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Qualifications, training, and perceptions of substance abuse counselors who work with victims of incest
Addictive Behaviors 28 (2003) 1193 – 1201
Short Communication
Qualifications, training, and perceptions of substance abuse counselors who work with victims of incest Timothy P. Janikowskia,*, Noreen M. Glover-Graf b a
Department of Counseling, School, and Educational Psychology, 409 Christopher Baldy Hall, University at Buffalo—SUNY, Buffalo, NY 14260-1000, USA b Department of Counseling and Human Services, Syracuse University, Syracuse, NY, USA
Abstract The study was an initial investigation into substance abuse counselors’ qualifications and their training related to providing counseling for incest. Perceptions regarding the incidence of incest and insights into the difficulties of serving this subpopulation were also gathered. A total of 121 practicing substance abuse counselors, randomly sampled from treatment facilities across the United States, completed the ‘‘Substance Abuse Counselor Survey on Clients with Incest Histories’’ (SACSCIH). Participants estimated that, on average, about 24% of their clients were victims of incest. They also suspected that, on average, an additional 14% of their clients were victims of incest but did not report this information to the treatment staff. Participants revealed how they collected incest-related information and the various challenges they face in treating these clients. Data are analyzed descriptively and recommendations for future research are presented. D 2002 Elsevier Science Ltd. All rights reserved. Keywords: Incest; Substance abuse counseling; Counselor perceptions; Counselor qualifications; Counselor training
1. Introduction Often, the behavioral and psychological adaptations that people make in response to incest trauma (Hyde & Kaufman, 1984) include the abuse of alcohol and/or drugs (Glover,
* Corresponding author. Tel.: +1-716-645-2484x1055; fax: +1-716-645-6616. E-mail address: [email protected] (T.P. Janikowski). 0306-4603/02/$ – see front matter D 2002 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0306-4603(02)00217-4
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Janikowski, & Benshoff, 1996). Research consistently shows that the rate of incest is much higher in alcohol/drug treatment populations than in the general population (Benward & Densen-Gerber, 1975; Cohen & Densen-Gerber, 1982; Covington, 1982; Sterne, Schaefer, & Evans, 1983). Research studies examining incest in alcohol/drug treatment populations are summarized in Table 1. These researchers have all hypothesized that psychoactive drugs may be used initially as a strategy to repress or deny the trauma of incest, which then may lead to the equally serious problems of chemical dependency and addiction. Hyde and Kaufman (1984) identified several psychological reactions that are indicators of sexual trauma and incest such as amnesia, disassociative episodes, phobias, flashbacks, low self-esteem, and poor body image. Substance abuse counselors are therefore confronted with such issues in clients who are incest survivors, however, little is known about how substance abuse counselors are prepared to deal with such problems. The purpose of the study was to survey a sample of substance abuse counselors about their qualifications, training, and experience related to counseling clients who were victims of incest, specifically: (1) training in issues related to incest and sexual abuse, (2) estimates of the frequency of incest victims on their caseloads, (3) method of discovering clients’ incest histories, (4) barriers to clients’ disclosure of incest histories, and (5) problems they faced in addressing incest-related issues in the context of substance abuse treatment.
Table 1 Research on the incidence of incest among adults in substance abuse treatment Researchers
Gender studied
Method
Type of treatment
Number of subjects
Percent reporting incest
Benward and Densen-Gerber (1975) Watley and Densen-Gerber (1976)
Females Females and males Females
Interview Interview
Drug Drug and alcohol Drug and alcohol Drug and alcohol
118 237
44% 38% (female), 25% (male) 40%
Drug Drug and alcohol Drug and alcohol Drug and alcohol Drug and alcohol
35 75
Hammond, Jorgenson, and Ridgeway (1979) Cohen and Densen-Gerber (1982)
Survey
Females and males
Survey
Covington (1982) Sterne et al. (1983)
Females Females
Interview Survey
Schaefer and Evans (1985)
Females
Survey
Glover, Janikowski, and Benshoff (1992) Glover et al. (1996)
Females and males Females and males
Survey
a b
Survey
Percentage was characterized as low but no value was reported. Percentage includes perpetrators and/or victims.
