Healing from Childhood Sexual Abuse: A Theoretical Model

Abstract

Childhood sexual abuse (CSA) is a prevalent social and healthcare problem. The processes by which individuals heal from CSA are not clearly understood. The purpose of this study was to develop a theoretical model to describe how adults heal from CSA. Community recruitment for an on-going, broader project on sexual violence throughout the lifespan, referred to as the Sexual Violence Study, yielded a subsample of 48 women and 47 men who had experienced CSA. During semi-structured, open-ended interviews, they were asked to describe their experiences with healing from CSA and other victimization throughout their lives. Constructivist grounded theory methods were used with these data to develop constructs and hypotheses about healing. For the Sexual Violence Study, frameworks were developed to describe the participants' life patterns, parenting experiences, disclosures about sexual violence, spirituality, and altruism. Several analytic techniques were used to synthesize the findings of these frameworks to develop an overarching theoretical model that describes healing from CSA. The model includes four stages of healing, five domains of functioning, and six enabling factors that facilitate movement from one stage to the next. The findings indicate that healing is a complex and dynamic trajectory. The model can be used to alert clinicians to a variety of processes and enabling factors that facilitate healing in several domains and to guide discussions on important issues related to healing from CSA.

Childhood sexual abuse (CSA) is a prevalent problem in the United States (Basile, Chen, Black, & Saltzman, 2007) that is associated with many long-term psychological, behavioral, social, and physical effects in women and men (Leserman, 2005). Much research has focused on how adults cope with the effects of CSA (Walsh, Fortier, & DiLillo, 2010). Yet, many individuals not only cope with these effects, but engage in dynamic healing processes that include growth as well as recovery (Calhoun, Cann, Tedeschi, & McMillan, 2000; Koss and Hoffman, 2000). Experts have called for a model of healing from CSA that reflects its overlap with other forms of childhood adversity and victimization later in life and that captures the evolving nature of healing throughout the lifespan (Saunders, 2003; Williams, 2003).

The purpose of this study was to construct such a model by synthesizing five qualitatively-derived frameworks related to healing from CSA. The frameworks were developed for a broader study on sexual violence and have been previously published by the authors (Draucker & Martsolf, 2008; Knapik, Martsolf & Draucker, 2008; Martsolf & Draucker, 2008; Roller, Martsolf, Draucker, & Ross, 2009; Stidham, 2009). In the following section we describe the incidence and prevalence of CSA, its long-term effects, coping factors that influence recovery, and healing processes.

Literature

Incidence and Prevalence

According to the National Child Abuse and Neglect Data System (NCAND), an estimated 777, 200 children were determined to be victims of abuse or neglect by a protective service agency in the United States in 2008, and 9.1 percent of these children (n = 69,184) were determined to have been sexually abused (U. S. Department of Health and Human Services, 2010). A national survey conducted between 2001 and 2003 documented that 1 in 15 adults in the United States had experienced forced sex during their lifetime (Basile et al., 2007). Of these respondents, 60.4% of the women and 69.2% of the men were 17 years of age or younger when the first incident of forced sex occurred. A study of 17,337 adult members of a health maintenance organization revealed that 16% of men and 25% of women experienced contact sexual abuse as children (Dube et al., 2005).

Long-term Effects

In women, sexual abuse is associated with poor health status, functional disability, high utilization of health services, and a variety of physical problems, including headache and gynecological and gastrointestinal symptoms (Leserman, 2005). In men, sexual abuse is also associated with a variety of physical problems, functional impairment, and poor subjective health (Leserman). In a national representative survey of 5877 adults in the United States, a history of CSA was associated with a number of mood, anxiety, and substance disorders in women, even when controlling for other childhood adversities (Molnar, Buka, & Kessler, 2001). For men, CSA was associated with post-traumatic stress disorder and a variety of substance disorders (Molnar, Buka, & Kessler, 2001). A history of CSA is also associated with marriage and family problems for both adult men and women (Dube et al., 2005).

Coping with Long-term Effects

The coping of adults who experienced CSA is often studied by identifying specific types of coping associated with negative or positive health outcomes. A theoretical and empirical review of literature on adult coping with CSA indicates that emotion-focused coping (i.e., regulating one's emotions rather than the stressor) and avoidant coping (i.e., denial of or disengaging from memories or feelings related to the stressor) used immediately following the event and over time are associated with psychological distress (Walsh et al., 2010). Approach coping (e.g., engaging in active strategies to address the stressor) is generally associated with positive outcomes (Brand & Alexander, 2003; Merrill, Thomsen, Sinclair, Gold, & Miher, 2001). Other coping strategies, such as garnering social support and finding meaning in the abuse, are often associated with positive outcomes (Walsh et al.). In Judeo-Christian populations, self-directed spiritual coping (i.e., self-initiative, no help from God), active surrender (i.e., handing control to God), and passive deferral (i.e., waiting for God to control situation) by survivors of CSA are associated with anxiety (Gall, 2006). Spiritual discontent (i.e., anger and dissatisfaction with God over the situation) is associated with greater levels of depressed mood, whereas active surrender and religious forgiveness (i.e., seeking God's help in letting go of negative emotions) are related to lower levels of depressed mood. The research on adult coping with CSA has been limited by inconsistencies in how coping is defined, reliance on cross-sectional designs, failure to account for the circumstances in which the coping strategies are employed, and failure to account for change across time (Walsh et al.)

Healing from CSA

Survivors of CSA do not only cope with the negative effects with CSA but engage in dynamic processes that include growth as well as recovery. Post–traumatic growth is defined as “the individual's experience of significant positive change arising from the struggle of a major life crisis” (Calhoun et al., 2000). Adults who experienced child abuse, for example, have identified positive change processes related to making sense of the abuse (Woodward & Joseph, 2003). Some survivors identify an inner drive toward growth and report positive changes in self-perception and new perspectives on life as a result of healing from their abuse. Such positive changes occur when they take control of the direction of their lives, experience acceptance from others, care for and nurture themselves, experience a sense of liberation and freedom, and gain a sense of accomplishment, achievement, belongingness, and connection.

The term “healing from CSA” rather than “coping with CSA” is often used as it encompasses positive growth beyond a return to pre-trauma functioning levels. The dynamic nature of healing from CSA has been captured by several qualitative studies that have described stages of healing. A framework of healing by female survivors of childhood sexual abuse, for example, was based on the metaphor “constructing a personal residence” to reflect healing as a laborious and constructive process (Draucker, 1992). A number of steps were involved in the process that was likened to building a house: determining to build rather than remodel, constructing the residence, regulating boundaries, and influencing one's community. A framework of healing by male survivors of sexual abuse was based on the metaphor “escaping the dungeon” to reflect how male survivors overcame experiences with powerlessness, isolation, and shame (Draucker & Petrovic, 1996). Healing was constituted by stages of breaking free from the dungeon, living free, and freeing those left behind. A framework entitled “resurrecting the buried self” was constructed to explain how women who survived incest healed from the experience (Godbey & Hutchinson, 1996). The stages of this model included reappearing of the buried self, revivifying the buried self, resuscitating the buried self, renovating the buried self, regenerating the buried self, reanimating the buried self, and reincarnating the buried self.

