A Salutogenic Approach to Healing Following Child Sexual Assault

Decades of research has now produced a rich description of the destruction child sexual assault (CSA) can cause in an individual’s life. Post-Traumatic Stress Disorder (PTSD), Dissociative Identity Disorder, Borderline Personality Disorder, depression, anxiety, Panic Disorder, intimacy issues, substance abuse, self-harm, and suicidal ideation and attempts, are some of the negative outcomes that have been attributed to this type of traumatic experience. Psychology's tendency to dwell within a pathological paradigm, along with popular media who espouse a similar rhetoric, would lead to the belief that once exposed to CSA, an individual is forever at the mercy of dealing with a massive array of accompanying negative effects. While the possibility of these outcomes in those who have experienced CSA is not at all denied, it is also timely to consider an alternative paradigm that up until now has received a paucity of attention in the sexual assault literature. That is to say, not only do people have the ability to work through the painful and personal impacts of CSA, but for some people the process of recovery may provide a catalyst for positive life changes that have been termed post-traumatic growth (Tedeschi & Calhoun, 1995). 
 
To begin with in this chapter, the negative sequale’ of childhood sexual assault it discussed initially. Inherent to this discussion are questions of measurement and definitions of sexual assault. The chapter highlights ways in which the term CSA has been defined and hence operationalised in research, and the myriad problems, confusions, and inconclusive findings that have plagued the sexual assault literature. Following this is a review of the sparse literature that has conceptualised CSA from a more salutogenic (Antonovsky, 1979) theoretical orientation. It is argued that a salutogenic approach to intervention and to research in this area, provides a more useful way of promoting healing and the gaining of wisdom, but importantly does not negate the very real distress that may accompany growth. This chapter will then present a case study to elucidate the theoretical and empirical literature discussed using the words of a survivor. Finally, the chapter concludes with implications for therapeutic practice, which includes some practical ways in which to promote adaptation to life within the context of having survived this insidious crime.


Introduction
Decades of research has now produced a rich description of the destruction child sexual assault (CSA) can cause in an individual's life.Post-Traumatic Stress Disorder (PTSD), Dissociative Identity Disorder, Borderline Personality Disorder, depression, anxiety, Panic Disorder, intimacy issues, substance abuse, self-harm, and suicidal ideation and attempts, are some of the negative outcomes that have been attributed to this type of traumatic experience.Psychology's tendency to dwell within a pathological paradigm, along with popular media who espouse a similar rhetoric, would lead to the belief that once exposed to CSA, an individual is forever at the mercy of dealing with a massive array of accompanying negative effects.While the possibility of these outcomes in those who have experienced CSA is not at all denied, it is also timely to consider an alternative paradigm that up until now has received a paucity of attention in the sexual assault literature.That is to say, not only do people have the ability to work through the painful and personal impacts of CSA, but for some people the process of recovery may provide a catalyst for positive life changes that have been termed post-traumatic growth (Tedeschi & Calhoun, 1995).
To begin with in this chapter, the negative sequale' of childhood sexual assault it discussed.Inherent to this discussion are questions of measurement and definitions of sexual assault.The chapter highlights ways in which the term CSA has been defined and hence operationalised in research, and the myriad problems, confusions, and inconclusive findings that have plagued the sexual assault literature.Following this is a review of the sparse literature that has conceptualised CSA from a more salutogenic (Antonovsky, 1979) theoretical orientation.It is argued that a salutogenic approach to intervention and to research in this area, provides a more useful way of promoting healing and the gaining of wisdom, but importantly does not negate the very real distress that may accompany growth.This chapter will then present a case study to elucidate the theoretical and empirical literature discussed using the words of a survivor.Finally, the chapter concludes with implications for therapeutic practice, which includes some practical ways in which to promote adaptation to life within the context of having survived this insidious crime.