44 178
100
28% (female), unreported (males)a 34% 46% 39%
77
54%, 40%b
732
55%, 29%
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2. Method 2.1. Instrumentation and procedures The authors created the Substance Abuse Counselor Survey on Clients with Incest Histories (SACSCIH) through adaptation of items taken from the Substance Abuse and Incest Survey— Revised (Glover et al., 1996). In addition to demographics, the survey gathered data about the estimated incidence of incest on counselor caseloads, what incest-related assessment procedures were used, and the challenges counselors faced in serving clients with incest histories.1 The SACSCIH was piloted on a group of 10 students enrolled in an introductory substance abuse course; all pilot test participants had work experience in the substance abuse field. Minor changes to the survey were made after the pilot to improve its clarity. The National Directory of Drug Abuse and Alcoholism Treatment and Preventions Programs: 1995 Survey was used to randomly select 50 accredited treatment facilities from throughout the US. In addition, two treatment facilities, which were accessible to the authors and also listed in the Directory, were added as a sample of convenience. The 52 treatment facilities were initially contacted by letter and follow-up telephone calls. A total of 39 (75%) of the facilities agreed to participate. A contact person identified at each facility (usually the Treatment Director) provided the number of counselors on their staff who were delivering treatment services. Research packets, one for each counselor, were mailed to the contact persons for distribution via staff meeting or through in-office mailboxes. Each Research Packet included: (1) a letter of explanation, (2) consent forms, (3) instructions, (4) the survey, and (5) an addressed and stamped return envelop. Participants given the following definition of incest: Client Incest History: Refers to any substance abuse treatment client who has had sexual contact with a blood relative or a person who has strong social ties (e.g., parents, grandparents, uncles, aunts, cousins, siblings, in-laws, step-relatives, or a parent’s boyfriend or girlfriend). The nature of the sexual contact involves acts of a sexual nature, such as the touching of sex organs or other body parts for the purpose of sexual arousal, vaginal or anal penetration, mouth to penis contact, mouth to vagina contact, mouth to anus contact, or masturbation or other sexual acts performed by the related person in the presence of the client. Incest history, in this case, also means that the contact was either forced or unwanted by the client or when the client was a child and the perpetrator was an adult or older relative.
3. Results and discussion 3.1. Participants Three-hundred-seventy surveys were mailed to the 39 substance abuse treatment facilities across the US. A total of 114 usable surveys were returned for a 31% return rate. Sixty-one 1
Not all data collected are reported here. The reader is referred to Glover-Graf and Janikowski (2001) for a report on additional information.
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(54%) of the sample were female; ages ranged from 20 to 63 years (M = 39.6, S.D. = 10.7). The primarily ethnicity of the sample was Caucasian (n = 89; 78%). The level of education reported varied markedly; the largest percentage held master’s degrees (37%), but 23% had less than a 4-year college degree. The majority with college degrees (74%) reported majoring in a human services field (e.g., psychology). The majority (61%) reported holding a relevant certification, primarily Certified Alcohol and Substance Abuse Counselors (23%) or Certified Alcohol and Drug Counselors (11%). Table 2 summarizes the education and certification qualifications of the sample. Participants were also asked if they considered themselves to be ‘‘in recovery’’ from alcohol or drugs. Forty-three (37.7%) indicated that they were in recovery. Given the historical and presumably widespread phenomenon of former clients becoming treatment counselors, this percentage was lower than the authors expected. The duration of recovery ranged from 4 months to 22 years (M = 4.5, S.D. = 6.3 years). The treatment field generally regards 1 to 2 years of recovery necessary to provide stability and enable substance abuse counselors to be effective. Participants were questioned about the nature and extent of their training directly in the areas of human sexuality, counseling for sexual abuse, and counseling for incest. Means, medians, and standard deviations of these responses are reported in Table 3. Participants were asked ‘‘How competent do you think you are in counseling clients for incest-related problems?’’ Responses were recorded via a Likert-type scale where: 1 (very competent), to 4 (not competent). Participants indicated that they were, on average, somewhat competent (M = 2.7, Mo = 3.0) in providing such services. Table 2 Education and certification of the sample Qualifications
f
%
Highest degree High school Associates Bachelors Masters Doctorate Other
15 11 40 42 02 02
13 10 35 37 02 02
College majors Human services Nonhuman services
84 09
74 08
Certification CASAC CADC Other certification Total certified
26 13 32 71
23a 11b 28 62
a b
Certified alcohol and substance abuse counselor. Certified alcohol and drug counselor.
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Table 3 Preparation related to incest-related issues Type of preparation
Mean
Median
S.D.
