Helping Victims of Incest: A Challenge to

Helping Victims of Incest:A Challengeto
Family Practice -
GrahamBresick
Summary
Two Patients disclosed tbeir secret of
incest in a.family practice setting,
wben tbrce aspectsoJ.lamily
medicine uere put it'tto practice:
pofiient -cent redness,a t b erapeutic
relationsbip ancl continuity of care.
Tbis made tbe autbor sensitiue to tbe
problem, and, by repofting these
patient studies, be wants to make
Jamily pbysicians auare c,tftbe size iJ'
tbe prr.tblem an(l bou u,ell tbqt are
placecl tc.tcare .for thesepatients.
S AfrFam Pract 1994;15:1O5-9
Dr G F Bresick
MBChB(UCr)DCH
Unit of Familv Practicc/Priman' Care
Dcpt of Medicine, Mcdical School, UOT,
Obsen'atorv.
KEYWORDS:
Physician,Family;Incest;
PhysicianPatientRelations;
CaseReport
Curriculum vitae
Grahan-rgrircluatcclin 1980 at UCT
(MBChB) and did his internship at ICng
Edu,arciVl I I in l)urban. Hc spent quite
somc timc ;rt various dc;lirrtncnts of
anacsthetics,but rctumed to the Cape to Red
Cross Hospital and obtaincd a DCH from thc
College of Medicine. Aftel general practice
u'ork, hc joined the SACLA Health Project at
Crossroacls(Cape) for threc )'ears. In l988
he joined the Primary Care/Famill'Practicc
Unit at UCT, rvhcre hc is prcscntlv invoh,ccl
in student teaching, thc clevelopmcntof
undcrgradLlrtecurriculum in Family Medicinc
a n d c l i r r i c allo r k i n l c o m n r u n i n p r i m r n c l r e
clinic. Hc is bus.vdoing the MPrax Med
thror.rghMcdunsa, and his mcdical intcrcsts
arc the application ofthe philosophr,,
principlesaud practice of family mcdicine in
priman'carc sen'icc,and the doctor patient
relationshipas an opportunity fbr en:rblir-rg
personalgro\\'th aud do,elopmcnt. Graham is
marricd to Jenn,vrvho u,orks in il pastoral care
tealI.
Patient-centredness,building a
thcrapeutic relationship and
continuity olcarc - thcseimportant
dimensionsof the family practice enable victims of incest to disclose
their'secret'.
consultation regarding the stress,and
while on her way to the door, she
expressedthe desireto discuss
anothcr matter at a subsequentvisit.
An appointment was made for the
following week. She related this
story:
While watching a TV documentary
on rape, she becameaware of feeling
intense discomfort but could not
understand why. The following day
she was visited by an uncle whom she
had not seen for 20 years and
immediately recalledan incident that
had occurred at age 7 years. He had
fondled her and threatenedthat ifshe
told her parents he would deny it and
that her father would punish her.
The incident was never disclosed.
She expressedfeelingsofanger and
of feeling 'dirty' and questioned
whether this incident could have
been a factor in her depression,and
whether she had been to blame.
An account of two disclosuresis
presentedand the implications for
family practice discussed.
DC, a 27 year old woman) presented
with intermittent backache.chest
pain and sweating. These symptoms
had been present for a few weeksand
occurred mainly at work. She had
consulted many doctors for similar
complaints and had received
svmptomatictrcatment.
M,v first contact rvith ]D, age 52) was
during a rolltine visit to the day
hospitalfor hcr anti hypertensive
rnedication. Previoushistory
included treatment for a peptic ulcer
and depressionat a tertiary hospital.
An inquiry regarding stressrevealed a
history of rape (for which she had
had 6 months of psychotherapy)the
previous year. l{er work situation
r.vasstressful and included demands
for sexualfavours by her employer.
During the consultation she revealed
a stressful relationship with her
brother. At the end of a fbllow-uu
This disclosureclearly embarrassed
DC but she seemedto need to talk
about it - even though it was my first
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SA Famih' PracticcMarch 1994
SA Huisartsprakn'k Maart 1994
... Helping Victims of Incest
contact with her. She experienced
guilt and inner conflict which she felt
accountedfor some of her symptoms
doing so was obviously difficult for
her and unsetded her fbr several days
afterward.
As this was a longstanding and
complex problem, I offered her a
further consultation and exoresseda
Discussion
Incest occurs far more often
than is commonly thought
willingnessto help. She expressed
r c l i e l ' a th a v i n gh a d t h e o p p o r t u n i t y
to talk openly and acceptedthe offer.
Subsequentconsultationsrevealed
that she had had a number of
admissionsto 3 differenttertiary
psychiatrichospitalsfrom age 17.