The impact of child sexual abuse: An overview of the pathological paradigm
For those who work therapeutically with individuals who have a history of child sexual abuse (CSA) there is no difficulty in understanding just how impactful this particular type of trauma can be on a person.The elements that CSA consist of in the context of traumatic events are remarkably unique.With few exceptions, such as war, persecution, and slavery, most traumatic events are just that, single episode events that occur unexpectedly and are unpredictable.With CSA however, the 'event' is something that often, though not always, occurs over and over again, with a certain amount of predictability.Furthermore, the person responsible for committing CSA acts is resoundingly more often someone the child knows, loves, and often depends on for survival (Fanslow et al., 2007;Kouyoumdjian et al., 2009).That is to say, more frequently than not, offenders are either related to the child directly or are closely involved with the child's family; trusted, influential, and deeply imbedded within the child's support network.The betrayal of trust, abuse of the child's love for, and devotion to, the offender, and confusion caused by being both hurt and loved by a trusted adult is in and of itself damaging to the child's emerging sense of self and their intrinsic worth.This in turn greatly influences the child's working models of relationships and their place within these relationships.A further unique aspect of CSA is the secrecy that surrounds this issue.With other traumatic events often the event is well known to others, and support is available to the aggrieved party.However, when a child is sexually assaulted, more often than not the child suffers in silence, feeling alone and isolated (Isely et al., 2008).In addition to the emotional isolation is fact that CSA is an offence that happens within the child's body.Even acts of physical violence occur to an individual; with CSA the violation physically crosses the line from outside to within, and there is nowhere to escape.All this can happen at a time when the child has limited resources, or recourses, open to them, due to developmental stages associated with childhood (e.g., cognitive development, dependence).It is little wonder that so many individuals who have experienced this particular interpersonal trauma are often left with deep psychological scars that resound through so many domains within their lives (Nelson et al., 2002).
The field of psychological enquiry has long been aware of the devastating effects CSA leaves in its wake.In the three decades since CSA was first brought openly into the light of scientific investigation much has been learned not only in relation to the myriad negative impacts that follow CSA, but also regarding the array of mediating and moderating factors found to contribute to the increase or decrease of the subjective impact felt.Overwhelmingly, the focus of psychological investigation has been through the lens of a pathological paradigm.The focus of the pathological paradigm is on the origins of ill-health in the form of diagnosable psychological disorders, in the process of seeking to understand what contributes to worse outcomes so that one can identify and alleviate distressing symptoms.The overarching intention is to identify ways to alleviate suffering.With this framework of investigation, the field of psychological research has provided a rich description of the pathology that often occurs as a result of a child being sexually assaulted.
Of all areas studied pertaining to CSA, the area given most attention has been that of the negative outcomes experienced by victims of this crime.Consistently, research has continued to show the direct link between CSA exposure and negative outcomes (e.g.Molnar et al., 2001;Nelson et al., 2002;O'Leary et al., 2010).Of the diagnosable disorders, major depressive disorder (Nelson et al., 2002), anxiety disorders (Calam et al., 1998), suicide attempts (Belik et al., 2009), sexual dysfunction (Gold et al., 1999), post-traumatic stress disorder (PTSD) (Shakespeare-Finch & De Dassel, 2009), and other psychopathology (Molnar et al., 2001) are commonly studied, demonstrating that those who have experienced CSA are at a significantly greater risk of developing these impairments.Even amongst sufferers of other tragedies and traumas, those who have experienced CSA show higher levels of impairment (Shakespeare-Finch & Armstrong, 2010), a testament to the highly invasive, personal, and damaging nature of the experience of sexual abuse in childhood.
The intrapersonal impact of CSA is perhaps the most pronounced and enduring of all the potential outcomes that can stem from a history of sexual abuse.Pervasive feelings of shame, guilt, and responsibility plague many of those who have endured this experience (Coffey et al., 1996).These particular effects show enduring consistency in those who have experienced repeated abuse over many years, through to those who have experienced one intrusive contact abuse act (Isley et al., 2008;Molner et al., 2002).Feelings of shame and responsibility permeate to the core of how an individual feels about themselves, not only as a person, but as a person within the abuse dyad.For a great many abuse survivors, a feeling of complicity exists, particularly if the offender is older, stronger, and in a position of authority over the child, and the abuse was not overtly challenged by the child.Survivors then take on the responsibility of the abuse, either in part or in full, believing had they said something, done something different, or been in some way different, this would not have happened to them.Through this process, core beliefs are formed about the self that often reflect worthlessness, hopelessness, or inherent 'badness'.Unfortunately, even therapeutic intervention has done little to create a shift in the global, negative way that individuals feel about who they are, as well as what they are worth as a person (Lev-Wiesel, 2000).From the vantage point of holding such a negative self-image, it is not difficult to understand how the interpersonal and social difficulties that can stem from CSA are encountered.
In the search for understanding the sources of difficulty and distress in survivors of CSA, the pathological paradigm has provided a rich description of the vast spectrum of potential negative outcomes that often follow sexual abuse.Adding to the understanding of pathology are an array of established mediating and moderating variables known to increase the risk of harm and suffering after experiencing CSA.Abuse-specific variables of a longer duration (Reyes, 2008), a familial offender (Zinzow et al., 2010), more intrusive abuse (Nelson et al., 2002), and subjective distress at time of abuse (Briere & Elliott, 2003) have all been shown to cause more distress and impairment.When an individual discloses their abuse, as well as how it is responded to, makes a difference to psychological outcomes.Often it is found that children who's abuse is disclosed or discovered in childhood fare much worse than those who choose to wait until adulthood (O'Leary et al., 2010), although the reverse has also been found (Ullman, 2007).If disclosure is met with silence, or worse, with condemnation of the victim, poorer outcomes are likely to follow (Del Castillo & O'Dougherty, 2009).Attachment has been shown to be an important variable in outcomes, as children who report having one non-offending parent who provides them with belief and support fare better than those who do not report such a relationship (Bolen & Lamb, 2007).In adulthood, support appears to be just as important; women with CSA histories have reported the often transformative act of being believed and accepted by another through the process of disclosure, if the disclosure is met with acceptance and validation (Del Castillo & O'Dougherty, 2009), while the damaging effects of stigma and judgement after disclosure has been reported as an area of further distress and isolation (Jonzon & Lindblad, 2004).
With what is already known through exploration using the pathological paradigm it can be said definitively and conclusively that CSA causes harm, and that a direct link exists between CSA and risk for adverse outcomes (Molar et al., 2001;Nelson et al., 2002;Wiffen & MacIntosh, 2005).With this being said, due to the heterogeneity of CSA experiences, individual differences in coping strategies during and after abuse, the interplay of the various mediating and moderating variables, as well as a host of other factors, a simple cause and effect model cannot be created to account for the myriad adverse outcomes that co-occur with the often traumatic experience of CSA (Putnam, 2003).This disparity not only exists among the types of experiences or environmental conditions that make up the population of those exposed to CSA; discrepancy and contradictions exist within the CSA literature itself.

CSA research and the plague of null findings
Despite robust and consistent findings throughout the CSA literature, research has also been plagued with null findings.It seems for any measured variable found to show an association with negative outcomes, another study will show the opposite.Age at the beginning of abuse, a closely related offender, longer duration of abuse, the use of force to elicit abuse acts, and a lack of support following disclosure, have all been shown to be related to greater levels of symptomology at time of measurement (O'Leary et al., 2010;Reyes, 2008;Zinzow et al., 2010).However, studies can also be found that show no such associations (see Paolucci et al., 2001).The one finding that maintains consistency however is that of intrusion: more intrusive, invasive, penetrative abuse acts have repeatedly been associated with worse outcomes for individuals (Nelson et al., 2002;Ullman, 2007).
Although consistency in research findings far outweighs the discrepancies, the fact that null findings continue to arise has led some to believe CSA is not as harmful as first thought (Rind et al., 1998).It can be argued, however, that the reason so many inconsistencies are found within the research base is not due to the possibility that CSA is not severe or damaging, but instead the ways in which research into this area is conducted is in and of itself problematic.For example, the choices of populations to study, a lack of standardisation in the definition of CSA, and the vast catch-all approach to including any form of sexual exposure of an individual during childhood in research samples, are all areas that contribute to the inconsistencies identified in the literature.

Populations
Population estimates of the prevalence of CSA among the general community in Western societies indicate an estimated 9% -35% of women and 4% -19% of men have experienced some form of sexual abuse in childhood (Pereda et al., 2009;Putnam, 2003).These figures themselves, though alarmingly high, are cautioned to be conservative estimates due to a combination of the sensitive and personal nature of CSA, the relatively high rates of nondisclosure (McGregor et al., 2010), and the likelihood that the data contains a healthy percentage of false-negatives (Nelson et al., 2002).These estimates are testament to the fact that a substantial percentage of functioning, non-clinical men and women in the general community have been affected by CSA.However, beginning research into CSA was often conducted on clinical female populations, with many participants being in-patients within psychiatric facilities (Gold et al., 1999).In general psychological clinical samples the rate of CSA is remarkably high and the type of abuse reported is often intrusive, enduring, and severe (Calam et al., 1998;Gold et al., 1999).The outcome of these investigations clearly showed the severe and lasting effects of the impact of CSA, with high impairments found across a number of domains within these women.However, clinical populations do not provide a representative picture of the majority of those who have experienced CSA, as evidenced by the large number of people within the general community who report experiencing abuse.
The rise of university student samples has been a popular choice for researchers for some time now (see Finkelhor & Browne, 1986).The benefit of using university students as research populations is that it provides researchers with access to large numbers of easily accessible participants.Although ease of gathering information with the use of this population is enticing, there are also inherent problems with the use of university student samples.First, within university samples, CSA prevalence rates have been shown to be lower than what is found within the general community, and the types of offences reported show a disproportionately higher percentage of non-contact abuse (exposure, pornography), and single-episode, non-penetrative abuse (Ullman, 2007;Zinzow et al., 2010) than those found within the general public (McGregor et al., 2010).A further limitation in utilising university students is that they often consist of relatively young people, the majority of whom are in their late teens to early thirties, who most often are not married and have no children (Harding et al., 2010;Zinzow et al., 2010).What this means in practice is that the sample consists largely of individuals who would be considered high-functioning, as evidenced by the fact they have met requirements to enter tertiary education, and who are also yet to go through significant life stages of partnering, marriage, and child rearing; stages that often cause one to think about the impacts of their own childhood on the way in which one conducts themselves as a spouse, mother or father (O'Dougherty et al., 2007).Not surprisingly then, university populations have been found to show less impairment than that found when studying individuals within the general population (Molner et al., 2001;Rojas & Kinder, 2009).
In reality, neither of these sample bases can be considered truly representative to the scope of individuals affected by CSA.With estimates of one in four women and one in seven men experiencing some form of CSA in childhood (Finkelhor, 1994) we only need to look at our workplaces, the local community, and indeed our own families, to see that if we have a mother, sister, aunty, and grandmother, the likelihood exists that one of these women have been affected (not withstanding familial correlates of CSA incidents).Similarly, a company board meeting consisting of 25 men could mean three or more of these men have also experienced CSA.What this means for research is that in order for our results to be truly meaningful, and to encapsulate the spectrum of individuals affected by this experience, broadening the use of general population samples would provide a more representative view of CSA and arguably, a reduction of null findings would also follow.