The Need for New Healing Models

Experts have suggested that new approaches are needed to study healing from CSA if research is to inform practice (Saunders, 2003; Williams, 2003). For example, much research on adult coping with CSA has not considered the overlap of CSA with other types of childhood adversity (Williams). Children who experience sexual abuse are often exposed to other forms of abuse (e.g., physical and emotional abuse), maltreatment (e.g., neglect), and family dysfunction (e.g., parental mental illness and substance abuse) (Saunders). Because many studies do not measure multiple forms of childhood adversity, the cumulative impact of childhood traumas and the interaction of different types of violence are poorly understood (Saunders). In addition, CSA is often associated with violence and maltreatment later in life (Banyard, Williams, & Siegel, 2001; Williams, 2003), but repeated victimization has rarely been linked in a life course perspective (Williams). Koss and Hoffman (2000) advocate a lifespan approach that examines the cumulative impact of violence at various life stages and considers responses involving resilience and strength as well as negative effects.

The Present Study

A model of healing from CSA that considers the context of the abuse, addresses the complexities and dynamic nature of healing, and places the CSA in a life course perspective is needed. In this study, such a model was constructed and was labeled the CSA Healing Model. The model was developed with an interactive analytic process that involved extraction and synthesis of concepts from five frameworks developed for a broader study on sexual violence “Women's and Men's Responses to Sexual Violence” (referred to as the Sexual Violence Study) and a re-examination of the narratives of participants from the Sexual Violence Study who had experienced CSA [eliminating those who had experienced adult sexual assault (ASA) only]. We refer to the products of the Sexual Violence Study as frameworks because they depict healing processes in a specific domain (e.g., parenting, spirituality) and the product presented here as a model because it is more overarching and depicts healing in several domains. Because the CSA Healing Model described in this article is based on analytic products and narratives from the broader Sexual Violence Study, a summary of this study is provided prior to a description of the procedures used to construct the CSA Healing Model.

The Sexual Violence Study

The specific aim of the broader Sexual Violence Study was to develop a theoretical framework to describe, explain, and predict women's and men's responses to sexual violence throughout their lives. The study was guided by qualitative constructivist grounded theory methods, which are used to develop constructs and hypotheses that offer new explanations and understandings of the responses of people experiencing a common life challenge (Charmaz, 2000). Grounded theory methods involve systematic and iterative processes of data collection, analysis, and interpretation (Glaser 1978; Schrieber, 2001; Schwandt, 2001).

Institutional Review Board approval for the Sexual Violence Study was obtained from Kent State University. Women and men over the age of 18 who had experienced sexual violence at any time in their lives were recruited. The sampling area was metropolitan Akron, OH, a midsize city located in in the Midwestern region of the United States. Adaptive sampling techniques developed by Campbell and colleagues (2001) for community sampling of rape survivors guided participant recruitment. The sampling area was divided by zip codes. U.S. Census data were used to select twelve zip codes to represent individuals of varying races and socioeconomic statuses. Research associates canvassed targeted zip codes for locales at which individuals were likely to gather, such as transportation stations, grocery stores, schools, coffee shops, nail and beauty salons, social service agencies, libraries, and churches. Fliers with a study description and a toll-free number to contact the researchers were placed at these sites. In addition, the research associates networked with residents, business proprietors, clergy, and social service workers, many of whom agreed to promote the study. For example, one pastor encouraged members of her congregation to participate in the study if they had experienced any sexual violence and provided the research team with space in the church to conduct the interviews.

Telephone assessments were conducted by Master's level mental health clinicians to screen out individuals at high risk for adverse emotional reactions, such as suicidality or acute stress reactions. No individuals were screened out for these reasons. Interviews were scheduled at private and secure locations in the participants' neighborhoods (e.g., library or church meeting rooms). The total sample for the Sexual Violence Study was 121 individuals (64 women and 57 men).

The interviews included semi-structured, open-ended questions. Participants were asked to describe any sexual violence they had experienced, the context of the violence, the ways in which it affected their lives, what facilitated or hindered their healing, and their health care experiences related to the violence. They were also asked to describe other experiences with abuse or violence and to construct a timeline that chronicled their lifetime experiences with violence. Participants received $35.00 to compensate for their time and travel expenses. The interviews were audiotaped and transcribed verbatim.

From the 121 transcribed narratives, five theoretical frameworks, each addressing healing in a specific domain, were constructed. Each framework was developed by several members of the research team, which included five nurse researchers and two nursing doctoral students. Consistent with a grounded theory approach, constant comparison analysis was used to construct each framework (Glaser, 1978). Relevant empirical indicators – participant statements related to each of the domains of interest (Schwandt, 2001) - were identified in the transcripts, uniformities were identified, and categories were developed. Theoretical formulations about the relationship between categories were proposed and examined for adequacy by re-examining the indicators and conducting theoretical sampling of additional relevant data (Schwandt). The credibility of each project was enhanced by an extensive audit trail, team analysis of data, peer debriefing with a community advisory board comprised of local clinicians and social service professionals, and consultation with Dr. Phyllis Stern, an expert in grounded theory.

The five frameworks are described in Table 1. Some are applicable to all survivors of sexual violence (both CSA and ASA) and some are applicable only to survivors of CSA. Each framework addresses one or more domains of functioning that the data revealed were of particular concern to participants. Living the Family Legacy (Martsolf & Draucker, 2008) describes how survivors of sexual violence parent their children. Determining My Sexuality (Roller, Martsolf, Draucker, & Ross, 2009) depicts four stages of sexual healing by survivors of CSA. Storying the Violence (Draucker & Martsolf, 2008) depicts processes by which survivors of sexual violence disclose their victimization to others. Being Delivered (Knapik, Martsolf, & Draucker, 2008) depicts stages through which survivors of sexual violence use spirituality to heal. Helping Others (Stidham, 2000) is a typology that describes how survivors of sexual violence engage in altruism in response to their abuse.

Table 1. Theoretical Frameworks Developed For The Sexual Violence Study.