Number of lectures completed on Human sexuality Counseling for sexual abuse Counseling for incest
2.9 3.2 2.7
2.0 2.0 2.0
3.1 3.8 3.7
Number of courses completed on Human sexuality Counseling for sexual abuse Counseling for incest
1.6 1.8 1.6
1.0 1.0 1.0
1.4 1.7 2.2
3.2. Work experience Participants had been employed in the substance counseling field from 0.5 to 25 years (M = 7.4; S.D. = 5.7) and were employed in their current position from 1 month to 25 years (M = 3.8 years, S.D. = 3.9 years). Caseload sizes varied from 3 to 60 clients (M = 16.3, S.D. = 13.1) with 108 (95%) offering individual counseling, 107 (94%) group counseling, and 46 (40%) family counseling services. The time spent in direct contact with clients ranged from 2 to 60 h per week (M = 23.4, S.D. = 11.0). 3.3. Incest and substance abuse counseling Participants were asked if their intake procedures asked about incest; 80 (70%) reported ‘‘yes.’’ Additionally, 82 counselors (71.9%) indicated that they routinely asked their clients about possible incest experiences. Participants were asked ‘‘About what percentage of clients on your caseload do you know have a history of incest?’’ Responses varied markedly, from 0 to 90%, with the average being 24% (Mo = 10%, S.D. = 23.9%). Responses to a similar question about the percentage of clients on their caseloads that they suspected having incest histories were slightly more varied, ranging from 0 to 95%, with the average being 38% (Mo = 50%, S.D. = 28.8%). Comparing known to suspected incest levels, substance abuse counselors estimate that about 14% of clients, on average, are not disclosing their incest histories to them. Participants were asked an open-ended question about how they typically discovered their clients’ incest histories. To examine these data, each response was recorded on a 3 5 index card. Cards were sorted independently by both authors who placed them in categories based on the context in which incest was disclosed. The majority of the cards were placed in similar categories and consensus was reached on the few cards that were sorted differently. In rank order, the most frequent approaches to discovering client incest histories was through: individual counseling sessions (n = 30), other assessments, instruments, or history taking (n = 22), group counseling interactions (n = 18), at intake (n = 12), family counseling sessions or other discussions with the family (n = 9), at referral or via file information (n = 8), and via psychosocial or biopsychosocial assessment (n = 7).
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Table 4 Counselor-ranked barriers to client disclosure of incest Barrier
fa
%
Feelings of shame Trust in the counselor Feelings of guilt Fear of emotional pain Fear of stigma Repression/denial Anger Other
78 42 37 36 22 21 12 10
30 16 14 14 09 08 05 04
a
The 114 participants recorded 258 responses due to the multiple response format of the item.
3.4. Client barriers to disclosure responses Counselors were asked to identify barriers they thought prevented clients from disclosing incest histories and engaging in incest-related counseling. The survey presented a list of nine barriers derived from the literature on the psychological sequelae of incest: difficulty with trust in the counselor, fear of stigma, anger, feelings of shame, fear of emotional pain, repression/denial, feeling of guilt, and the perceived need of keeping it secret (an ‘‘other’’ category was also included as an option). Counselors were asked to identify the top three barriers that most prevented disclosure. Table 4 contains the participant response frequencies of the collapsed rankings (rankings 1, 2, 3 were tallied) of each barrier. 3.5. Counselor challenges to counseling for incest In order to examine nonclient-related obstacles to the treatment of incest in the context of substance abuse counseling, counselors were asked, ‘‘What problems or issues would/do
Table 5 Problems or issues that make it difficult to address incest in substance abuse treatment Problem or issues
fa
%b
Insufficient training/skill Insufficient time Insufficient resources Other Discouraged by administration Legal problems Separate issue from substance abuse Ethical problems Too few substance abuse clients have incest histories
73 68 42 25 15 12 12 08 06
28 26 16 10 06 05 05 03 02
a b
The 114 participants recorded 261 responses due to the multiple response format of the item. Percent totals 101% due to rounding.
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make it difficult for you as a substance abuse counselor to address incest-related issues that may exist in your client caseload?’’ Counselors were provided with the following list of potential treatment obstacles gleaned from the literature: Legal Problems, Ethical Problems, Insufficient Time, Insufficient Training/Skill, Insufficient Resources, Discouraged by Administration, It is a Separate Issue from Substance Abuse, Too Few Substance Abuse Clients with Incest Histories, and Other. Response frequencies are presented in Table 5. 3.6. Conclusions Some imitations to the study must be noted. The low return rate of the survey (31%), although typical of survey research, limits the generalizability of results to the population of substance abuse counselors. Counselors were asked about their education and preparation to deal with incest. The length of time and intensity of these courses likely varied among participants and this research did not allow for an examination of those differences. Likewise, it is possible that a response bias existed in which counselors presented themselves in the most acceptable direction and overreported amount of training, services provided, or their feelings of competence. It is hoped that the anonymous design of the study helped minimize these threats to validity. The accuracy of counselors’ suspicions related to the incidence of incest cannot be confirmed. Yet, it is interesting to note counselors’ beliefs because their behaviors are likely influenced by their perceptions (i.e., how often they choose to ask about incest history and how sensitive they are to indicators of sexual abuse). With these limitations in mind, the majority of counselors had received some type of training in the areas of human sexuality and sexual abuse and incest; an encouraging result for clients. This result