Definitions and measurement
Other problematic issues within research lays both within the way CSA is defined and measured.As it stands, no universal definition exists as to what actually constitutes CSA.This alone is contentious, as an obvious question is then of how is it possible for contradictory findings not to emerge if there is yet to be an agreement on what CSA actually is.Definition and measurement discrepancies lay within the types of experiences classified as abuse, the age of the victim at time of the assault, and a lack of enquiry into the subjective distress of the individual at the time of the experience.These factors are expanded on in the following sections.
Definitions of what constitutes CSA vary widely between studies.Some studies use questionaries from previous research (Rojas & Kinder, 2009;Ullman, 2007), others choose to use a more legal definition (see Paolucci et al., 2001) and some researchers use no definition at all, choosing to simply ask if participants had experienced sexual abuse in childhood (O'Leary et al., 2010;Phanichrat & Townshend, 2010).The latter approach in directly asking participants if they have experienced sexual abuse in childhood appears to be in the minority, with researchers often framing questions to read more on the lines of enquiry into sexual experiences (Ullman, 2007), sexual contact (Harding et al., 2010), or sexual activities (Zinzow et al., 2010) in childhood.The problem with such varied definitions of what constitutes CSA, is the likelihood of samples being inflated with the inclusion of falsepositives, because not all experiences classified as CSA by the researcher may be equally classified as abuse by the participant.This point becomes pertinent when looking at responses from men who have been designated into a 'sexually abused' group on the definition of 'sexual experiences in childhood'.By this definition, a surprising majority of these men state their experience as being 'positive' (Schultz & Jones, 1983).In their qualitative study on men who had endured sexual abuse as boys by members of the clergy, Isley et al., (2008) did not find one man who rated their experience as being 'positive'.However they did report that all the men themselves spoke of experiencing pervasive feelings of inadequacy, shame, isolation, and a belief they were 'damaged' by the abuse.In contrast, for a man who, at 15 had a sexual encounter with a woman in her 20's, the likelihood of that man rating his experience as 'positive' is substantially greater.However, all too often both of these men would likely be grouped together as being 'abused'.When the operational definitions of abuse vary so greatly, it is hardly surprising that such discrepancies exist within research findings.Age of the victim at time of abuse is another area that varies widely between studies, and has the potential to contribute to inconsistent findings.Common cut-off ranges for age at beginning of abuse or abusive episodes are 14 years (Ullman, 2007;Ullman et al., 2009), 16 years (Rojas & Kinder, 2009) and 18 years of age (Harding et al., 2010;Zinzow et al., 2010).Some studies chose to include both an upper and lower age range (Palesh et al., 2007), while others provide no age descriptors at all (Del Castillo & Dougherty, 2009;McGregor et al., 2010;O'Leary et al., 2010).The age of an individual is a potentially important factor due to the relevance of emerging sexuality and sexual experimentation that is integral to the adolescent life stage.A five-year age gap between a 16 and 21 year old is not unusual for a consenting relationship; a sexual relationship between a 17 and 22 year old is also not uncommon (Darroch et al., 1999).And within these relationships, or within other contexts that adolescents find themselves in, intrusive and unwanted sexual experiences do most certainly occur.However, these types of unwanted sexual experiences are not representative of the dynamics of what CSA is known for.The sexual abuse of a child is just that, it is an abuse of power, an abuse of trust, and an abuse of authority over a minor, through the abnormal use of a child for an adult's, or significantly older teenager's, own sexual gratification.The inclusion of age ranges that extend to 18 years of age, well above the legal age of consent of 16 years of age in many places, creates the potential for individuals being included in the cohort of those experiencing CSA, when in fact this may not be the case.Therefore, the compounding effects of the lack of an agreed-upon definition of CSA, coupled with the inclusion of unwanted sexual experiences of teenagers well into their sexual experimentation years, has the potential to confound results with the inclusion of acts that are not what would be considered to be within the realm of sexual abuse of a child, nor incorporates the relevant factors of grooming, complicity, shame, power-over, and secrecy that are important factors in the initiation and continuation of CSA.
Gaining an accurate account of subjective distress, rather than assuming inferred harm, is perhaps one avenue that could contribute to reducing null findings and inconsistencies within the literature.All too often, the phenomenological experience of the individual is overlooked within research of any description.Without an understanding of the subjective distress at the time of the abuse, there is a higher likelihood that researchers are comparing "apples with oranges".A point has been made that just because an act is considered morally wrong, that in and of itself is not enough to assume that harm has been done (Rind et al., 1998).Obviously, individual differences in coping abilities and factors associated with notions of dispositional resilience play their part, for it is not possible to know all the underlying factors that cause someone to be more or less resilient than someone else who has experienced the same type of encounter.Nor is it possible to measure in detail how any particular risk or resilience factor, let alone all of the ones currently known, may contribute to a person's perception and subsequent reaction to sexual abuse.However, it must be considered that not all incidents are experienced or interpreted equally.For instance, in relation to non-contact abuse, a pre-teen girl who was 'flashed' by a stranger in a park may show no long-term ill-effects, while a similar-aged girl who's older brother intentionally invades her privacy by leering at her whilst showering, may show more distress.Similarly, in relation to contact abuse, someone who experienced being touched on their breast over the top of their clothes by the brother of an older playmate may be less affected than someone who experienced being fondled on their genitals underneath their clothes by their uncle.
Given the above examples of areas of potential confounds within CSA research, it could be argued that research into CSA would do well to increase its rigour around these particular areas.The use of community samples as the choice of populations to study would provide a more useful participant base from which to extrapolate findings that hold more meaning across the scope of individuals who have experienced CSA.Finding an agreed-upon operational definition of what constitutes CSA, one that includes pertinent aspects of CSA such as grooming and the use of trust and/or power to gain compliance and secrecy, as well as one that is more descriptive of CSA rather than simply sexual experiences, could assist in decreasing discrepancies, by reducing confounds of false-positives through methodological wording.Finally, gaining an accurate understanding of the subjective impact CSA has had on an individual can be an avenue that reduces assumptions in research, and allows for a more authentic view of the real impact of different degrees of CSA exposure.
Yet, even with the potential areas for problems, research has provided us with a wealth of information into the serious, damaging, and pervasive negative effects that a history of sexual abuse in childhood can have on an individual.This information arms researchers and clinicians alike with a valuable knowledge base into not only the workings of CSA, but also the likely effects that may follow, and in light of this, efforts can be made to alleviate distress within individuals who have suffered this experience.However, the pathological paradigm has its limitations, and perhaps as an antidote to this, a relatively new wave of research is beginning to emerge; one that seeks to add a new body of information on CSA; a complimentary, innovative way in which we both understand and work with survivors of this particular trauma.