She was not able or was reluctant to
saywhat diagnosishad been made
but revealeda history of3 overdoses.
1. Tbesize of tbeproblem
Incest is defined as sexualintercourse
or other sexual activity bctrveen
personsso closelyrelated that
marriage between them is legally or
culturally prohibited.'
Recent reports indicate that incest
occurs far more frequently than is
commonly thought and that most
casesremain hidden. Accurate
statistics are not available in Sor-rth
Africa but estimatesof child sexual
abuse'givesome idea of the
prevalence:
involving fbrce .3
A surveyof 796 American college
students showed that 28% werc
victims of incest - half involr.ed
siblings- and that l9% had been
exploitative.n
2. Long-termeftbcts
The presenceand severityof longterm efTectsare related to tl'redegree
of force r"ised,the extent of thc
physicalintrusion and the length of
the period during which incest
occurred.
50% of fbmale victims in a
cornmunity-based(non clinical)
sample believed that the abusehad
* 80% of abusersare known to the
child. most of whom are family
members. 20o/owerefbund to be the
child's natural father.
About one in three girls is
sexuallyabusedby age l8
* approximately one in three girls is
sexually abused in some r,vayby age
l8 years.
significant long-lasting effectson
their lives. A clinic basedsample
showed much higher rates of longterm eflbctsand greater morbidity.s
These estimatescorrelatewith
American studies:930 women were
* very lor'vself esteem: evident in
both the patients presented.
She expresseddisillusionment with
past treatment and was unwilling to
consider referral. I therefore decided
to establisha therapeutic relationship
and provide continuity of care as a
basisfor further management. A
number of sessionswent by before
she began to respond more openly.
Although she was willing to attend,
she was reluctant to talk. There was
clearly more to her story than had
been offered. During this time she
was clinically depressed.
80% ofabusersare l(Ilown to
the child, often family
members
Initially she was unwilling to discuss
her childhood. When pursuing this
at a later stage,she disclosedthat she
h a d b e e nt h e v i c t i m o f i n c e s t
perpetrated by two older brothers
from age 8 yearsto 14 years. She
had never disclosed this before and
interviewed in a random sample of
San Franciscohouseholds. 38% had
been sexually abused befbre they
were 18 yearsold and 16% had been
v i c t i m so f ex p l o i t a t i v ci n c c s t ,i e
* chronic traumatic neuroses:
repetitive thought, emotional and
behaviouralintrusions eg
n i g h t m a r e sf,la s h b a c k sp,a n i c
attacks,recurrent obsessiveideas,
promiscuous behaviour. Patients
commonly re-experiencethe
frightening and painful elementsof
the actual abuseafter disclosure
and show an exacerbationoftheir
symptoms. Disclosure unsettled
D C , r e q u i r i n gm o r e f r e q u e n t
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SA Huisartspraktyk Maart 1994
SA Familv Practice March 1994
,
HelpingVictimsof Incest
consultations. JD was destabilised
when her memory was triggered
and required psycho-emotional
support.
* continuing relational imbalances:
difiiculties with relationships hinder
the development of character,a
s e n s eo f s e l fa n d m a i n t a i r r i n g
positive relationships. DC has a
poor senseof self and has difficult
relationshipswith her family nnd
has no meaningful friendships.
* other long-term effectsincludc
depression,anxiety, substance
abuse,self-destructivebehaviour
including suicide,sexual
maladjustment.l DC periodically
abusesalcohol and has taken
severaloverdoses.
Victirns of incest in childhood were
found to have a higher prevalence of
virtuaily every psychiatric disorder
o t h e r t h a n a n o r e x i ar ) e r v o s am) a r r i a ,
pathological gambling and
schizophrenia. They also had a
higher number of psychiatric
diagnosesthan comparison subjects.'
The two accountspresenteddiffer
markedly in terms of the degreesof
force used, the duratior-rof incest and
the extent ofphysical intrusions. lD
showed a few of the long-term effects
and her symptoms resolvedquicldy.
DC required longer-term and more
experiencedhclp.
J. Help-seeking pattern and
presentation
Most victims do not presentwith
complaints of having been abused.
The majority seekhelp for psychiatric
symptoms or interpersonalproblems.
DC preser-rtcd
with somatisation
hiding and underlying depression. In
earlier care, the absenceofcontinuity
and continuing care probably
contributed to this pattern.
JD repressedthe memoqr of the
o r i g i n a ls t r e s s o r .M a n y v i c t i m sa r e
known to presentwith the sequelae
and the history of incest llrll only be
obtained if memory is triggered."