may be related to the fact that most participants were professionally trained (three-fourths held human service degrees and almost half had postbaccalaureate degrees). Participants appeared to be sensitive to the issue of incest in that they knew of incest histories in about one third of the clients on their caseloads, but suspected that the actual number of incest victims was closer to half. These estimates are comparable to results from surveys of substance abuse clients. There are apparent efforts to screen for incest at intake and also through routine questioning of clients. Even though most facilities reported including incest questioning at intake, counselors indicated that when disclosure did occur, most frequently, it was during individual or group counseling sessions. It might also be helpful for counselors to be aware of the increased potential for disclosure at particular points in treatment such as when childhood is discussed or when issues of anger or lack of trust emerge. Another opportunity for client disclosure presents itself when discussing potential causes of relapse. If alcohol or drugs were being used as a coping strategy to numb feelings and repress memories, the client’s newfound sobriety may release intense and unpleasant feelings, which may present a risk for relapse. It is not surprising that counselors point to the issues of shame, trust, and guilt as the primary client-related barriers to incest disclosure and treatment. In a society that insists upon independence and self-sufficiency, individuals who have been preyed upon often feel the shame that accompanies having been a victim. Society too shares in placing guilt on the victim. Women who have been victimized are frequently labeled as promiscuous and males
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are seen as weak or homosexual. Therefore, it is not surprising that secrecy is chosen over disclosure. In comparing this study to a survey of substance abuse clients with incest histories, who were also asked about barriers to treatment (Janikowski, Bordieri, & Glover, 1997), it is clear that counselors and clients are similar in their beliefs. Clients indicated that the most significant barriers to receiving treatment were: not wanting to think about incest, issues of maintaining privacy, shame, and avoidance of emotional pain. Trust in counselors was seen as a difficulty, but not to the same extent as indicated by counselors in this study. Regarding other challenges or barriers, participants pointed first to insufficient training and skill in the area of treatment of incest-related issues. It is not acceptable or ethical for illprepared counselors to provide incest therapy because some aspects of effective treatment for incest are distinctly different from the traditional, confrontative approach used in most substance abuse treatment. Nearly 70% of the counselors surveyed reported having provided incest counseling to clients while on average, participants characterized themselves to be only somewhat competent to do so. However, even with the reported lack of resources, collaboration with other community agencies could lead to training at a minimal expense to agencies. The dilemma of insufficient time certainly cannot be minimized. Health care providers allot less time for treatment, so that even basic treatment may become skeletal. The picture presented here by the counselors surveyed is both encouraging and discouraging in that counselors appear to recognize that clients with unresolved abuse issues exist in the treatment facility in large numbers. Counselors seem to be aware of the specific difficulties that exist for this population (trust, guilt, etc.), but they admit feeling less than competent in dealing with this issue, in part because of a lack of training, time, resources, and sometimes discouragement by administrations. From this perspective, clients may be faced with superficial and insufficient treatment that does not directly address important issues surrounding the development and maintenance of substance abuse or addiction. The authors believe that failing to both identify incest history (when it exists) and explore its relationship to the development and/or maintenance of substance abuse places the client at substantial risk for relapse and treatment failure.
References Benward, J., & Densen-Gerber, J. (1975). Incest as a causative factor in antisocial behavior: An exploratory study. Contemporary Drug Problems, 4, 323 – 340. Cohen, F. S., & Densen-Gerber, J. (1982). A study of the relationship between child abuse and drug addiction in 178 patients: Preliminary results. Child Abuse and Neglect, 6, 383 – 387. Covington, S. S. (1982). Dysfunction and abuse: A descriptive study of alcoholic and non-alcoholic women. PhD Dissertation, Union Graduate School. Glover, N., Janikowski, T. P., & Benshoff, J. J. (1996). Substance abuse and past incest contact: A national perspective. Journal of Substance Abuse Treatment, 13(3), 1 – 9. Glover, N. M., Janikowski, T., & Benshoff, J. J. (1992). The incidence of incest histories among clients receiving substance abuse treatment. Journal of Counseling and Development, 73, 475 – 480. Glover-Graf, N. M., & Janikowski, T. P. (2001). Substance abuse counselors’ experiences with clients who have been victims of incest. Journal of Substance Abuse Treatment, 20, 9 – 15.
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Hammond, D. C., Jorgenson, G. Q., & Ridgeway, D. M. (1979). Sexual adjustment of female alcoholics. Salt Lake City: University of Utah. Hyde, M. L., & Kaufman, P. A. (1984). Women molested as children: Therapeutic and legal issues in civil actions. American Journal of Forensic Psychiatry, 5, 147 – 157. Janikowski, T. P., Bordieri, J. E., & Glover, N. M. (1997). Client perceptions of incest and substance abuse. Addictive Behaviors, 4, 447 – 459. Schaefer, S., & Evans, S. (1985). Women’s sexuality and the process of recovery. Journal of Chemical Dependency Treatment, 1, 91 – 120. Sterne, M., Schaefer, S., & Evans, S. (1983). Women’s sexuality and alcoholism. In P. Golding (Ed.), Alcoholism: analysis of a world wide problem (pp. 421 – 425). Lancaster, England: MTP Press. Watley, R., & Densen-Gerber, J. D. (1976). Incest: An analysis of the victim and the aggressor. New York City, NY: New York Odyssey Institute.