The salutogenic paradigm: Growth from the ashes
"The world breaks everyone, and afterward some are strong at the broken places" Hemmingway In a move from the more traditional focus on pathological outcomes of trauma, and the understanding of what makes a difference in terms of reducing severity and duration of negative outcomes, research is now opening up to the broader scope of human experience and has begun to investigate factors related to more positive outcomes after trauma or severe stress.Concepts such as hardiness (Kobasa, 1979) and resilience (e.g., Bonanno, 2004;Rutter, 1987) have arisen as important determinants implicated in maintaining a person's base-line well-being in the face of traumatic or aversive life events.What these investigations have shown is that despite enduring personal traumas, some people, due to things such as favourable environmental conditions (e.g., support) and personality elements, are able to continue to function well, or are able to 'bounce back', with more ease and speed from these stressors than others.Walsh (2002) conceptualises resilience as "bouncing forward", suggesting that trauma changes a person's life and therefore "back" is not possible, and may not be desirable.Resilience and hardiness however, do not encapsulate the wide variety of ways of coping after stressors and traumas, and to this end, other investigations into how people cope with adversity and suffering have emerged in the literature.
The Salutogenic paradigm (Antonovsky, 1979) is one such reference theory that is interested in exploring the question of "What is it that keeps people well?", not only enduring personal traumas, but also within the bounds of more ordinary experiences of life stress, personal hardships, and setbacks.It was through his work with menopausal women, a sub-group of who had survived the holocaust, that medical sociologist Aaron Antonovsky began to wonder this very question.Studying these women who had endured unimaginable horrors, he discovered, to his surprise, that within the sub-group of menopausal holocaust survivors, nearly one third of the women were not only maintaining a good level of health, but were also managing to lead a fulfilling life, despite the trauma of their experiences.It was this discovery that led Antonovsky to depart from the more traditional, reductionist focus of pathology into a new paradigm of human capacity for health and wellness.Antonovsky's focus shifted to an attention on how people use their resources to remain well, even in the wake of very difficult circumstances.What he found was that the people who were able to remain relatively healthy after adversity had a certain way of looking at the world and their life, and he also noted differences in the way they coped with their life stressors.He suggested such people had a "sense of coherence".
Antonovsky's (1979) salutogenic theoretical approach views well-being as a multidimensional continuum, with health/ease on one end of the continuum, and dis-ease at the other, with fluid movement between the ends of these two poles being the normative experience.This way of thinking takes into account the very real fact that life is in and of itself inherently stressful, and that heterostasis, illness, and senescence are part of the human condition.This is a sentiment echoed by an ancient philosopher over 2 ½ thousand years ago, in the words of Buddha, "Life is suffering".From this perspective, the focus is on coping resources that contribute to movement towards the healthy end of the wellbeing continuum, or at the very least, which assists in the maintenance of one's position.In this way, salutogenesis is an investigation of the total story of a person, discovering how one successfully resolves tension in their lives and maintains or enhances their position on the well-being continuum despite, or perhaps because of, their difficulties.
At the core of the salutogenic paradigm is the theory behind the perceptual differences Antonovsky discovered in individuals who were able to maintain wellness despite their previous or current circumstances, what Antonovsky coined the sense of coherence (SOC).The SOC comprises three main components across cognitive, behavioural, and emotional domains, being comprehensibility, manageability, and meaningfulness.Comprehensibility is the extent to which an individual views stressors as understandable, clear and ordered.Manageability is the extent that resources are perceived to be available to the individual, and that these resources are adequate to meet the challenges a person might face.Meaningfulness is the extent to which an individual believes their emotional life makes sense, and the emotional demands they face are worth investing energy into.Therefore, healthy coping, according to Antonovsky, is when one is able to make sense of their situation, believe they have the abilities to cope with what is in front of them, and believe that the emotional struggle to deal with their difficulties is of importance and worthy of investment (Antonovsky, 1987).

