman forfeits the role of victim, the man retains the role of date or friend, and the proper response for the woman is to become more effective in handling or avoiding problematic situations. Yet, a woman may not desire the identities (e.g., victim/criminal) or outcomes (e.g., legal involvement) implied by the first definition, and may feel that the second definition is inadequate to reflect her experience. Rather than embracing either definition, the women in the study used discursive strategies to formulate the rape in their own ways. They tried out different constructions of the event; combined various formulations; negotiated their formulations in interactions with other people, including the rapist; acknowledged some control over aspects of the rape; and/or avoided naming the experience.
The discursive process Wood and Rennie (1994) described resonates with the functions of dialectic synthesis Lavine (1984) described. This process served to “cancel the conflict” (p. 211) between the definition of the event as a rape and the definition of the event as a date. They rejected the dichotomy imposed by society and preserved elements of both definitions when formulating their experiences. Wood and Rennie found that women did not claim either victim or non-victim status, but instead distinguished between being a victim and being victimized, attributed the rape to an unrepresentative action (e.g., they were a victim in one rare, anomalous occasion), constructed themselves as agents for some aspects of the event but not for others, or cast off the identity of victim as the rape became more distant. The findings of this study indicate that women “transcend the opposition and … raise the conflict to a higher truth” (Lavine, 1984, p. 211). As Wood and Rennie (p. 144) concluded:
Much of the previous work on women’s experience of rape has emphasized dichotomous attributions and identities. In contrast, the present study shows how women use discourse in complex ways to claim and reject various identities for themselves and others and to construct multiple versions of control, blame, and responsibility.
Discussion
Our qualitative metasynthesis of findings from 51 qualitative studies of how men and women heal from sexual violence reveals the existence of seemingly conflicting responses within four interrelated healing domains (managing memories, interacting with others, seeking safety, and reevaluating the self). The three functions of synthesis, as outlined by Lavine (1984), resonated with the experiences of these participants as described by the authors of these reports. By using the imported concept of the dialectic, based primarily on Hegel’s explication of the phenomenon, we found that the synthesis of apparently conflicting responses of the participants who had experienced sexual violence constituted their efforts to create a new reality for themselves. These new realities provided more options for healing, were based on a sense of agency, and proved to be more satisfying.
Responses identified in this study were similar to the correlates of recovery addressed in reports of quantitative studies of the aftermath of sexual violence. The effort to keep others out, for example, is similar to the avoidance-coping strategy of social withdrawal (Frazier et al., 2005), whereas the effort to seek others out is similar to the approach-coping strategy of engaging with others (Frazier et al., 2004). Similarly, escaping memories and constricting one’s lifeworld share aspects of avoidance-coping (Frazier et al., 2005; Rosenthal et al., 2005; Whiffen & MacIntosh, 2001), and reforming one’s lifeworld resembles the action-oriented aspects of approach- coping (Frazier et al., 2005; Frazier et al., 2004). The experience of dwelling on the sexual violence to understand it, a phenomenon identified in our study, served to restore perceived control, much like attributions discussed in the existing literature (Frazier, 2003; Frazier et al., 2005; Frazier et al., 2004). Our study extends this body of literature by positing that healing factors are not dichotomous, nor are they primarily positive or negative. Rather, they reflect opposing responses that, when synthesized, constitute healing. Our findings challenge the paradigm that there are discrete positive coping strategies that promote healing and discrete negative coping strategies that exacerbate distress.
Our findings should be placed in the following contexts. First, the metasynthesis represents our constructions of the findings presented by the authors of the original reports and are thus three steps removed from the participants’ experiences. The work is therefore a “social product” (Sandelowski & Barroso, 2003b, p. 478) resulting from a unique encounter between our research team and the 51 texts from which our review was derived.
Second, 10 of the 51 reports reviewed were authored by the first author of this article. This inevitably influenced the findings. Yet, research syntheses are typically conducted by reviewers working in the targeted domain of review. Moreover, the first author was part of a team of reviewers who reached consensus on the analysis and interpretation of findings.
Third, we identified general dialectical processes shared by the participants but did not examine variations based on factors likely to be relevant, such as the pervasiveness and severity of the sexual violence, the relationship of the individual to the perpetrator, and demographic variables such as gender and race. We also found that participants’ responses to sexual violence evolved over time; indeed, several authors have outlined trajectories that included stages and critical junctures to healing (Draucker & Petrovic, 1996; Godbey & Hutchinson, 1996; Symes, 2000). Now that we have described the essence of healing, our next step is to create an in-depth description of the factors that influence the process of healing and the trajectories that depict how healing changes over time.
New treatment approaches based on the dialectic of healing, rather than on attempts to ameliorate specific responses to sexual violence (e.g., negative thinking), may yield new paradigms of treatment. Such approaches would acknowledge the complexity of healing from sexual violence.
Acknowledgments
This study is funded by the National Institute of Nursing Research [R01 NR08230-01A1]. Claire B. Draucker, Principal Investigator
We would like to acknowledge Dr. Barbara Schloman, Associate Dean, Library and Media Services, Kent State University, for her assistance with the literature search.
Contributor Information
Claire Burke Draucker, Kent State University.
Donna S Martsolf, Kent State University.
Ratchneewan Ross, Kent State University.
Christina Benson Cook, Kent State University.
Andrea Warner Stidham, University of Akron.
Prudencia Mweemba, University of Zambia.
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