The Construction of the Frameworks	The Frameworks	Domains Or Stages From Framework Incorporated Into the CSA Healing Model
Living the Family Legacy(Martsolf & Draucker, 2008) The purpose of this theoretical framework is to describe the processes by which survivors of sexual violence respond to childhood adversity and parent their children. Data were drawn from interviews with 60 female and 46 male survivors of sexual violence who described significant adversity in their families of origin. Grounded theory methods were used and data were analyzed using the constant comparison method. Findings suggest parenting is best understood in the context of a lifetime process labeled “Living the Family Legacy.” This legacy begins when children inherit a violent way of living or a vulnerability to violence. The framework includes three life patterns and three parenting processes associated with the legacy.	Living the Family Legacy Life Patterns (influenced by those who challenge or affirm the legacy) Being Stuck in the Legacy (living with abuse and chaos) Being Plagued by the Legacy (being distressed by the effects of the abuse) Rejecting the Legacy (finding new ways to live without abuse and maltreatment) Parenting Processes Passing on the Legacy (passing abuse on to children) Taking a Stab at Leaving a New Legacy (making sincere, but ineffective, attempts to protect children from abuse) Leaving a New Legacy (protecting and nurturing children)	Life patterns (domain) Parenting (domain)
Determining my Sexuality(Roller, Martsolf, Draucker, & Ross, 2009) The purpose of this framework is to depict the process by which CSA influences the sexuality of women and men survivors. Data were drawn from interview transcripts of 95 men and women who experienced CSA. Using constant comparison analysis, the researchers determined that the central phenomenon of the data was a process labeled “Determining My Sexual Being.” The participants sought to understand what the abuse was (e.g., was it rape? Love?), why it happened (e.g., was it my fault?), and what it did to their sexuality (did it make me promiscuous?). To answer these questions, the participants engaged in four processes: Grappling, Figuring Out, Tackling, and Laying Claim To…	Determining my Sexual Being Grappling With The Meaning Of The CSA (trying to understand what the abuse was, why it happened, and how it affected one's sexuality) Figuring Out The Meaning Of The CSA (coming to understand what the abuse was, why it happened, and how it affected one's sexuality) Tackling The Sexual Effects Of CSA (taking steps to improve one's sexual life) Laying Claim to One's Sexuality (asserting one's right to one's own sexuality)	Grappling with the meaning of the CSA (stage) Figuring out the meaning of the CSA (stage) Tackling the effects of CSA (stage) Laying Claim to One's Life (stage)
Storying the Violence (Draucker & Martsolf, 2008) The purpose of this theoretical framework is to explain how survivors of childhood sexual abuse (CSA) tell others about their abuse experiences. Data were drawn from open-ended interviews conducted with 74 individuals who experienced ongoing CSA by a family member or close acquaintance. Grounded theory methods were used to develop the framework. The psychosocial problem shared by the participants is that CSA both demands and defies explanation. The core psychosocial process used in response to this problem is “Storying Childhood Sexual Abuse.”.	Storying the Violence Starting The Story: The Story-Not-Yet-Told (private storying of the abuse at the time it happens) Coming Out With The Story: The Story-First-Told (revealing the abuse for the first time either as a child or as an adult) Shielding The Story: The Story-As-Secret (keeping the abuse a secret due to a negative response to one's coming out with the story) Revising The Story: The Story-As-Account (telling the abuse to supportive others after a positive response to one's coming out with the story and incorporating the perspectives of others in the way one stories the abuse) Sharing The Story: The Story-As-Message (sharing one's story of abuse for the purpose of helping others)	Disclosure of CSA (domain)
Being Delivered (Knapik, Martsolf & Draucker, 2008) The purpose of this theoretical framework is to explain how survivors of sexual violence use spirituality to respond to, or recover from, sexual violence. Data were drawn from open-ended interviews of 27 women and 23 men who had experienced sexual violence. Grounded theory methodology was used to develop the core category of “Being Delivered,” reflecting the participants' experiences of being rescued, saved, or set free from the effects of sexual violence by a spiritual being or power. The theoretical framework describing “Being Delivered” is composed of three dimensions.	Being Delivered Spiritual Connection (connecting in a divine manner with God or a spiritual power) Spiritual Journey (an ongoing spiritual process with direction and purpose) Spiritual Transformation (experiencing a profound sense of divine intervention that is lasting and permanent).	Spirituality (domain)
Helping Others Typology (Stidham, 2009). The purpose of this framework was to describe the ways in which survivors of sexual violence engaged in altruism in response to their experiences with violence. Individuals engaged in helping others in a variety of ways.	Ways of Helping Others Protecting Children Participating In The Study Being Understanding Thinking About Helping Choosing A Helping Profession Providing Guidance Providing Advocacy Stopping Perpetrators Speaking Publicly	Altruism (domain)

Construction of the Theoretical Model of Healing from CSA

Our goal was then to develop an overarching model that describes how adults heal from CSA. The definition of CSA that guided this project was “any sexual activity with a child where consent is not or cannot be given …. [including] sexual contact that is accomplished by force or threat of force, regardless of the age of the participants, and all sexual contact between an adult and a child, regardless of whether there is deception or the child understands the sexual nature of the activity” (Berliner & Elliott, 2002, p. 55). The two data sources used to develop this model were concepts from the five frameworks (described above and in Table 1) applicable to CSA and the narratives of a subset of participants in the Sexual Violence Study who described experiences that met our definition of CSA.

Sample

Ninety-five of the 121 participants in the Sexual Violence Study had described CSA experiences. Because the other 26 individuals had experienced sexual violence as adults, but not as children, their narratives are not represented in the theoretical model presented below. From this point on, therefore, references to “the sample” or “the participants” indicate these 95 individuals.

Fifty-one percent (n = 48) of the sample were women. Of the women, 50% (n = 24) were African American and 40% (n =19) were Caucasian. The remaining participants were multi–racial or did not report race. Forty-nine percent (n = 47) of the participants were men. Of the men, 40% were Caucasian and 36% (n = 17) were African American. The few remaining participants were multi-racial, of another race (e.g., Hispanic or Asian), or did not report race. The participants ranged in age from 18 to 62. Fifty-six (n = 53) were single, 18% (n = 17) were married, and 17% (n = 16) were separated or divorced. The other participants did not report marital status. Sixty-eight percent (n = 65) were employed in a variety of occupations, including entertainment, teaching, nursing, sales, service, and construction. Nineteen percent (n = 18) of the participants were unemployed, 11% (n = 10) were students, and 2% (n = 2) were retired. About half (n = 49) reported an income under $10,000/year, 18 % (n = 17) reported incomes between $10,000 and $30,000/year, 13% (n = 12) reported incomes between $30,000 and $50,000/year, 12% (n = 11) reported incomes above $50,000/year, and 6 % (n = 6) did not report income. Approximately eighty-one percent (n = 77) reported a religious affiliation that would be considered in the Judeo-Christian tradition. These participants reported belonging to a wide variety of faith-based denominations (e.g., Baptist, Roman Catholic, Jewish). The remaining participants indicated that they were atheist, had no religious affiliation, or were spiritual, but not religious.

