– Highlight Loc. 476-77
The Impact of Event Scale (IES; Horowitz 1976) was widely used for exploring the psychological impact of a variety of traumas.
– Highlight Loc. 480
posttraumatic stress disorder (PTSD)
– Highlight Loc. 590-91
Posttraumatic Stress Disorder Checklist (PCL) The PCL (Weathers et al. 1993) is a 17-item self-report rating scale that parallels DSM-IV’s diagnostic criteria B, C, and D for PTSD.
– Highlight Loc. 695
Dissociative Experiences Scale (DES)
– Highlight Loc. 701-2
The DES consists of 28 items that describe dissociative experiences including experiences of amnesia, depersonalization, derealization, imaginative involvement, and absorption. It is a self-report measure that can be administered in approximately 15 minutes.
– Highlight Loc. 717
Children’s Impact of Event Scale-Revised (CHIES-R)
– Highlight Loc. 3025-33
The impact of child sexual abuse, especially when it occurs in a family context, goes beyond simple PTSD symptomatology. In general, effects of sexual abuse on children are seen in the disruption of their emotion regulation, behavioural disturbance, cognitive difficulties, interpersonal difficulties, and posttraumatic stress reactions (Berliner and Elliott 2002). In another review of studies on the impact of sexual abuse on children by Kendall-Tackett, Williams, and Finkelhor (1993), several factors were found to lead to more symptoms, including: close relationship with the perpetrator, high frequency and long duration of the abuse, use of force, penetration, lack of maternal support at disclosure, and victim’s negative coping style. Symptom expression is also different during different developmental stages of the children. To illustrate, anxiety, nightmares, general post-traumatic stress symptoms, and inappropriate sexual behaviour are more common among preschoolers. School-age children exhibit more fear, aggression, regressive behaviour, school problems, and general mental health problems. For adolescents, depression, self-injurious behaviour, illegal acts, running away, and substance abuse are more common.
– Highlight Loc. 3224-32
For example, one woman felt outraged at her husband for having sexually abused their daughter, as her religion and her family all along taught her that men are head of the household who are to protect and look after the family rather than harm them. Another woman came from a social and family background where she had the belief that women are strong emotionally and have to take care of men by sacrificing and putting aside their needs, wants and rights. Though angry with her husband, she sympathized with him and worried what might become of him if he was to go to prison. She expected her daughter to follow suit and to forgive her father. The role of the therapist is not to challenge those beliefs right away, even though he or she may not agree with them. Instead, the therapist explores with the client the meaning of such beliefs — the origin of the beliefs, how the client is impacted by these beliefs in their life, whether the beliefs are helpful to or limit their choice of actions, whether the client has other more preferred values that are in conflict with their beliefs — to open up possibilities for change.
– Highlight Loc. 3244-46
In addition, some systemic formulations also link the mother’s deficits as partner and as parent to her family-of-origin experiences ― for example, the notion that the mother’s difficulties protecting her child once she knows about the abuse may be influenced by her own childhood experience of sexual abuse.
– Highlight Loc. 3260-65
Take the example of a man who has sexually abused his daughter. He may hold the stereotypical gender belief that for a man to be a man, he must not express vulnerability (e.g., feelings of pain, or need for care) nor exhibit any “female” characteristics (such as being dependent, or being empathic and taking care of others). He may objectify women and view them as secondary to men. We believe that to create more long lasting change in such a man’s abusive behaviour, it is essential to create a context in therapy to invite him to examine the rigid stereotypical beliefs that have sustained his abusive acts, so as to bring about a change towards more flexible images of manhood, in his definition of masculinity, and in his view of women.
– Highlight Loc. 3281-89
As noted earlier, when a child is sexually abused within the family, the trauma is not just about physiological and psychological symptoms, but is also a relational one (Sheinberg and Fraenkel, 2001). She faces confusions and dilemmas, both in her sense of self as well as her relations with other members in family. The child struggles with many relational dilemmas such as whether to tell or not to tell, if she would be believed or blamed, how to make sense of the relationship with the parent who abuses her but also takes care of her, and how to relate with the other parent who is torn between her and the family member who abuses, etc.9 The experience of being sexually abused by someone close in the family is fundamentally a betrayal and disruption of the trust and the attachment bonds between the child and her parents or caretakers. Such disruptions would negatively affect the child’s internal representations of self and relationships with others. Re-building the trust and the attachment bonds between the child and the non-offending parent or other supportive adult figures is therefore crucial to ensure that the family will become a secure base again for the child to develop trust and a positive sense of self.