Short Communication
Qualifications, training, and perceptions of substance abuse counselors who work with victims of incest Timothy P. Janikowskia,*, Noreen M. Glover-Graf b a
Department of Counseling, School, and Educational Psychology, 409 Christopher Baldy Hall, University at Buffalo—SUNY, Buffalo, NY 14260-1000, USA b Department of Counseling and Human Services, Syracuse University, Syracuse, NY, USA
Abstract The study was an initial investigation into substance abuse counselors’ qualifications and their training related to providing counseling for incest. Perceptions regarding the incidence of incest and insights into the difficulties of serving this subpopulation were also gathered. A total of 121 practicing substance abuse counselors, randomly sampled from treatment facilities across the United States, completed the ‘‘Substance Abuse Counselor Survey on Clients with Incest Histories’’ (SACSCIH). Participants estimated that, on average, about 24% of their clients were victims of incest. They also suspected that, on average, an additional 14% of their clients were victims of incest but did not report this information to the treatment staff. Participants revealed how they collected incest-related information and the various challenges they face in treating these clients. Data are analyzed descriptively and recommendations for future research are presented. D 2002 Elsevier Science Ltd. All rights reserved. Keywords: Incest; Substance abuse counseling; Counselor perceptions; Counselor qualifications; Counselor training
1. Introduction Often, the behavioral and psychological adaptations that people make in response to incest trauma (Hyde & Kaufman, 1984) include the abuse of alcohol and/or drugs (Glover,
* Corresponding author. Tel.: +1-716-645-2484x1055; fax: +1-716-645-6616. E-mail address: [email protected] (T.P. Janikowski). 0306-4603/02/$ – see front matter D 2002 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0306-4603(02)00217-4
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Janikowski, & Benshoff, 1996). Research consistently shows that the rate of incest is much higher in alcohol/drug treatment populations than in the general population (Benward & Densen-Gerber, 1975; Cohen & Densen-Gerber, 1982; Covington, 1982; Sterne, Schaefer, & Evans, 1983). Research studies examining incest in alcohol/drug treatment populations are summarized in Table 1. These researchers have all hypothesized that psychoactive drugs may be used initially as a strategy to repress or deny the trauma of incest, which then may lead to the equally serious problems of chemical dependency and addiction. Hyde and Kaufman (1984) identified several psychological reactions that are indicators of sexual trauma and incest such as amnesia, disassociative episodes, phobias, flashbacks, low self-esteem, and poor body image. Substance abuse counselors are therefore confronted with such issues in clients who are incest survivors, however, little is known about how substance abuse counselors are prepared to deal with such problems. The purpose of the study was to survey a sample of substance abuse counselors about their qualifications, training, and experience related to counseling clients who were victims of incest, specifically: (1) training in issues related to incest and sexual abuse, (2) estimates of the frequency of incest victims on their caseloads, (3) method of discovering clients’ incest histories, (4) barriers to clients’ disclosure of incest histories, and (5) problems they faced in addressing incest-related issues in the context of substance abuse treatment.
Table 1 Research on the incidence of incest among adults in substance abuse treatment Researchers
Gender studied
Method
Type of treatment
Number of subjects
Percent reporting incest
Benward and Densen-Gerber (1975) Watley and Densen-Gerber (1976)
Females Females and males Females
Interview Interview
Drug Drug and alcohol Drug and alcohol Drug and alcohol
118 237
44% 38% (female), 25% (male) 40%
Drug Drug and alcohol Drug and alcohol Drug and alcohol Drug and alcohol
35 75
Hammond, Jorgenson, and Ridgeway (1979) Cohen and Densen-Gerber (1982)
Survey
Females and males
Survey
Covington (1982) Sterne et al. (1983)
Females Females
Interview Survey
Schaefer and Evans (1985)
Females
Survey
Glover, Janikowski, and Benshoff (1992) Glover et al. (1996)
Females and males Females and males
Survey
a b
Survey
Percentage was characterized as low but no value was reported. Percentage includes perpetrators and/or victims.