While a few of the participants reported discrete, single-episode incidents of extra-familial sexual abuse, most experienced on-going sexual abuse by a family member, a close family acquaintance, or a care provider. In many cases, the participants were abused by several different perpetrators throughout childhood and adolescence. The sexual abuse most often occurred in the context of other types of childhood adversity, including parental substance abuse, mental illness, and incarceration; physical and emotional abuse and neglect; and family instability (e.g., parental abandonment, foster placement, homelessness, and frequent relocation). Many of the participants experienced on-going victimization in adulthood, including adult sexual assault (ASA) and domestic violence, as well a variety of physical and emotional illnesses and disturbed interpersonal and sexual relationships. Some participants would be considered marginalized; several lived in poverty, had been diagnosed with a severe and persistent mental illness, had engaged in criminal activities, were recently incarcerated, and had serious physical health problems (e.g., HIV/AIDS). The model, therefore, represents healing of individuals who experienced CSA as well as considerable adversity throughout the lifespan.

Analysis

Several analytic techniques were used to construct the CSA Healing Model. The first two authors re-examined the five frameworks and constructed relational statements of theoretical connections among constructs pertinent to healing from CSA. For example, several of the five frameworks contain descriptions of phases of healing in one of the domains. The Storying the Violence framework, for example, describes the process of disclosure over time (see Table 1) (Draucker & Martsolf, 2008). An early phase in the process, referred to as shielding the story, included keeping experiences of violence secret due to a negative reaction by another to an earlier disclosure. The Living the Family Legacy framework (see Table 1) (Martsolf & Draucker, 2008) describes phases of parenting. An early phase in the process, referred to as passing on the legacy, included abuse of one's children. The team noted that parents had abused or failed to prevent the abuse, of a child because they not discussed their own abuse with anyone, and therefore, they continued to believe that abuse was normal. Shielding the story and passing on the legacy were therefore theoretically connected. Such connections provided the foundation for the description of the first phase of healing in the CSA Healing Model.

The first two authors simultaneously re-read the 95 transcripts of the CSA survivors to identify empirical indicators related to healing from CSA that could be used to confirm, reject, or modify our relational statements. For example, we found statements in the transcripts in which participants acknowledged that they considered abuse normal and, therefore, never considered that their abusive treatment of their children was wrong. The model thus was the result of an iterative process of moving between the constructs of the frameworks and participant data. The first two authors often obtained input about the relational statements that formed the basis of the theoretical model from the research team (the six authors of this article) that meet weekly throughout the study. The team would often “return” to the data (the transcripts) to confirm or modify emerging connections.

Through this process, and in consultation with the research team, the first two authors determined that the stages outlined in the framework Determining My Sexuality (Roller et al., 2009) were applicable to all domains of healing, not just sexual healing. The team determined that these stages would thus provide the cornerstone of the model. The names of the stages were modified to reflect the broader focus. The stages - grappling with the meaning of CSA, figuring out the meaning of CSA, tacking the effects of CSA, and laying claim to one's life - are depicted horizontally across the top of the model (Table 2).

Table 2. The CSA Healing Model.

STAGES1
	Grappling With The Meaning Of the CSA	Figuring Out The Meaning Of The CSA	Tackling The Effects Of The CSA	Laying Claim To One's Life
	ENABLING FACTORS2
	Affirming messages	On-going support	Critical life event
	Personal agency	Personal resolves	Commitment to transcend the CSA
DOMAINS3
Life patterns	Living a troubled life	Living a troubled life, with some positive experiences	Living a life of troubles and successes	Living an empowered life
Parenting	Passing on the abuse	Wishing to stop the abuse cycle	Attempting to stop the abuse cycle	Stopping the abuse cycle
Disclosure of CSA	Keeping the CSA a secret; Disclosing the CSA indirectly; Disclosing the CSA indiscriminately	Discussing the CSA to make sense of it	Discussing the CSA to strengthen a new understanding; Discussing the abuse to pass on wisdom	Disclosing the abuse to help others
Spirituality	Having no meaningful or comforting spiritual connection	Having some spiritual connections	Experiencing a spiritual journey	Experiencing a spiritual transformation
Altruism	Being aware of the suffering of others	Thinking about helping others	Being compassionate; planning altruistic activities	Engaging in altruism

¹The stages are dynamic phases of healing that represent change over time

²The enabling factors facilitate movement from one stage to the next

³The domains are areas of functioning, important to participants, in which healing areas

The five domains on the vertical access are drawn from the five theoretical frameworks, each which addressed one or more particular areas of functioning related to healing from CSA. [Note: There is not a direct correspondence between the five frameworks and the five domains on Table 2; the Living the Family Legacy framework (Martsolf & Draucker, 2008) addressed two domains – life patterns and parenting – and the Determining My Sexuality framework (Roller et al., 2009) – yielded stages rather than a domain.] We then reexamined the narrative data from the participants to ascertain how each domain was evidenced during each stage of healing. As we were particularly interested in how individuals progressed through the healing process, we also reviewed each transcript to determine which factors enabled or facilitated movement from one stage to the next. These factors, which we refer to as enabling factors, are also displayed at the top of the model. For the theoretical model, therefore, CSA is represented as a process that includes four stages, five domains of functioning, and six enabling factors that facilitate movement from one stage to another.

A stage model that represents change over time implies that most people experience the first stage, fewer experience each subsequent stage, and a limited number reach the culminating stage. We do not intend to imply, however, that all CSA survivors heal in an orderly, step-wise fashion. Some participants bypassed stages, reverted to earlier stages, or experienced several aspects of different stages simultaneously. The stages in the model, therefore, are intended as a conceptual rendering of a common lifespan trajectory that leads to laying claim to one's life following CSA. While some participants discussed childhood healing experiences, most of the data described how they healed as adults. Thus, the model depicts healing in adulthood.

The four stages that structure the CSA Healing Model are described below. The healing processes related to life patterns, parenting, disclosure, spirituality, and altruism that take place in each stage are detailed. Case descriptions are provided to exemplify the healing processes of the four stages. Some non-essential facts from the participant narratives are changed to protect the participants' identities.

Grappling With the Meaning of CSA

All the participants were driven to understand the CSA and integrate it in their life story. Yet, doing so was challenging because the sexual abuse occurred in childhood, was often perpetrated by an intimate other, involved sexual activities for they were not prepared, and was shrouded in secrecy (Draucker & Martsolf, 2008; Roller et al., 2009). Healing required some understanding of (a) the nature of the abuse – whether it was victimization, love, or discipline; (b) why it happened to them – especially whether they were to blame; and (c) what effects it had on their lives – including how it contributed to their current troubles (Draucker & Martsolf, 2008; Roller et al., 2009). Finding satisfying answers to these questions and making life changes based on an evolving understanding of the CSA and its effects fueled the healing process.