Post-traumatic growth
The overall outlook of the salutogenic orientation is to offer a theoretical perspective of successful coping.Inherent in this theory is the notion that human wellness is more than an absence of pathology, and takes into consideration the human ability to flourish and experience positive change after the experience of a major disruption or trauma.Positive changes that arise from the struggle to cope with a traumatic event have been termed posttraumatic growth (PTG) (Calhoun & Tedeschi, 2006;Tedeschi & Calhoun, 1996).The notion of PTG is a burgeoning field of research that takes the notion of resilience and resistance to stress to a new level.Consequently, the past 15 years of inquiry has provided research demonstrating positive post-trauma changes in individuals who have struggled with many types of trauma (Janoff-Bulman, 2006;Tedeschi & Calhoun, 1995).
One theoretical process model of the pathways to PTG asserts that the experience of trauma is so powerful that it shakes the very foundations on which we view ourselves, our world, and our place in it (Janoff-Bulman, 2006).Fundamental cognitive assumptions held about the self and one's environments, assumptions that serve to make life predictable, logical, and intelligible, and which are based on concepts such as safety, benevolence, and good things happening to good people, and bad things happening to someone else, are believed to be in dissonance with reality after a perceived traumatic event, due to the profound loss of safety, protection and certainty the experience of trauma often brings (Janoff- Bulman, 2006;Calhoun & Tedeschi, 2006).The internal disruption of one's inner world through the experience of loss of safety and security is believed to overwhelm ordinary defences, leaving one with a sense of threat, helplessness, and vulnerability.Coping, then, becomes a process of reworking internal fundamental assumptions, moving from overgeneralisation of danger and helplessness, to a place that incorporates both the new reality of the uncertainty of the world and one's own vulnerability.In other words, there needs to be a cognitive shift from being a 'victim' to being a 'survivor', while also allowing for a more positive sense of self and the world to emerge; one that is aware of, but is not defined by, vulnerability.Janoff- Bulman (2004Bulman ( , 2006) ) postulates that the path to successful coping is achieved through three psychological process; strength through suffering, psychological preparedness, and existential re-evaluation.Strength through suffering allows for knowledge gained through the struggle of coping to open an individual to a deeper understanding of themselves.Psychological preparedness is the process of the strengthening of inner resources through coping, which also makes future traumas more easily dealt with, as with experience one is more prepared for future challenges.While existential re-evaluation is the process of more fully connecting to one's life, such as developing a new-found appreciation of one's existence in the world, or developing a greater appreciation of one's life, as well as encompassing changes to one's philosophy of life and how they engage with themselves, others, and their environment on a day-to-day basis.
Theoretically however, the notion of trauma shaking the foundations of one's assumptive worlds does not entirely fit for those who experience trauma as children.Childhood and adolescence is seen as a time when one is building assumptive worlds about the self, others, and the world (Erikson, 1980).Therefore, it can be postulated that instead of shaking one's internal assumptions, childhood traumas like CSA could be seen to actually create assumptions about the self, as the trauma is co-occurring at a time when these attributions are being formulated.This can be seen in research findings where individuals who were abused at a later age of onset, or experienced abuse that continued into their adolescence, are found to attribute the blame for the abuse on themselves (Zinzow et al., 2010).Frequently, research and clinical practice reveals that individuals who experience CSA hold inherent perceptions of themselves based on concepts of wrongness, damagedness, and separateness (Isely et al., 2008;Zinzow et al., 2010).Perhaps growth then, for those who experience traumas at a time when they are constructing their internal assumptions, could be more of a process of uncovering the false perceptions of the self and connecting to their true nature, or the truth about who they really are.An example of this can be seen in Phanichrat and Townshend's (2010) study of men and women who regard themselves a healed from CSA. Sentiments echoed from these individuals show that the process of letting go of shame and truly accepting themselves, and shifting the way they viewed themselves in relation to the abuse, were fundamental avenues that lead to their healing.Other research has revealed that gaining an understanding of power differentials, hierarchical relationships, and personal boundaries helped women to shift their perspective of selfblame to a more realistic and healthy view that the offender was responsible for the abuse, and not them (Flynn, 2008).By these reports, shifts in self-perception are seen as important aspects that allow for an experience of inner transformation and contribute significantly to healing from CSA.
A further theoretical postulation of PTG comes from Tedeschi and Calhoun (2004) who have found that through the process of actively dealing with the experience of trauma, people often report growth and change in three major domains; in ones' sense of self, their relationships with others, and in their philosophy in life.People report feeling a greater sense of personal strength, self-reliance and competence through successfully negotiating the struggle to cope with their traumatic experience, a strengthening in their relationships with others and greater freedom of self-disclosure within personal relationships, a shift in their philosophy of life, such as greater appreciation of the 'little things', changed priorities, or changes in religious or existential beliefs (Calhoun & Tedeschi, 2006;Tedeschi & Calhoun, 1999).Calhoun and Tedeschi (2006) propose growth is both a process and an outcome, in that processes such as volition rumination, self-disclosure, and managing distress, lead to the three broad outcome domains.This is a sentiment echoed in existing theories of coping that assert the struggle to process negative events, through mechanisms such as meaning making, leads to growth outcomes of cognitive reappraisals of fundamental assumptions (Park & Folkman, 1997;Park, 2009).An example of this can be seen in Flynn's (2008) investigation of women sexually abused by members of their church clergy.Although PTG was not examined in this study, the qualitative reports reveal that the process of being believed and supported was influential in these women being able to shift their negative view of themselves to a more realistic and positive view.Further, the women in this study also reported that shifting their focus of spirituality from a hierarchical, patriarchal church structure to a more relational, spiritual connection, allowed for a deeper connection to self and inner transformation.Although the question of whether PTG is a process or an outcome is left to be answered, from a philosophical perspective, an outcome depends on only where you stand in time.There are others however, who suggest that the pathways to growth are not necessarily the same as the outcomes of growth, and that research would do well to explore further the pathways taken that result in positive post-trauma change (Janoff- Bulman, 2004;Woodward & Joseph, 2003).
Within these above-mentioned complimentary perspectives of human wellness and growth, the recurrent themes of three major processes are apparent.Antonovsky's SOC concept of manageability is echoed in Janoff-Bulman psychological preparedness and Tedeschi and Calhoun's strengthening of relationships with others, as each of these have components of being able to utilise resources, both intrapersonally and interpersonally, as that which assist in the facilitation of adaptive coping.Similarly, comprehensibility, strength through suffering, and changes in the way one views themselves all resonate with the notion that an increased knowledge and understanding of the self is important for positive change and growth.Finally, meaningfulness, existential re-evaluation, and changes in one's philosophy of life have at their core the assumption that changes in one's connection and commitment to one's life is an important determinant of growth, healing, and wellness after adversity.Reflected in these perspectives are themes such as connection, deepening of relationships, the use of knowledge as power, gratitude, and appreciation.By opening up to the whole story of the person, rather than merely focussing on negative outcomes from trauma and distress, a fuller picture of the human capacity to cope, survive, and thrive after adversity emerges.
The phenomenon of PTG has now been shown to occur after an array of traumatic events, from bereavement (Cadell, 2003) and motor vehicle accidents (Shakespeare-Finch & Armstrong, 2010), to acts of terrorism (Take et al., 2008).However, the external event in and of itself is not what 'creates' the conditions for PTG to occur, but instead, it is more the internal disruption the experience creates, the subjective experience of it, and, most importantly, the struggle engaged in to incorporate the event into life.This is demonstrated by the fact that not all witnesses or survivors of a potentially traumatic experience suffer long-term negative effects from their exposure.Indeed some people may perceive an experience to be traumatic whereas the same experience may not be perceived as traumatic by another.The majority of people exposed to any of the myriad of sudden, unexpected, negative events that could be construed as a traumatic experience tend to show initial, shortlived posttraumatic symptoms (a normal response to such an experience) however, most people will not develop PTSD (Bonanno, 2004).Although this holds for the broader scope of traumatic events, sexual trauma is significantly different.Not only are those who experience CSA at a significantly high risk of developing PTSD at some stage than survivors of other sorts of trauma, they are also more likely to endure lifetime PTSD symptoms (Rodridues et al., 1998).Another difference found when contrasting CSA survivors with other trauma populations is the trend for them to show less growth as a group compared to those who have survived serious motor vehicle accidents or sudden bereavement (Shakespeare-Finch & Armstrong, 2010).These differences could be due to the fact that CSA is often a prolonged, intentional trauma, most commonly perpetrated by a loved and trusted abuser, rather than single incident trauma, such as a car accident.Recently it has been suggested that the domains of PTG may have different values to different trauma populations, and to this end it would be wise to explore different types of trauma separately (Shakespeare-Finch & de Dassel, 2009), or with very large and tightly defined groups permitting in-depth analysis of the dimensions of growth in relation to other variables, including depression, anxiety, and PTSD.