44 178
100
28% (female), unreported (males)a 34% 46% 39%
77
54%, 40%b
732
55%, 29%
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2. Method 2.1. Instrumentation and procedures The authors created the Substance Abuse Counselor Survey on Clients with Incest Histories (SACSCIH) through adaptation of items taken from the Substance Abuse and Incest Survey— Revised (Glover et al., 1996). In addition to demographics, the survey gathered data about the estimated incidence of incest on counselor caseloads, what incest-related assessment procedures were used, and the challenges counselors faced in serving clients with incest histories.1 The SACSCIH was piloted on a group of 10 students enrolled in an introductory substance abuse course; all pilot test participants had work experience in the substance abuse field. Minor changes to the survey were made after the pilot to improve its clarity. The National Directory of Drug Abuse and Alcoholism Treatment and Preventions Programs: 1995 Survey was used to randomly select 50 accredited treatment facilities from throughout the US. In addition, two treatment facilities, which were accessible to the authors and also listed in the Directory, were added as a sample of convenience. The 52 treatment facilities were initially contacted by letter and follow-up telephone calls. A total of 39 (75%) of the facilities agreed to participate. A contact person identified at each facility (usually the Treatment Director) provided the number of counselors on their staff who were delivering treatment services. Research packets, one for each counselor, were mailed to the contact persons for distribution via staff meeting or through in-office mailboxes. Each Research Packet included: (1) a letter of explanation, (2) consent forms, (3) instructions, (4) the survey, and (5) an addressed and stamped return envelop. Participants given the following definition of incest: Client Incest History: Refers to any substance abuse treatment client who has had sexual contact with a blood relative or a person who has strong social ties (e.g., parents, grandparents, uncles, aunts, cousins, siblings, in-laws, step-relatives, or a parent’s boyfriend or girlfriend). The nature of the sexual contact involves acts of a sexual nature, such as the touching of sex organs or other body parts for the purpose of sexual arousal, vaginal or anal penetration, mouth to penis contact, mouth to vagina contact, mouth to anus contact, or masturbation or other sexual acts performed by the related person in the presence of the client. Incest history, in this case, also means that the contact was either forced or unwanted by the client or when the client was a child and the perpetrator was an adult or older relative.
3. Results and discussion 3.1. Participants Three-hundred-seventy surveys were mailed to the 39 substance abuse treatment facilities across the US. A total of 114 usable surveys were returned for a 31% return rate. Sixty-one 1
Not all data collected are reported here. The reader is referred to Glover-Graf and Janikowski (2001) for a report on additional information.
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(54%) of the sample were female; ages ranged from 20 to 63 years (M = 39.6, S.D. = 10.7). The primarily ethnicity of the sample was Caucasian (n = 89; 78%). The level of education reported varied markedly; the largest percentage held master’s degrees (37%), but 23% had less than a 4-year college degree. The majority with college degrees (74%) reported majoring in a human services field (e.g., psychology). The majority (61%) reported holding a relevant certification, primarily Certified Alcohol and Substance Abuse Counselors (23%) or Certified Alcohol and Drug Counselors (11%). Table 2 summarizes the education and certification qualifications of the sample. Participants were also asked if they considered themselves to be ‘‘in recovery’’ from alcohol or drugs. Forty-three (37.7%) indicated that they were in recovery. Given the historical and presumably widespread phenomenon of former clients becoming treatment counselors, this percentage was lower than the authors expected. The duration of recovery ranged from 4 months to 22 years (M = 4.5, S.D. = 6.3 years). The treatment field generally regards 1 to 2 years of recovery necessary to provide stability and enable substance abuse counselors to be effective. Participants were questioned about the nature and extent of their training directly in the areas of human sexuality, counseling for sexual abuse, and counseling for incest. Means, medians, and standard deviations of these responses are reported in Table 3. Participants were asked ‘‘How competent do you think you are in counseling clients for incest-related problems?’’ Responses were recorded via a Likert-type scale where: 1 (very competent), to 4 (not competent). Participants indicated that they were, on average, somewhat competent (M = 2.7, Mo = 3.0) in providing such services. Table 2 Education and certification of the sample Qualifications
f
%
Highest degree High school Associates Bachelors Masters Doctorate Other
15 11 40 42 02 02
13 10 35 37 02 02
College majors Human services Nonhuman services
84 09
74 08
Certification CASAC CADC Other certification Total certified
26 13 32 71
23a 11b 28 62
a b
Certified alcohol and substance abuse counselor. Certified alcohol and drug counselor.
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Table 3 Preparation related to incest-related issues Type of preparation
Mean
Median
S.D.