Many participants continued to struggle with these questions in adulthood. Those who remain consumed by them were determined to be in the stage of grappling with the meaning of the CSA (referred to as the grappling stage). They were beleaguered by thoughts and memories of the CSA, remained mired in difficult life situations, and exhibited a number of psychological, behavioral, and physical symptoms. They continued to hold childhood beliefs about the CSA – typically, that it was normal, that they were to blame for it, and that it destroyed their life.

Life patterns

Participants in the grappling stage often had troubled lives that involved abuse, compromised health, and instability (Martsolf & Draucker, 2008). Many experienced ongoing maltreatment by intimate others or extra-familial violence, including physical assaults and rape. People in this stage often reported a variety of psychological, physical, and sexual health concerns (Roller et al., 2009). They often had unstable life courses that included substance abuse, lack of steady employment, lack of stable housing, inability to maintain enduring supportive interpersonal relationships, poverty, and legal problems.

Parenting

Some participants in this stage “passed on” abuse to their children. Deprived of positive parenting, these participants were unable to create a home environment in which their children could thrive. Some physically, emotionally, or sexually abused their children or failed to protect them from molestation by others (Martsolf & Draucker, 2008). An intergenerational cycle of abuse often occurred because parents believed that child mistreatment was normal or inevitable.

Disclosure of CSA

Many participants in the grappling stage kept the CSA a secret (Draucker & Martsolf, 2008). They did not disclose the CSA because they suppressed thoughts of it, were ashamed, feared they would be blamed or disbelieved, or wished to protect the abuser or their family. Many had no supportive confidants who were willing or able to hear about the CSA. Because no one provided a new perspective on the CSA, these participants maintained their childhood understanding of it. Those who did disclose the CSA did so indirectly or indiscriminately. Some “hinted” about the CSA by mentioning it obliquely or leaving notes or diaries about it hoping someone would find them. Some disclosed the CSA but were not selective and thoughtful about whom they told and often received negative reactions of blame or disbelief, which lead to further silence.

Spirituality

While in the grappling stage, most participants did not experience a comforting or meaningful spiritual connection that facilitated their healing (Knapik et al., 2008). They did not communicate with a higher power who helped them, experience a higher power as present in their lives, or have a strong commitment to spiritual beliefs.

Altruism

Participants in the grappling stage did not often engage in altruism. They often knew others who suffered from abuse or victimization but lacked the resources to offer support or help (Stidham, 2009). In addition, they did not feel they could aid others because they continued to believe that abuse was inevitable.

Exemplar

A 62-year-old African-American woman, who was sexually abused as a child and raped as an adolescent, was in the grappling stage. She was one of thirteen children; she never felt loved by her mother and never knew her biological father. As a child, she was sexually abused by several family acquaintances and raped by a “sex offender.” She had her first child at thirteen. She stated, “You know, I feel [because of the CSA] like my whole life was f'd up - period.” She explained, “It really hurt me to be violated like that…. All this, all this…. Even though I am 62 years old, all this is still in my mind. It [the power of the CSA to ruin her life] never goes away” (grappling).

As an adult, she had never been employed, had a long history of substance abuse, had been depressed and attempted suicide and was sexually assaulted on several occasions (living a troubled life). All three of her children were taken from her by protective services because of abuse or neglect and placed for adoption (passing on the abuse). When asked if she had revealed her CSA to anyone, she responded, “I never did tell my [step]-father because no one cared. I'll put it that way, so I never did tell nobody” (keeping the CSA a secret). Her only spiritual reference was to wonder why God would not provide anyone to love her (having no comforting spiritual connection).

Figuring out the Meaning of CSA

Some participants engaged in processes that rendered a new understanding of the essence, cause, and consequences of the CSA (Draucker & Martsolf, 2008; Roller et al., 2009). These participants had experienced the stage of figuring out the meaning of the CSA (referred to as the figuring out stage). They figured out that the CSA was abusive regardless of its circumstances (e.g., their age at the time of the abuse), how they were engaged in the abuse (e.g., coercion, force), or their response to it (e.g., pleasure, disgust, arousal, terror). Over time, they gained an increasingly nuanced understanding of the conditions that contributed to the CSA (e.g., troubled family dynamics, a society that condones violence) and the motivations of the perpetrator (e.g., power and control rather than romantic desire). Most importantly, they came to believe that they were not to blame. They also developed an appreciation of how their current distress (e.g., troubled interpersonal relationships, on-going abuse) was related to the CSA and its effects (e.g., a sense of betrayal; inability to determining whether others are safe).

Enabling factors

Two factors enabled participants to move from the stage of grappling to the stage of figuring out. The first factor was a message from at least one person that the CSA they experienced was wrong and they were not to blame. These affirming messages were given by family members, friends, teachers, or clinicians. In some cases, the messages came from talk shows, public service announcements, or classroom discussions. Often, the messages had come many years after the abuse has ended. Participants did not always immediately embrace these messages, but the messages provoked reconsideration of long-held assumptions about the abuse -especially self-blame. The other factor that enabled movement to the figuring out stage was a sense of personal agency. Participants began to figure out the abuse because they decided they had the capacity to confront it without being destroyed.

Life patterns

Participants in the figuring out stage often continued to live troubled lives (Martsolf & Draucker, 2008). Yet, their troubles were often interspersed with positive experiences and burgeoning accomplishments, including academic or occupational achievements, the forming of positive interpersonal relationships, a period of sobriety, or a change in health-behaviors (e.g., weight loss, commitment to an exercise program) (Draucker & Martsolf, in press). While some of these experiences were tenuous or short-lived, they demonstrated to the participants that they could make positive changes in their lives.

Parenting

As participants began to figure out the meaning of their CSA, they became more concerned about not passing abuse on to their children. In this stage, participants often experienced a desire to parent differently than they were parented (Martsolf & Draucker, 2008). Because they were still figuring out the CSA, however, they had not yet garnered the resources necessary to effectively prevent their children from experiencing abuse or maltreatment. Some used harsh punishment, found out their child had been molested, or were powerless to stop a partner from abusing their children. Yet, they experienced a strong desire to do what they could be protective parents.

Disclosure of CSA

As participants figured out the meaning of the CSA, they were more likely to discuss the abuse with others (Draucker & Martsolf, 2008). They were more discriminating about disclosing to others who were “safe” and began to share their experiences with these others in more depth. In fact, discussing the abuse with others was the main process by which participants figured out the abuse. These discussions most often occurred with a mental health clinician, but also occurred with family members and friends as well. Discussions with others helped participants arrive at an understanding of the abuse that was more complex and multidimensional.