Growth, healing, and wellness after CSA
Currently the research exploring wellness and PTG processes and outcomes on the single population of adult survivors of CSA is still emerging and is relatively scarce (Lev-Wiesel et al., 2004;Shakespeare-Finch & de Dassel, 2009;Woodward & Joseph, 2003).What research has uncovered at this point in time however, is that growth and healing after sexual abuse in childhood is possible, that the relationship between growth and distress is currently unclear, and that the traditional ways of working therapeutically with CSA survivors may not be as facilitative of growth and change as other modalities.
Contrary to historical views of outcomes of CSA, research has shown that positive change and growth can and does occur in many individuals.O'Dougherty and colleagues (2007) explored the ways in which 60 women with children found ways of positively resolving their CSA histories.In this sample almost half of the women conveyed that they perceived they had gained great benefit as a result of working through their trauma, whereas only 7% felt nothing positive had come from their experience of CSA.Resonating with PTG theory, the women who felt they had gained something reported positive changes in areas of personal strength and knowledge, changes in their relations with others, including a positive influence in the way they parented their children, and changes in their spiritual or religious domains.Where women situated themselves on their healing journey was important in relation to the amount of growth felt, as those who reported greater meaning as a result of their struggle were also more likely to report their abuse as mostly resolved.Similarly, in a study investigating turning points in men and women's lives who had experienced CSA, Woodward and Joseph (2003) also found people reported positive changes in the way they saw themselves, in their relationships with others, and in their philosophy of life.Further, their findings revealed that it was more the process of gaining a sense of mastery and control over one's life, be that by taking the offender to court, developing a kinder intrapersonal connection, or investing in nurturing relationship with others, that was seen as an important factor for health and recovery in these individuals.
Another finding from PTG research is that is that growth as a result of dealing with CSA and distress from CSA appear to be independent of each other.Lev-Wiesel and colleagues (2004) explored both PTSD and PTG in women who were abused by either a family member or a stranger.Their findings revealed a high positive relationship between PTG and PTSD.Further, those who experienced abuse at the hand of a relative were both more likely to have high levels of PTSD and were also more likely to report positive change and growth.A similar relationship between distress and growth can also be seen in the sample of women studied by O'Dougherty and colleagues ( 2007), although benefits reported from the struggle to cope with abuse resonated across intrapersonal, relational, and existential domains, these perceived benefits were not associated with lower depressive symptoms.What these findings suggest is that the relationship between growth and distress is not yet clear.As has been previously stated, the likelihood of growth occurring out of a traumatic experience is dependent upon both the trauma being severe enough to cause disruption to one's internal world, as well as one's active engagement in rebuilding one's self after such an experience.The process of actually facing the impact CSA has had one one's life and actively engaging in healing from this experience is in itself a process of turning towards the pain and working through it.With that in mind, it does make intuitive sense that growth and distress would occur at the same time.
An interesting finding from research into positive change and growth after CSA is the role of coping in healing.Qualitative research into processes that lead to positive change and growth reveal the adaptive nature of avoidant coping and how individuals often choose avoidant strategies as a way of managing overwhelming distress until the time comes when they have adequate resources to actively deal with their trauma (Phanichrat & Townshend, 2010).Expressions of avoidant coping strategies being 'best-friends' or 'life-savers' show that these ways of coping, for a time, can be highly adaptive and can allow one to function in their lives until such time that they are able to move from avoidance to active engagement (Phanichrat & Townshend, 2010).Although avoidant coping has been reported as being adaptive during a point in time in ones healing journey, staying with this way of coping is not facilitative of growth, and in fact has been shown to negatively correlate with growth (Shakespeare-Finch & De Dassel, 2009).What has been shown is that the absence of avoidant coping, and thereby implied the presence of acceptance of what has actually occurred, or successful coping, assists in the positive resolution of CSA (O'Dougherty et al., 2007).But there is perhaps an optimum time for this transition from avoidant coping to happen, which is likely to be highly individualised.
Beyond coping, Bogar and Hulse-Killacky (2006) found some similar processes of resilient women who had experienced CSA and who were actively engaged in their lives, and who rated their lives as meaningful.What these women revealed is that the processes of moving on from their old self-constructs, active participation in their healing, and achieving a sense of closure to their CSA experiences, is what made the difference to their healing.Traditionally, treatments for CSA have focussed on reducing post-traumatic symptoms in order to facilitate change and psychological improvement (Chambless & Hollan, 1998;Foa et al., 1999).As the majority of adult CSA survivors who seek therapy have experienced PTSD at some point in their lives (Rodridues et al., 1998), the most advocated approach to the treatment of PTSD in sexual trauma survivors has been through the use of cognitivebehavioural therapy (CBT), with particular emphasis on exposure and desensitisation (Foa et al., 1999).Clinical practice however, often reveals that it is precisely this focus on the constant revisiting of the trauma that causes people to terminate CBT interventions early, often with reports that range from dissatisfaction in the therapeutic process by not exploring the core issues relating to their inner experience, through to feeling more traumatised than before therapy due to the constant revisiting of the abusive acts via the process of desensitisation.Far from needing to talk about the specifics of their abuse and to de-sensitise to their traumatic memories, the well-functioning women in Bogar and Hulse-Killacky's (2006) study reveal that actively connecting to the impact the experience of CSA had on their lives and on their sense of self, and changing the way in which they viewed themselves, was the most important determinant of wellness and being able to move on.

A case study in growth and healing from CSA
The following story outlines some of the major themes explored in this paper, and is taken from a women in her 40's who has participated in the authors' research project looking at pathways to health and healing after CSA.Kate (not her real name) experienced on-going, intrusive, contact sexual abuse by her older brother from the age of 8 till 14.She did not disclose her abuse in childhood, and when her abuse was made known to her family as an adult, she was not believed or supported by them.The story is punctuated with reference to the themes covered in this chapter to connect the theory and research discussed to the story of one woman's journey to healing.

Secrecy and shame
The reaction to being asked by someone to come out about the abuse is often too confronting.Kate had a typical reaction to the suggestion: "NO! Imagine what that would do to the family!"

Subjective distress at the time of abuse
Kate was asked to use a five-point scale (1 = a little upsetting -5 = extremely distressing) to describe her levels of distress at the time of the abuse.She said: "(when it was happening) I don't think I knew enough, but maybe 2 ½ -3.Looking back now I would say a 4. I feel as a child, with more time and knowledge, and because it had carryon effects and the effects were more after then during.So then I would say 4 ½, give it a 5!!!It is interesting how it changed!"Negative effects of the abuse "Depression, suicidal ideation, being scared of everything in the world, headaches, low selfesteem, poor body image, fear, guilt, shame, perfectionism.It made me feel worthless, not loveable.I thought the world was scary.I had a sense that there was something wrong with me and that I was all alone.Lack of trust, I couldn't trust myself.Really, really poor selfesteem.Always wondering what people were thinking of me and did people see through me?There was just this fear that I could not cope, lack of trust in myself.Poor relationship with my mother".
On how the attachment relationship was more impactful than the abuse "I remember before I was eight, I thought I had the best mother in the world, and there was a time when I was eight or nine when it all changed.I feel strongly that the poor relationship with my mother has had more detriment than the actual abuse, and the way she reacted to it (the abuse) too, it has a bearing on that.The first reaction (from my mother) was "No, it didn't happen", and she has said "well this is just the things that kids do".And whether it is just in my mind thinking that "your mum doesn't love you", I have learnt that this has a BIG impact; it has had one on me".