– Highlight Loc. 3291-94
All in all, how can justice, fairness, respect, and integrity be upheld and regained in a situation in which the family is haunted by shock, shame and guilt? To address these complex relational challenges, we choose a family-based relational approach with different therapy modalities to work with children of sexual abuse and their families. Here, the idea of “relational approach in family therapy” from Sheinberg and Fraenkel (2001) in their work with families of incest is adopted.
– Highlight Loc. 3296-99
In the coming sections, we would discuss the relational approach in terms of different therapy modalities, namely individual work with the child, family work that strengthens the child’s relationship with her non-offending parent and that fosters the family to be a safe and nurturing place, and group work that helps to break down the sense of isolation and stigmatization often experienced by children who have experienced sexual abuse in families.10
– Highlight Loc. 3304-9
In the context of family child sexual abuse, the therapists’ gender may have an effect on the therapy process. For instance, in individual and family sessions, therapist of the same gender would facilitate the development of a secure context where the child or the adolescent feels safe to share her abuse experience. It also allows her to identify with the therapist and model after her in role identification. For group sessions, a co-therapy team of mixed gender is preferred whenever possible. It helps members to have experiential learning on the positive interaction between both genders and have the expanded experience that men can be supportive and caring (Fraenkel, Sheinberg, and True 1996). If co-therapy is impossible, again, a same-gender therapist is preferred.
– Highlight Loc. 3311-13
The primary goals are twofold: to assist the sexually abused child to overcome and reclaim her life from the negative effects of the abuse; as well as to develop safe and nurturing relationships in the family.
– Highlight Loc. 3315-17
The individual sessions with the child serve as a forum whereby the child can clarify and freely express her feelings, thoughts and struggles, and discuss why she finds it difficult to talk about these issues with her parents.
– Highlight Loc. 3318-19
The goal here is to strengthen the child’s relationship with the non-offending parent, so that the parent can support and protect the child.
– Highlight Loc. 3321-28
There are many reasons that the non-offending parent, apart from not being legally bound to do so, does not come for therapy. She may feel too shameful to talk to an outsider about the sexual abuse; she may be angry with the child for the disclosure; she may not believe the child or see therapy as helpful for them; or she may still be very much dominated by or dependent on the offending family member financially and emotionally, and dare not do anything to rock the boat further such as going to see a therapist, etc. In extreme cases, the child may even be rejected and ostracized from the family. To reduce the child’s sense of isolation and disconnection from the family, the therapist may have to seek out the child’s other support networks, such as inviting other significant supportive figures, a teacher, a house-parent, a friend, perhaps, to the sessions. Sometimes, the therapist may have to find ways to evoke and enrich the presence and positive influence of these other significant people who cannot be physically present.
– Highlight Loc. 3328-31
At the same time, the therapist also needs to strengthen the child’s sense of personal agency and help her regain a positive identity. When the child experiences significant distress or difficulties as a result of the abuse and the disclosure, the therapist needs to find ways to assist the child to overcome and get her life back from the difficulties.
– Highlight Loc. 3332-35
Besides, young children, because of their language and cognitive development, may not be capable of articulating their distresses and concerns through words adequately. Therapists have to adapt their ways of working to fit a young child’s development and needs. Individual play therapy can be a helpful alternative to facilitate children’s expression of feelings, confusions and thoughts.