Spirituality

In the figuring out stage, some participants relied on spiritual connections to guide their healing. Many experienced a sense of spiritual connection to a divinity, although it was often tenuous (Knapik et al., 2008). As they tried to figure out the meaning of the CSA, for example, some participants prayed to God for answers to their question whereas others questioned why God allowed the abuse to happen. During this stage, some participants enlisted the support of clergy or fellow worshippers to help them in the healing process.

Altruism

In this stage, as participants began to obtain an understanding of the dynamics of their abuse, especially the fact that they were not to blame, they often became concerned about others who continued to be abused or maltreated and thought about ways to help them (Stidham, 2009). While many participants in this stage experienced a desire to help others, they seldom engaged in altruistic acts because they were still figuring things out and continued to struggle with their own life problems.

Exemplar

A 37-year-old Caucasian woman, who was molested by a family acquaintance at age 4 and by her father at age 8, was in the figuring out stage. She claimed that the abuse by her father, which included sexual intercourse, was particularly destructive because he “would always bring love into it, so that kind of twisted [her] perception of that….” At 19, she was raped by a boyfriend whom she later married. Her husband sexually, physically and emotionally abused her for sixteen years. She held some “good” jobs over the years but did not maintain them for a long period of time. At the time of the interview, she had left her husband and was taking computer classes but remained unemployed and continued to struggle with several mental health issues (living a troubled life, with some positive experiences).

Despite years of abuse, she was in the process of figuring out the CSA and the abuse she had experienced by her husband. She believed she had “some kind of inner strength” that allowed her to survive and begin healing (personal agency). She first realized that what her father did was wrong when she saw “movies and stuff on TV” about CSA (affirming messages). She explained that she “was able to kind of work on [me] in the brain” (figuring out). Regarding the CSA by her father, she stated, “It took me years to realize it was not romantic love – and it took me years to figure out that it was wrong and he was just messing with my mind and I needed to get past that” (figuring out). Of the abuse by her husband, she explained, “It was toward the very end that I started figuring out that he was wrong…. It's like he could talk me into anything and so I was actually buying into this is normal and it took me all these years to realize it wasn't” (figuring out).

She had wanted to protect her son, who had autism, from abuse by her husband (wishing to stop the abuse cycle). Because her son mimicked her moods, she hid her feelings so he would not become upset. Yet, her husband at one point had beaten and bitten her son. At the time of the interview, she was seeing a counselor every week: “She's pretty good. Mostly, she'll just listen and I think that is really important” (discussing the CSA to make sense of it). As a child, she had been suicidal but did not act on it because her church preached “fire and brimstone,” and she not want to “burn in hell.” She had questioned why God had let so many bad things happen to her but felt she never got any answers. She stated she has “some faith” now (having some spiritual connections). She indicated that she lived by the “do onto to others…” philosophy but did not provide any specific examples of helping others (thinking about helping others). At the time of the interview, her divorce had just become final and she explained that she was “just trying to pick it all up and get it together”

Tackling the Effects of CSA

Once they figured out the meaning of the CSA, some participants engaged in a variety of processes to mitigate its long-term negative outcomes. These activities occurred in the stage of tackling the effects (referred to the tackling stage). In this stage, they sought psychological, psychiatric, or substance abuse treatment; ended abusive relationships; improved their physical health; made changes in their interpersonal relationships and sexual lives; and sought new occupational or educational opportunities. Although participants experienced this stage as challenging and, at times, tedious, they felt like they were doing the “work” of healing. This phase was often long, arduous, and taxing.

Enabling factors

Two factors enabled participants to move from the figuring out stage to the tackling stage. One was on-going support from others. Isolated, affirming messages were not enough; participants needed others, such as family, friends, or professional helpers, to be available during difficult times. The experience of having someone “be there for me” was foundational to making sustainable life changes. Personal resolve was also required to move into the tackling stage. Participants needed to call on their inner strength and resilience in order to tackle the effects of the CSA.

Life patterns

In this stage, participants engaged in new life patterns that included a mix of troubles and successes. Because they were still tackling the effects of the abuse, many still experienced a number of life challenges but felt their lives were “settling down” (Martsolf & Draucker, 2008). Their adult lives became more stable, healthier, and fulfilling. In the prior stage, accomplishments were infrequent and tenuous; in this stage, they were common and enduring.

Parenting

While tackling the effects of the CSA, many participants began to make changes in the way they parented their children in order to protect them from the abuse (Martsolf & Draucker, 2008). In the prior stage, they verbalized the intent to be better parents; in this stage, they made discernible attempts to be more nurturing and protective. They alerted their children to potential abuse situations, kept them away from family members who were abusive, and invited them to discuss concerns they have about abuse. Because participants in this stage were still dealing with their own problems, however, their attempts to effectively protect their children “fell short.” Some were too zealous in shielding their children from adversity and failed to accurately ascertain which situations or participants realistically posed danger. For most participants, however, becoming better parents was clearly a salient concern as they tackled the effects of CSA.

Disclosure of CSA

In this stage, participants no longer disclosed their CSA as a way to understand it, but rather as a way to cement and pass on their new account of it (Draucker & Martsolf, 2008). Each time they discussed their CSA with supportive others, they became more certain it was abuse, was not their fault, and no longer had to determine their life course. They also shared such wisdom with others who were abused, most often to convince them that they were not to blame and can heal.

Spirituality

In the tackling stage, a number of participants experienced a dynamic and directed spiritual process that facilitated their healing; they describe this as a spiritual journey (Knapik et al., 2008). Some experienced the presence of a divine being who accompanied and sustained them as they engaged in difficult recovery processes. Others experienced a sense of spiritual awakening that was integral to their healing. Some believed that healing involved overcoming the trials and tribulations that God provided for them in order to make them stronger.

Altruism

Participants in the tackling stage showed compassion to those who were abused, maltreated, or disadvantaged (Stidham, 2009). Instead of expressing general sympathy and concern for those who suffered, they provided support and encouragement to them. They believed that because they had been abused and experienced some healing, they could help others better than those who have never experienced abuse. Many planned to become involved in altruistic activities, such as joining victims' organization or speaking of their abuse in public.

Exemplar

A 49-year-old African-American woman, who had been sexually abused throughout much of childhood by an uncle, brother, and grandfather, was in the tackling phase. She was raised by her grandmother because her mother worked as a prostitute and her father had schizophrenia.