Acknowledgement of abuse started the healing process
"The first time in my adult life that I ever had talked face to face with (the offender) he said, "It was nothing", and I said "It's not like nothing happened".That was the first time that I had acknowledged it in his company.And then, because I was having flashbacks and not sleeping after that phone call, I then rang the SA (sexual assault) unit and started the first real counselling that I had".Prior to this phone call, Kate had brief discussions with her husband about her abuse, but would minimise the impact it had on her, saying: "It wasn't much; I was one of the lucky ones.I think I allayed his (her husband) anxieties by saying I was one of the lucky ones, I am fine".After verbally acknowledging the abuse to her offender, this brought to the surface all the latent emotions that were still within her and started Kate on her path to healing.
After a process of active engagement in her healing, these are some of the pathways Kate identified in her eventual resolution of the past and her new appreciation of herself and her life.

Growth as a process
"There were times (after the disclosure) when I was feeling very vulnerable with two young children and all this going on and lots to carry once it had blown up, and I stood on my own.And it was all good, for me to prove that once I am in the firing line I was able to trust my own judgement, and that helped me get through too.Circumstances transpired that put me in situations to enable me to have a chance to prove to myself that I can cope".This quote indicates the perception of manageability and also of psychological preparedness for future life experiences that may threaten her sense of self, and being able to trust that she could cope.
When describing the turning points for her that were gained through a therapeutic process, Kate said: "Something in counselling that has really helped is that I am only responsible for myself, but I AM responsible for my stuff.That was very powerful, and it helped me release old feelings of responsibility for others and for the abuse.Overcoming the mind talk, that has been a wonderful gift.Just being able to know that I am not my mind, I am not my collection of thoughts, I am so much more.I have come a long way; I was so in my head and could not get out -knowing now that I am not my collection of thoughts.I read a lot about CSA and perpetrators and got all this knowledge.I think the knowledge helped too, once I saw that it wasn't just me and I read it is NEVER YOUR FAULT -that was a turning point, once I stopped blaming myself it was a real unblocking.Also, moving from the 'victim mode' (was important).I think the victim phase served me, it helped, because if I never felt like that I would not have been able to release all the stagnant energy and toxicity in me.I had to feel it to heal it, but I didn't know that yet.And victim is not a good place to be so I wasn't going to stay there".In this quote, Kate reveals her new-found capacity for comprehensibility of her experiences.She also demonstrates that she has found a new sense of personal strength through her suffering.This quote also highlights the importance of connecting to the pain of being a victim, and how it is described as a necessary place to be, for a time.It also shows the transformative power of moving on from only seeing one's self as a victim to feeling more in control.
A very important component in growth from trauma is the notion of acceptance (e.g., Shakespeare-Finch & Copping, 2006).Acceptance does not mean that you are accepting of the abuse but rather, that it occurred: "I let myself FEEL.And there was SO MUCH STUFF IN THERE!!I felt it pushed down to my toes, burying, bottled, and pressure.And whenever I cried, it would just let it.At first I would stop it because it hurt, but I learnt very quickly that the more I let out I felt lighter and better.And rather than trying to stop it I just let more come up and I got very good at it, and it would come up and up and up, and in the end I just loved it because when I went through those periods I saw past it as another big step forward.So cry, cry, cry!It's all good" In the latter part of this quote, Kate is describing a sense of meaning that she attached to this process, and how the process of accepting the reality of the pain of her felt experience of her emotions allowed her to gain a sense of mastery.

Growth as an outcome
The following quote demonstrates a belief that Kate has; that she has changed fundamentally: "In terms of the old self-beliefs, they are non-existent now.I know they are non-truth.Now I think of myself as pure, intact, not damaged, very loving, I don't need to judge myself.The shame has gone, and the guilt.Knowing that the way I do it is rightbecause that is something that I grappled with from a self-esteem point of view, feeling damaged -(I felt that) everyone knew how to do it (life) right but I didn't.And I didn't trust my own intuition.But the way I do it is the way that is right".Her change in her view of herself was described as "That was amazing".Kate also expressed that she had experienced changes in relationships with others through the conscious struggle she engaged in to come to terms with her abuse: "I think my growth has affected my parenting in that my children, they have to KNOW that I love them.I also have a paradigm that I live with now, that everything is part of a perfect plan.And I have an appreciation of nature!Through healing, growth, and looking within, by connecting to self I realised I am connected to nature" This comment describes a fundamental shift in philosophy of life.

On-going healing
As we have said throughout this chapter, healing and growth do not discount elements of ongoing distress such as intrusive thoughts.However, Kate said: "Things still come in to my mind but I recognise them straight away, I am not scared of my thoughts anymore, I see the thoughts for what they are".Below is a summary of some of the pivotal points along her journey that Kate states as being the most fundamental in her healing.
"I had a Lomi Lomi massage and I think that was a big, big, big turning point, and I haven't stopped growing.I just totally opened to receiving healing (active engagement in healing).I first thought 'Oh wow, spirituality', but I was ready for it.She (the Lomi Lomi therapist) also sat and talked to me first, and it was who she was, and it was just an open, non-judging relationship "(acceptance).
"My husband being a supportive partner has been very significant in my healing.I really respect him and he respects me.He saw through the manifestations (negative effects of the abuse) and saw the real me.And I have had snippets of the real me throughout this time, but generally it was with people in my life that I felt real love.I felt my husband loved me for who I was underneath and it just helped me get rid of the shame, the guilt.It was acceptance" This is obviously another example of the power of acceptance, and also of validation and connection; being able to connect with the truth of herself as being worthy of love and respect.
There were also significant others who assisted Kate on her healing journey.The following quote explains the importance of emotional and instrumental support in promoting wellbeing: "And something significant in my healing, I had an uncle and as a young child I idolised him.I thought he was kind and gentle and handsome, strong and a man of his word, held his own.He met a partner and she and I connected, she was the most beautiful woman in the world, to me she was an angel on this earth, and I think (the relationship) had an impact on the rest of my life.It was a really significant relationship connection.I saw the love between the two of them, so I saw what was possible.That good, healthy modelling and I think it opened my eyes up and started to connect to the real me, and I resonated with that.And I would hang out every evening for hugs, because I would get a hug every evening before bed, I wished it would never stop that hug, particularly from her, but my uncle as well.I could trust, there was no mistrust there, but I did not disclose to them".Kate continued to discuss how her uncle's partner was a pivotal person in her life.She said: "She taught me that the most simple things in life are to be celebrated.Every meal she would set the table beautifully, clean sheets on the bed, daily a fresh towel, and if it was raining she would cherish the rain.And that is with me now to this day and that has just grown bigger and bigger.Love of nature and that hope that you could have a marriage that was beautiful, happy, loving.So to me that put a standard in my head that that is what I wanted.So that was a really significant thing in my healing, she was an angel on earth and I have no doubts about that, so that bought the real me out that I knew was there.It seemed pure, clean, loving.Pure love without all the games.Trust."It was through this relationship that Kate connected with a feeling of self-love.Kate describes this particular relationship in her life as reminding her of: "A faint memory of love for myself" that she drew upon as a source of strength whilst working through her healing.
Describing processes that lead to healing, Kate said of herself: "She [the Lomi Lomi therapist] told me to do a burning ceremony and that really helped, the visualisation.She came up with good things to read.I read so much"!! Kate also engaged in journaling."Gratitude journaling, I would highly recommend it to anybody.That got me in touch with who I am and what resonated with me.That is self-love, because it made me stop and actually think 'what do I like'?And one thing led to another and then I could see, even just sensing, what kind of things I was writing down -beauty.It showed me what was important in my life; relationships, nature.Yeah, so gratitude journal is right up there for power for me".In this quote, Kate is describing how the process of learning to connect with herself, and what is important to her, allowed for a deepening relationship to her inner life, and connected her to the truth of who she really is.
Kate was also asked to reflect upon any benefits she felt had come out of her healing journey; elements of her life that perhaps may not be there, had she not engaged in healing from her experiences of CSA.To this Kate stated: "A deep desire to be happy and content.Spiritual awareness.Spiritual development.Peace.Self-love.Living in my heart more, trusting intuition.Art, painting, that has been wonderful.I was always good at art and somewhere along the line as a child I got the message that was a waste of time, but reconnecting to that has been a big part of my healing.Improved relationships.Improved parenting.Flowing with things that are happening without reacting".In this quote, Kate clearly expresses how the struggle to heal from CSA has not only provided her with a deep and fulfilling life, but that she also feels her life has been more enriched and meaningful for the painful experiences she has actively engaged in overcoming.