Number of lectures completed on Human sexuality Counseling for sexual abuse Counseling for incest
2.9 3.2 2.7
2.0 2.0 2.0
3.1 3.8 3.7
Number of courses completed on Human sexuality Counseling for sexual abuse Counseling for incest
1.6 1.8 1.6
1.0 1.0 1.0
1.4 1.7 2.2
3.2. Work experience Participants had been employed in the substance counseling field from 0.5 to 25 years (M = 7.4; S.D. = 5.7) and were employed in their current position from 1 month to 25 years (M = 3.8 years, S.D. = 3.9 years). Caseload sizes varied from 3 to 60 clients (M = 16.3, S.D. = 13.1) with 108 (95%) offering individual counseling, 107 (94%) group counseling, and 46 (40%) family counseling services. The time spent in direct contact with clients ranged from 2 to 60 h per week (M = 23.4, S.D. = 11.0). 3.3. Incest and substance abuse counseling Participants were asked if their intake procedures asked about incest; 80 (70%) reported ‘‘yes.’’ Additionally, 82 counselors (71.9%) indicated that they routinely asked their clients about possible incest experiences. Participants were asked ‘‘About what percentage of clients on your caseload do you know have a history of incest?’’ Responses varied markedly, from 0 to 90%, with the average being 24% (Mo = 10%, S.D. = 23.9%). Responses to a similar question about the percentage of clients on their caseloads that they suspected having incest histories were slightly more varied, ranging from 0 to 95%, with the average being 38% (Mo = 50%, S.D. = 28.8%). Comparing known to suspected incest levels, substance abuse counselors estimate that about 14% of clients, on average, are not disclosing their incest histories to them. Participants were asked an open-ended question about how they typically discovered their clients’ incest histories. To examine these data, each response was recorded on a 3 5 index card. Cards were sorted independently by both authors who placed them in categories based on the context in which incest was disclosed. The majority of the cards were placed in similar categories and consensus was reached on the few cards that were sorted differently. In rank order, the most frequent approaches to discovering client incest histories was through: individual counseling sessions (n = 30), other assessments, instruments, or history taking (n = 22), group counseling interactions (n = 18), at intake (n = 12), family counseling sessions or other discussions with the family (n = 9), at referral or via file information (n = 8), and via psychosocial or biopsychosocial assessment (n = 7).
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Table 4 Counselor-ranked barriers to client disclosure of incest Barrier
fa
%
Feelings of shame Trust in the counselor Feelings of guilt Fear of emotional pain Fear of stigma Repression/denial Anger Other
78 42 37 36 22 21 12 10
30 16 14 14 09 08 05 04
a
The 114 participants recorded 258 responses due to the multiple response format of the item.
3.4. Client barriers to disclosure responses Counselors were asked to identify barriers they thought prevented clients from disclosing incest histories and engaging in incest-related counseling. The survey presented a list of nine barriers derived from the literature on the psychological sequelae of incest: difficulty with trust in the counselor, fear of stigma, anger, feelings of shame, fear of emotional pain, repression/denial, feeling of guilt, and the perceived need of keeping it secret (an ‘‘other’’ category was also included as an option). Counselors were asked to identify the top three barriers that most prevented disclosure. Table 4 contains the participant response frequencies of the collapsed rankings (rankings 1, 2, 3 were tallied) of each barrier. 3.5. Counselor challenges to counseling for incest In order to examine nonclient-related obstacles to the treatment of incest in the context of substance abuse counseling, counselors were asked, ‘‘What problems or issues would/do
Table 5 Problems or issues that make it difficult to address incest in substance abuse treatment Problem or issues
fa
%b
Insufficient training/skill Insufficient time Insufficient resources Other Discouraged by administration Legal problems Separate issue from substance abuse Ethical problems Too few substance abuse clients have incest histories
73 68 42 25 15 12 12 08 06
28 26 16 10 06 05 05 03 02
a b
The 114 participants recorded 261 responses due to the multiple response format of the item. Percent totals 101% due to rounding.
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make it difficult for you as a substance abuse counselor to address incest-related issues that may exist in your client caseload?’’ Counselors were provided with the following list of potential treatment obstacles gleaned from the literature: Legal Problems, Ethical Problems, Insufficient Time, Insufficient Training/Skill, Insufficient Resources, Discouraged by Administration, It is a Separate Issue from Substance Abuse, Too Few Substance Abuse Clients with Incest Histories, and Other. Response frequencies are presented in Table 5. 3.6. Conclusions Some imitations to the study must be noted. The low return rate of the survey (31%), although typical of survey research, limits the generalizability of results to the population of substance abuse counselors. Counselors were asked about their education and preparation to deal with incest. The length of time and intensity of these courses likely varied among participants and this research did not allow for an examination of those differences. Likewise, it is possible that a response bias existed in which counselors presented themselves in the most acceptable direction and overreported amount of training, services provided, or their feelings of competence. It is hoped that the anonymous design of the study helped minimize these threats to validity. The accuracy of counselors’ suspicions related to the incidence of incest cannot be confirmed. Yet, it is interesting to note counselors’ beliefs because their behaviors are likely influenced by their perceptions (i.e., how often they choose to ask about incest history and how sensitive they are to indicators of sexual abuse). With these limitations in mind, the majority of counselors had received some type of training in the areas of human sexuality and sexual abuse and incest; an encouraging result for clients. This result