I r r b o t h t h c s cp a t i e n t si n c e s l
r e m a i n c du n d i s c l o s e fdi c rr n a n yl e a r s
despiterepeatedcontactswith
p r i m a q , s c c o n d a r ya n d t e r t i a r y
- incl'ding
scrr,,ices
PsYchiatry.
Incest remained undisclosed
for many yearsdespiterepeated
contact with primary
secondaryand tertiaryservices
- including psychiatry
1. Tbe appctrentfailure
of tbe
seTaices
Both lD and DC had had psycl-riatric
treatment br"rtthe incest was never
disclosed. DC's treatment included a
number of admissionsaswell as
b e i n g t r e a t e da sa n o u t p a t i e n t .
Researchersl-ravefbund that incest
victims are generally unlikely to
receivebenefit from mental health
institutions.
"... the underlying negative eflects do
not emerge in any recognisableform
u n t i l a l i e r d i s c l o s r r r eb,u t i u c e s t
victims very rarely disclose
spontaneouslyand therapistsdon't
I07
SA Familv PracticeMarch l994
ask. Instead, fbrmer victims present
for trcatmcnt rvith a clraractcristic
'disguisedpresentation'. If this
becomesthe focus of treatment, the
history remains hidden and the
effects are not available for
treatment."
The result is frustration and failed
therapy. Expcriencedworkers have
fbur"rdthat although patients do not
disclosespontaneollsly,they will
'almost invariably discloseafter
specificinquiry ... patients have
broken silencesofup to 56 years."'
5. Implications J'or Fctmily
Practice
Points to note:
* Incest is a common problem'uvith
often serioussequelae.
* Most of the problem is hidden and
presentsin a disguisedmanner.
* Facilitating disclosureis the first
stepin the healingprocess.
* Experiencedu,orkersagreethat it is
treatableand that much can be
done in primary care.
* The size of the problem outweighs
specialistservicesavailable.
Questions raised:
* can the family rnedicine approach
contribute toward carlier
recognition and trcatmentf
* what attitudes, knowledge and
skills are required to help patients
in the lamily practice settingl
SA HuisartspraktyhMaart 1994
Helping Victims of Incest
" rvhat treatment is appropriatein
farnilv practicef
* rvhat prcventive strategiescould be
appliedf
6. Toutard assisting (adult)
uictims oJ'incest in Family
Practice
Raising ottr leuel o.fawareness: by
reading, speakingto expcrienced
w o r k e l sl u d l t t e n d i u g s c r n i n l r r se,t c .
I u'as scnsitisedto the problcm and
its extent thror-rghthe encountcr with
nvo patients rvho rverc willing to risk
disclosureand become my teachers.
Thcy highlighteda gap irr m1'
kno.,vledgeand experienceand
stimulated learning.
Identilying uictints and.facilitating
clisclosure: aspectsof the family
rnedicineapproachmay enable thc
identificati<>nof victims ar-rdfhcilitate
disclosure:
- x t t e l ) t i o ut o t h c t h e r a p e r r t i c
pcrson-centredncss
relatior-rship,
and continuity of care.
- an understandingof hclp-sccking
prttcrns rvhich mav point to a
hic'ldcnproblem.
- a systemsa;rproircht<>
understanding and helping farnilies.
Direct qlrestioning of adults rvith
l o n g s t r u d i u gp s y c h i a t r i sc v m p t o m si s
advocated.
Irr thc tu'o ilccoul'ltsgivcrr,a paticutcentrcd approach,continuity of care
and a therapeutic doctor-patier-rt
relationshipfacilitated disclosr-rre.
Management
'An experiencedgeneral clinician is
usually able to provide excellcnt
trcatment ... given knowledge of the
underlying negativeeflbcts.'u
Both supportivc and insight
psychothcrapyare commonly used in
generalpracticeTand given a
knorvledgeof incest, the same
principles and techniqucs can be
applicd.
JD rcquircd brief insight and
supportive thcrapy (2 sessions)to
restore eouilibriurn after disclosure.
I found it helpful to set aside
an afternoon per week for
counselling- it prevents
disrupting clinical demandsand
helps maintain a more
appropriatemindset.
psychiatrist. Refcrral should be to
someonewith experiencein dealing
with victims of sexualabuse.
All victims of ongoing incest and
sadisticincest require refcrral to a
specialist.u
7. Preuention-
the real cballenge
i) In tbe clinical setting
Incest is a family problem. Family
physicianshave a concern lor the
individual within the family context
and are therefore well placed. The
following should be r-roted:
* a raisedindex of suspicion. The
hidden nature and high prevalencc
meansthat we see (and
misdiagnose)many of the victims
and potential victims without being
ar,vareof it.
* identilf ing children/families at risk.