Implications for therapeutic practice
There are many implications for main-stream therapeutic practice that can be taken from this case study.First, it is important to acknowledge that "mainstream practice" indicates the Western tendency in psychiatric and psychological literature to favour CBT as a therapeutic intervention of choice following any kind of trauma (e.g., Forbes et al., 2007).Although CBT clearly has its strengths, the processes outlined in this case study highlight aspects that speak to deep processes, such as the importance of healthy and authentic responsibility-taking, connection to inner experience, including the energy of emotions within the body, as well as the relationship one has with ones-self, including beliefs about the self and learning to trust, both in one's self, and also in others.
Feelings of responsibility and guilt for the abusive experiences, either in part or in full, are commonly experienced by those with a CSA history.In addition, there is also the assumed responsibility that survivors place on themselves in relation to the ramifications of disclosure of the abuse, which often impacts on relationships within their family of origin, particularly if the offender is intra-familial.This was highlighted in Kate's statement regarding her thoughts on disclosure "Imagine what that would do to the family".In the therapy room, assisting those who have experienced CSA to clearly understand the dynamics of abuse, including unequal power dynamics, grooming behaviours, and learned helplessness, is a most helpful way of assisting clients to begin transforming the way they see themselves within the abusive relationship.Searching for specific, concrete examples within the client's narrative that provide ways of showing how the offender is solely responsible for the abuse, and providing many opportunities to uncover the unique effects their experience has had on the way they come to terms with the issue of 'responsibility' in their day-to-day lives, can help to facilitate this change.Further to this is the importance of learning to accept a genuine and authentic measure of responsibility in order to gain control and mastery over one's life, thus facilitating the move from feeling like a victim, to knowing they can cope with what is in front of them.
Acceptance of the emotional impact of CSA, such as connecting to the often painful, physical experience of feeling emotions within the body and acknowledging their existence, was an important turning point for Kate.Physical detachment, or dissociation, from emotions is a common coping mechanism in those who have experienced CSA, and occurs in varying degrees of detachment.However, a common occurrence is that, with the protracted use of dissociation from inner experience as a means of coping, comes a sense of not knowing one's self.Further, being detached from physical experience can impair one's ability to identify emotions within the body, and as such, people often report having a sense of existing 'outside' of their bodies.This again reaffirms the important distinction of this particular trauma happening within the body; shutting off one's connection to felt sensations is an understandable way to deal with such an intrusive, physical experience.Within therapy, teaching modalities that assist in the development of acceptance of experience, such as breathing techniques, meditation, and tactile exercises such as body work, can all be used as ways of assisting clients to become more aware of, and comfortable with, their inner experience.Learning to reconnect with one's body through acknowledgment and acceptance of emotions is another avenue that provides opportunities to experience a sense of mastery and control.It is also of great benefit to clients if therapists have a personal and working knowledge of how the processes of meditation and breath work are both utilised and cultivated, and to this end it is suggested that therapists choosing to use such activities with clients are themselves practitioners of these things.
Learning to see the truth of who one is, distinctly from the 'un-truth' of long-held intrapersonal misconceptions, such as the negative core beliefs often held by those who have experienced CSA, is another point demonstrated in the case study as being important in healing from CSA. Core beliefs based on feelings of inherent badness, wrongness, or deficiency are commonly expressed in the therapy room by survivors of CSA, and also by Kate.As Kate expressed, "Once I stopped blaming myself; that was a real unblocking".This point speaks to the importance of assisting clients in their development of a caring, unconditional acceptance of who they are.This process allows clients to move from a place of shame and guilt to a more honest view of seeing themselves as whole and possessing selfworth.
Another aspect noted in the case study is the importance of a sense of mastery, self-efficacy, or a trust in one's own abilities; in being able to trust in one's own judgment and prove that one can cope.Being able to shed the identity of 'victim' requires a movement from helplessness into a position of knowing one can help one's self.Learning to trust one's own judgment is an essential foundation on which to begin to build, or re-build, trust in others; an issue that often is a point of difficulty for survivors of CSA, in light of the abuse of trust CSA often entails.Inherent within discussions of strength, mastery, and most importantly the judgment of self that occurs with such experiences, healing, as it were, is best discussed with clients as something that should be viewed as a dynamic and on-going process.

Summary
Research regarding the experience of negotiating childhood sexual assault has postulated numerous variables that apparently inform outcomes.The outcomes that research and literature have predominantly focussed on are largely deprivational, which is understandable, and arguably morally just, but are also largely void of hope, growth, or transformation.Trauma is labelled as such because it is an experience, or perhaps multiple experiences, of having one's inner core fundamentally shifted by something so profound, so threatening, and helplessness rending, that it affords significant life change.Literature has focused on the insidious impacts, overtly displayed or covertly expressed, and a number of potentially diagnosable pathological impacts of such life experiences.What is evident is that many more people than not are living normal lives as survivors of CSA, and other traumas, and most importantly, that one outcome measure denoting difficulty in adjustment does not negate the presence of other markers of positive development.
It is important in the pursuit of promoting mental health, to also acknowledge the many ways in which a CSA survivor may heal, learn, and/or use the experience of their lives in a positively transformative way.It is the very nature of CSA being insidious, invasive, pervasive, shameful, anxiety-provoking, soaked in self-doubt, and brimming in hypocrisy and betrayal that makes it the single (or enduring) trauma type that is constantly shown to be predictive of a higher prevalence of negative impacts than other traumatic experiences.However, there is a more holistic picture that needs to be kept in mind.Beyond the oftenreported negative impacts, there are also many survivors who find a path to healing from these deleterious effects, or at the very least, find ways that allow them to be able to maintain a level of well-being and functionality that leads to productive and engaged lives.Exploring with greater scope the pathways and determinants that contribute to health, wellbeing, healing, and growth in individuals who have experienced CSA, could assist greatly in broadening the way therapeutic intervention is looked at and undertaken with individuals who have experienced this particular trauma.