may be related to the fact that most participants were professionally trained (three-fourths held human service degrees and almost half had postbaccalaureate degrees). Participants appeared to be sensitive to the issue of incest in that they knew of incest histories in about one third of the clients on their caseloads, but suspected that the actual number of incest victims was closer to half. These estimates are comparable to results from surveys of substance abuse clients. There are apparent efforts to screen for incest at intake and also through routine questioning of clients. Even though most facilities reported including incest questioning at intake, counselors indicated that when disclosure did occur, most frequently, it was during individual or group counseling sessions. It might also be helpful for counselors to be aware of the increased potential for disclosure at particular points in treatment such as when childhood is discussed or when issues of anger or lack of trust emerge. Another opportunity for client disclosure presents itself when discussing potential causes of relapse. If alcohol or drugs were being used as a coping strategy to numb feelings and repress memories, the client’s newfound sobriety may release intense and unpleasant feelings, which may present a risk for relapse. It is not surprising that counselors point to the issues of shame, trust, and guilt as the primary client-related barriers to incest disclosure and treatment. In a society that insists upon independence and self-sufficiency, individuals who have been preyed upon often feel the shame that accompanies having been a victim. Society too shares in placing guilt on the victim. Women who have been victimized are frequently labeled as promiscuous and males
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are seen as weak or homosexual. Therefore, it is not surprising that secrecy is chosen over disclosure. In comparing this study to a survey of substance abuse clients with incest histories, who were also asked about barriers to treatment (Janikowski, Bordieri, & Glover, 1997), it is clear that counselors and clients are similar in their beliefs. Clients indicated that the most significant barriers to receiving treatment were: not wanting to think about incest, issues of maintaining privacy, shame, and avoidance of emotional pain. Trust in counselors was seen as a difficulty, but not to the same extent as indicated by counselors in this study. Regarding other challenges or barriers, participants pointed first to insufficient training and skill in the area of treatment of incest-related issues. It is not acceptable or ethical for illprepared counselors to provide incest therapy because some aspects of effective treatment for incest are distinctly different from the traditional, confrontative approach used in most substance abuse treatment. Nearly 70% of the counselors surveyed reported having provided incest counseling to clients while on average, participants characterized themselves to be only somewhat competent to do so. However, even with the reported lack of resources, collaboration with other community agencies could lead to training at a minimal expense to agencies. The dilemma of insufficient time certainly cannot be minimized. Health care providers allot less time for treatment, so that even basic treatment may become skeletal. The picture presented here by the counselors surveyed is both encouraging and discouraging in that counselors appear to recognize that clients with unresolved abuse issues exist in the treatment facility in large numbers. Counselors seem to be aware of the specific difficulties that exist for this population (trust, guilt, etc.), but they admit feeling less than competent in dealing with this issue, in part because of a lack of training, time, resources, and sometimes discouragement by administrations. From this perspective, clients may be faced with superficial and insufficient treatment that does not directly address important issues surrounding the development and maintenance of substance abuse or addiction. The authors believe that failing to both identify incest history (when it exists) and explore its relationship to the development and/or maintenance of substance abuse places the client at substantial risk for relapse and treatment failure.
References Benward, J., & Densen-Gerber, J. (1975). Incest as a causative factor in antisocial behavior: An exploratory study. Contemporary Drug Problems, 4, 323 – 340. Cohen, F. S., & Densen-Gerber, J. (1982). A study of the relationship between child abuse and drug addiction in 178 patients: Preliminary results. Child Abuse and Neglect, 6, 383 – 387. Covington, S. S. (1982). Dysfunction and abuse: A descriptive study of alcoholic and non-alcoholic women. PhD Dissertation, Union Graduate School. Glover, N., Janikowski, T. P., & Benshoff, J. J. (1996). Substance abuse and past incest contact: A national perspective. Journal of Substance Abuse Treatment, 13(3), 1 – 9. Glover, N. M., Janikowski, T., & Benshoff, J. J. (1992). The incidence of incest histories among clients receiving substance abuse treatment. Journal of Counseling and Development, 73, 475 – 480. Glover-Graf, N. M., & Janikowski, T. P. (2001). Substance abuse counselors’ experiences with clients who have been victims of incest. Journal of Substance Abuse Treatment, 20, 9 – 15.
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Hammond, D. C., Jorgenson, G. Q., & Ridgeway, D. M. (1979). Sexual adjustment of female alcoholics. Salt Lake City: University of Utah. Hyde, M. L., & Kaufman, P. A. (1984). Women molested as children: Therapeutic and legal issues in civil actions. American Journal of Forensic Psychiatry, 5, 147 – 157. Janikowski, T. P., Bordieri, J. E., & Glover, N. M. (1997). Client perceptions of incest and substance abuse. Addictive Behaviors, 4, 447 – 459. Schaefer, S., & Evans, S. (1985). Women’s sexuality and the process of recovery. Journal of Chemical Dependency Treatment, 1, 91 – 120. Sterne, M., Schaefer, S., & Evans, S. (1983). Women’s sexuality and alcoholism. In P. Golding (Ed.), Alcoholism: analysis of a world wide problem (pp. 421 – 425). Lancaster, England: MTP Press. Watley, R., & Densen-Gerber, J. D. (1976). Incest: An analysis of the victim and the aggressor. New York City, NY: New York Odyssey Institute.