She described a troubled life pattern throughout much of her adulthood. She claimed she “ran the streets” and had many sex partners. She was diagnosed with bipolar disorder but avoided psychiatrists. She always felt like a bad person and lamented the fact that she never married. She went to two beauty schools – “a White school and a Black school” – so she could do all women's hair. She established a successful business, but lost it when she became addicted to crack cocaine.

She pointed to age 40 (nine years prior to the interview) as the time when she began “dealing with” her CSA. She had been writing about it, “working [it] out,” “getting [it] out,” and going to a psychiatrist and a counselor (tackling). She received drug treatment and was “clean” for two years (living a life of troubles and successes). She stated that “God, my counselor, and my psychiatrist” provided the support she needed to help her in her healing (on-going support).

As a child, there was no one to whom she could disclose the abuse because her family life was so troubled. As a young adult, she tried to talk to a brother about the CSA, but he denied it, insisting they “had a good raising.” At the time of the interview, she was talking with a counselor about her CSA: “It's still hard to talk now, but I been doing better, since, when I first started talking about it, when I was 40, since I was really, really, healing for real.” She stated that every time she talked about it, she felt a little more like it was not her fault (discussing the CSA to strengthen a new understanding).

Spirituality was an integral part of her healing. She asked God to provide direction in her life: “Cause I had to ask God. I needed to ask for direction, why has my life been like this? And he showed me why… And I'm healing since 40 years old” (experiencing a spiritual journey). She realized there are “a lot of stories out there like mine” and wished all people who had been abused had someone to talk to so they “would feel normal and better” (being compassionate).

Laying Claim to One's Life

Some participants asserted their right to conduct their lives in ways they saw fit and, in some instances, to seek justice from those who hurt them. These participants had reached the stage of laying claim to one's life (referred to as the laying claim stage). They embraced the belief that overcoming the effects of the CSA rendered them capable of determining the course of their lives and making a difference in the world. They had moved through the first three stages of healing and felt empowered to live healthy and fulfilled lives.

Enabling factors

Two factors enabled participants to move from tackling to laying claim. One was the experience of a critical life event that served as a major life turning point. The events were either very positive, such as a spiritual awakening or a major life accomplishment, or very negative, such as a devastating loss or a particularly severe episode of violence. Either way, such events spurred participants to make drastic changes in their lives. In addition, they made a commitment to transcend the CSA rather than just recover from it. They were determined to ensure that something good came from the CSA - either for themselves or for others.

Life patterns

As participants laid claim to their lives, they embraced a life pattern that they experienced as empowered. They led lives that were markedly different from those of their families-of-origin. While they continued to face daily challenges, they took control of their own life patterns. They were adamant that they would no longer be abused and would develop “equal” relationships, “get healthier,” and engage in activities to improve the lives of others.

Parenting

Many participants who laid claim to their lives were committed to passing on abuse-free lives to their children (Martsolf & Draucker, 2008). While some of their children had been abused in the past, participants in this stage were committed to protecting their children. They provided reasoned advice to them about staying safe, refused to expose them to abusive family members, and taught them to be assertive and self-confident. If their children were grown, participants in this stage often did these things for other children in their families.

Disclosure of CSA

In this stage, participants disclosed their abuse almost exclusively for the purpose of helping others (Draucker & Martsolf, 2008). They were committed to “getting out” the message that a child was never at fault for CSA and that people can heal from violence. They gave speeches to youth groups, told their stories in the media, and shared their successes in treatment facilities. Their disclosures often became proclamations.

Spirituality

Some participants in this stage experienced a meaningful spiritual transformation as a result of healing from the CSA (Knapik et al., 2008). They experienced a strong sense of divine intervention and considered their healing to be miraculous. Some believed that healing from CSA redeemed them from past sins. Others were inspired by their healing because it allowed them to know God in a special way and to pass on their spiritual gifts to others.

Altruism

During this stage, participants engaged in a variety of altruistic activities. As they laid claim to their own lives, they were strongly committed to improving the lives of others. They became involved in advocacy and volunteer activities (e.g., speaking out about abuse, working for victims' rights organizations). They chose helping professions in order to make a difference in the lives of those who abused, oppressed, or disadvantaged. As discussed above, they often spoke publicly about their abuse.

Exemplar

A 55-year-old African-American man, who was sexually molested beginning at age 14 by an uncle who was a pastor at a large parish, was in the laying claim stage. The participant had became his uncle's “mistress” for many years as a teen. After the relationship ended when the participant was a young man, he began to “carry on with a lot of different people” and contracted HIV. He suffered with depression and was very ill for many years. At the time of the interview, however, he “lived healthy” and ate well-balanced meals. He was no longer sexually active and regularly attended support groups for HIV. He described his life in terms of choices; he chose when to be active in his church and when to “take a break,” he chose to live alone because he “gets bitchy” when others interrupt his routine, and he chose not to “allow stress into [my life]” (living an empowered life).

He experienced one decisive event that changed the direction of his life. At a particularly low point in his life, a woman from his parish took an interest in him and encouraged him to attend church to “make an altar call” one New Year's Eve. He said, “And I think the Lord just took the depression from me. I returned to work. I put it on him. I am fine now. I'm content. I am very happy” (critical life event).

Prior to this “altar call,” he had disclosed the CSA to many people. As a young adult, he revealed the molestation at a large family gathering and was devastated when some family members denied his claim that his uncle had molested him. Later, however, he was encouraged when one cousin contacted him and stated that she believed him. After the “altar call,” he would often reveal his experiences whenever the topic of clergy abuse came up. He felt it was important to address the hypocrisy of the church and prevent other boys from experiencing what he had (disclosing the abuse to help others).

Because the CSA happened with a minister, it affected his spirituality for many years. However, his spirituality was important to his healing. As described above, the critical event that opened the way for him to lay claim to his life was a spiritual awakening. He stated that “through prayer and attending church, I got over what happened to me” (experiencing a spiritual transformation). This participant was involved in a number of benevolent activities; he worked at several community organizations, made speeches for a national HIV group, and helped senior citizens in his neighborhood do their taxes (engaging in altruism). As he was ending the interview, he reinforced that he had laid claimed to his life. He revealed that he had irreversible neuropathy but chose not to let that keep him down: “I need a cane to get up in the choir stands. Other times I dance. If you would see me out at parties and stuff, you would say that man ain't got no problems….”

Discussion

The theoretical model presented here represents the complexity of healing from CSA. The analysis of the narratives of the 95 adults who experienced CSA suggests that there are four stages through which healing may occur – from grappling with the meaning of the CSA to laying claim to one's life. Obtaining an increasingly complex understanding of the dynamics of CSA was foundational to the process of healing. They participants came to understand not only that the CSA was not their fault, but that if occurred because of disturbances of the perpetrator, the dysfunction of their families, and the ills of society. Factors that enabled movement from one stage to the next involved person factors (e.g., personal agency, personal resolve, a commitment to transcend the abuse) as well as contextual factors (e.g., affirming messages, on-going support). Movement to the final stage – laying claim to one's life – followed a critical life event. Healing was associated with living a satisfying life, stopping the cycle of abuse, and disclosing the abuse to help others. For some, it included experiencing a spiritual transformation and engaging in altruism.