Availi,rbleseruicesdcpend on the arca
and should bc discussedn'ith a local
social 'uvorker,psychologistor
The family at risk is one where the
mothcr is cmotionally and physically
cxhaustedand thc fhtheris
demanding and emotionally needy
becauseof a deprived childhood.
Thc daughter begins to fulfil some of
her father's emotional needs. I(nown
as thc parentified child, she is one
who, at an earll, age, does more than
merely help her mother (often a
parentified child herself) in the home,
but rvill actually assumeresponsibility
fbr domestic activitiessuch as
cooking, clcaning and caring fbr
siblings etc. If thc mothcr Ieaves
home fbr a while (eg fbr a
confincment) and the father is angry
that his rvife is not available,the
parentified dar"rghteris at risk of
being r.rsedto fulfil sexualnceds as
well.
I08
SA Huisrrtspr.rktvl<Maart 1994
DC required rnorc intensive and
skilled therapy. This is being done in
conjunction urith a psychotherapist.
Practicalpoints: I have found it
helphrl to set asidean aftcrnoon a
rveek fbr counselling. It helps avoid
thc disruption of other clinical
dcmandsand enablesthc shift into a
more appropriate mind-set. The
need fbr confidentiality has required
i scpar.ltc,confidentialpatient
record.
I{eferral
SA Familv PracticcMrrch 1994
... Helping Victims of Incest
* Otber risk
factors:
- the disinhibiting effect of alcohol.
- after the emotionally needy father
has suffered an important relational
loss e.g. the loss of a parent.
- family history: women who are
untreatedvictims of incestare at
risk of becoming the mothers of
incest victims and the wives of
offenders. The parentifying process
leads them to choose men who are
emotionally deprived and in need
of caring. The cycle is then
repeated.
Informed history taking and assessing
family function may elicit these risk
factors. Early attempts to support
the family and/or referral for family
therapymay be important preveutive
interventions.
ii) Beyond tbe clinical setting- Rape
Crisispublication'
* promoting children's rights.
* working toward improving the
status of female children and adults
i n a m a l ed o m i n a t e ds o c i e r y .
* promoting respectfor children.
* educating children to recognise
situations/actions which place
them at risk and how to respond in
such situations.
Conclusion
While some may consider treatment
of incest victims by family
practitioners to be inappropriate,the
size and seriousnessof the oroblem
demand the following:
- an awarenessof the nature and
extent of the problem.
- an ability to recognisea victim and
someone at risk.
- an ability to facilitate disclosureand
manage the immediate postdisclosurephasesensitively.
- knowledge of availableresourcesfor
help and referral.
Researchin the family practicesetting
could make a significant contribution
to understanding and treating the
victims of incest - many of whom
have significant morbidity. The size
ofthe problem suggeststhat the rate
of mis-diagnosisand inappropriate
t r e a t m e n tr e s u l t si n s i g n i f i c a n t l y
prolonged suffering and wastageof
resources.
Help should be more readily available
for vicrimsin the communiry, eg
Comirg
in April
community health centresshould
have a trained person who can
provide a primary level of care and
collaborate with other workers.
Prevention provides the biggest
challenge. Much of our work is
'...often like pulling drowning people
out ofthe river, never having the
time to go upstream and stop
whoever is pushing them in.'s
References.
1. Pribor E F, Dinu,iddie S H. PsychiatricCorrelates
oflncest in Childhood. Am J Psychiat1992;
119(.I):52-6.
2. Yan Zvl N, Shapiro R. Child SexualAbuse. Ilrpe
Crisis 1989.
3. RussellDEH. The SecretTrauma: hcest in the
Lives of Girls and Women. New York: Basic
Books,1986.
4. Finkclhor D. SexuallyVictirnised Children. New
York: Frcc Prcss,1979.
5. Hernan J, Russell D, Trocki K. Long-tcnn 811'ccts
of Incestuous Abuse in Childhood. An ] Ps,vchiat
1 9 8 6 ; 1 4 3 ( 1 0 ) : 1 2 9 36
6. Gelinas D J. The Persisting Ncgativc Effccts of
Incest. Ps,vchiat19831 46:312-32.
7. Peterkin A D. Drvorkind M. Comparirrg
Psychotherapics in Prinary Care. Can Fan Ph,vs
l99ll.37:719-25.
8. Brier J. Therapy lbr Adults Moleste d as Childre n.
Springer Publishing, 1989.
Note:
I r.vish to thank Dr Esther Sapire for her
helpftil
comments
in the writing
of this article.
... the New
$OUTHAFRICAN
ru
* altering the perspectivethat sex and
violence are two sidesof the same
coin.
* campaigningfor a more
appropriateChild Care Act.
109
SA Familv lractice March 1994
SA Huisartsprakn,kMarrr 1994