Study Limitations

The findings must be understood in the context of several study limitations. The sample included primarily adults who had experienced severe CSA in the context of highly dysfunctional families and went on to endure much victimization and adversity throughout their lives. Thus, the model does not represent healing from CSA that was less severe, brief, and occurred in the context of healthy, supportive families. Yet, because the model was based on the narratives of adults who experienced chronic trauma, multiple co-morbidities, and enduring life stress, it is applicable to many CSA survivors who seek therapy and who have complex treatment needs.

There were several limitations related to the socio-demographic makeup of the sample. The overall income level of the participants was low and the model may not reflect the healing of individuals with more economic resources. In addition, participants were primarily Caucasian and African American and most espoused Judeo-Christian beliefs. The model, therefore, would not reflect the experiences of individuals who are from non-Western cultures or who are agnostic or atheist.

In addition, the participants' narratives were retrospective. Their memories of events, many of which occurred many years in the past, could have been distorted or diminished. We nonetheless believe that their presentation of their life stories provided rich data that help us understand their healing experiences.

The CSA Healing Model is a stage model that suggests that healing is a dynamic and progressive trajectory that involves four processes that build upon one another. However, we do not wish to imply that all individuals move sequentially from stage to stage in an orderly and predictable manner. To the contrary, many our participants experienced elements of two stages simultaneously, passed over stages, or returned to earlier stages. While we identified factors that frequently facilitated movement by participants from one stage to the next, we recognize that there are likely to be other factors that facilitate or impede healing that we did not identify. Similarly, while all the participants in our sample who reached the stage of laying claim had experienced a critical event, we recognize that individuals may well reach this culminating stage in a more gradual fashion. Whereas some older participants were able to provide data related to their experiences going through several stages, many participants, especially young adults, were in the early stages of healing. Thus, the model serves as an heuristic that depicts a theoretical depiction for how healing happened in our group of participants.

Consistency with Existing Research

Our findings are consistent with much prior research on healing from CSA. Our model, for example, incorporates many tenets of post-traumatic growth theory and positive psychology, particularly the human tendency to create accounts of difficult life experiences as a way to heal (Neimeyer, 2006). Understanding the nature, cause, and consequences of CSA served to provide meaning and coherence to a life experience that was otherwise felt senseless to them (Baumeister & Vohs, 2005). Our model incorporates other constructs from positive psychology including the restorative power of perceived self-efficacy (tackling) (Maddox, 2005), personal control (laying claim) (Thompson, 2005), altruism and empathy (Batson, Ahmad, Lishner, & Tsang, 2005), and spirituality (Pargament & Mahony, 2005). Despite the fact that our sample of adults had experienced severe adversity across their lifespans, their narratives provided a robust description of both healing from and transcending CSA. The findings also support prior research that has suggested disclosure, rather than always being beneficial, is an evolving and complex phenomenon (Ullman, 2003; Ullman, Foynes, Shin Shin Tang, 2010). This complexity is evidenced in a recent study of 172 adults who were sexually abused as children. The findings revealed that those participants who told someone about the abuse at the time it occurred experienced more mental health symptoms as adults. A greater number of mental health symptoms was also related to whether that person told someone else without the child's permission. Those participants who had discussed the abuse (rather than just told someone about it) within one year experienced fewer mental health symptoms (O'Leary, Coohey, & Easton, 2010).

Practice Implications

The model has utility for clinicians who work with survivors of CSA. By determining a client's current stage of healing, a clinician would be alerted to the therapeutic work facing the client in a variety of domains and to the enabling factors that might facilitate movement to the next stage. The findings indicate, for example, that a client who is in the grappling stage needs both affirming messages and some sense of agency to move on, whereas the client who is in figuring out stage needs to have on-going support and a strong sense of personal resolve to begin to tackle the effects of the CSA.

The model might also broaden clinicians' perspectives with regard to the variety of domains in which healing occurs and, therefore, in which clinicians can facilitate progress. The changes in life patterns that accompanied healing, for example, suggest that clinicians should consider a broad range of experiences that signal healing and be particular vigilant to small life successes that might represent significant therapeutic gains. Underpinning changes in life patterns was a developing sense of empowerment. Because parenting was of great concern to most participants, it should routinely be addressed as a therapeutic issue. The model suggests that parenting should not be considered a dichotomous factor – that is, one either abuses or one nurtures one's children. Rather, the processes of wishing to stop the cycle of abuse and attempting to stop the cycle of abuse were critical steps that need to be acknowledged and fostered. Clinicians should also have an understanding of the dynamic and nuanced processes by which disclosure occurs over the lifespan. Here also, disclosure is not a dichotomous factor - that is, one tells of the abuse or keeps it secret - but a process that changes and evolves over the lifespan. Disclosure is heavily influenced by the responses of others, including clinicians, and is intimately related to how one incorporates the abuse into one's life narrative. Clinicians, therefore, should not merely ask clients if they have told anyone of their abuse, but should discuss experiences of disclosure at multiple points throughout their lifespan, obtain an in-depth description how others responded, and explore how discussing the abuse shaped clients' understanding of it. The model also suggests that other issues, such as spirituality and altruism, which are often not the focus of trauma treatment, should be discussed if they are important to clients.

Future Research

Further research might include a longitudinal prospective study to validate the stages and factors that enable transitions. Such as study would also allow a contemporaneous rather than retrospective exploration of the nuances of the transitions from stage to stage. For example, while other researchers have identified the importance of turning points in the life courses of adults who experienced maltreatment as children (Thomas & Hall, 2008), a better understanding of the role of such events in healing is needed. We also suggest further research on gender and ethnic differences in healing from CSA. Minor differences between men and women and African Americans and Caucasians were found in the component projects, but were obscured in this model due to its level of abstraction.

Conclusion

The CSA Healing Model is a model that represents the multifaceted and dynamic process of healing from CSA over the lifespan. The model does not focus on discrete variables associated with positive or negative coping but rather captures some complex healing processes that culminate in the experience of laying claim to one's life. The qualitative synthesis procedures used to combine elements of the five existing frameworks and to further examine and integrate participant narratives allowed for an analytic product that was more comprehensive than any of the existing frameworks. The model indicates that clinicians should focus on how clients might move from grappling with the meaning of the CSA, to figuring out its meaning, to tacking its effects, and ultimately, to laying claim to their lives and should be ready to discuss healing in any one of several domains.