– Highlight Loc. 3344-3435
This is the story of Mei, a 6-year-old girl, who was sexually abused by her father. The abuse happened two years ago and lasted for a year. She only disclosed the abuse after the mother, Kwan, separated from the father. A report was made to the police but she was so fearful and embarrassed that she was not able to describe the incidents in detail. The police eventually dropped the case. When the father requested access, Mei was highly distressed. She was afraid to see her father. The mother was also scared as Mei’s father was verbally abusive and had harassed her numerous times. Mei had bad dreams, and refused to eat and go to bed. She became irritable, threw temper tantrums, hit and bit her younger brother, let her school grades deteriorate and sometimes even refused to go to school. Kwan did not understand why Mei had become so difficult and uncooperative. She coaxed her, reasoned with her and scolded her but was to no avail. Kwan felt helpless and incompetent as a mother when she brought Mei into therapy. Mei was a smart and articulate little girl, but in the early stage of therapy, she made it clear that she did not want to talk about the abuse incidents. Mei was invited to express her feelings towards the sexual abuse through expressive play therapy techniques, such as drawings and artwork. It was clear that she struggled predominantly with anger and fear. Yet, Mei did not want to say more about what she was angry and fearful about. The therapist talked with Mei about the Anger and the Fear as if they were separate entities in Mei’s life. The therapist asked questions such as what the Anger and the Fear were doing to Mei’s life, how Mei thought about the Anger and the Fear, whether she liked or disliked them, and what she wanted to do about them. The therapist invited Mei to draw pictures of what she thought the Anger and the Fear looked like. The therapist was talking in ways that externalize and separate the problem of Anger and Fear from Mei.11 Through this kind of talking, the therapist helped to create some space and distance between Mei and the problem, so that it was easier for Mei to get access to her strengths and resources to deal with the problem. The therapist did not see Mei’s identity as defined solely by the problem of Anger and Fear (thinking beyond the problem narrative) but was interested to learn more about Mei’s strengths and resources that she could use to deal with the problem. With the help of Kwan, who supplemented information and filled in details, Mei expressed that the Anger made her throw temper tantrums, hit her brother, and the Fear made her unable to sleep at night, and reluctant to go out, including Working with Familial Child Sexual Abuse 151 to school. She did not like the Anger and the Fear’s company in her life, because they made her feel bad about herself, and also made every one unhappy at home. At this point, Kwan described what Mei was like before. She told little stories of how Mei was a conscientious, caring, helpful and responsible little girl. Then the therapist asked this question, “Mei, you said that you don’t like the Anger and the Fear cling close to you, because they make you feel bad about yourself and every one unhappy. Have you got any ideas on what may be a good way to get rid of them in your life?” Mei thought for a while, and then said that the best way would be to change them into Happiness. The therapist then invited Mei to use some miniature toys to show what a happy life would be like for her. Mei liked the idea and was very involved in making what she subsequently named the Happy Kingdom, which she built in a sand box using miniature toys. In this Happy Kingdom, there was a birthday party with food and balloons, some children were playing happily, a fairy was watching over and there were lovely flowers and a rainbow. Then Mei and the therapist talked about what would be some happy activities for her (the double foci of both meaning and action). Apparently, after the construction of the Happy Kingdom, Mei was able to express more about the Anger that was bothering her. She wrote on the white board the name of her father, then she wrote “bad guy”. The same night at home, Mei told her mother that she would be happy if the police caught all the bad people. She also asked her mother why her father could walk away without any consequence despite that he had done bad things. This helped Kwan to see Mei differently. She shifted from seeing Mei as difficult and uncooperative to seeing Mei as being angry because she felt so hurt by what her father had done, and because she felt so unfair that her father could get away without any consequences. In the following weeks, Mei did gradually turn Anger and Fear into Happiness. She told the therapist that she had moved to live in the Happy Kingdom. She said that as long as she did the good things that she used to do, she could shut out Anger and Fear from the Happy Kingdom. She and her mother then gave the therapist a list of the good things she did, including studying hard, eating meals, going to bed on time, engaging in happy activities (reading story books, playing on the computer, playing with her brother) and talking to her mother. At this juncture, the therapist was interested in fostering a different sense of identity for Mei. When the therapist asked what it meant for her to be able to regain happiness after so many difficulties, Mei said that this must mean she was a happy person, as a happy person would try to be happy even when things were bad. Kwan joined in and told the therapist that actually the family used to nickname Mei “Smiley” when she was small, because she had those abilities to bring happiness to people around her, and Kwan gave many examples. The meaning of being “Smiley” was interweaved with daily examples of actions (double foci of meaning and action). Kwan’s sharing helped to enrich and reinforce this happy 152 Ellen Yee-man Ma and Delphine Cheuk-wai Yau self that Mei was re-discovering in herself, and obviously a more preferred self for Mei. As a ritual to commemorate Mei’s rediscovery of this more preferred identity, “Smiley”, the therapist invited Mei to make a citizenship card of the Happy Kingdom for herself. Mei was enthusiastic about the idea. She eventually designed one for herself, one for her mother and one for her little brother. She proclaimed that she, her mother and her brother were the first three citizens in the Happy Kingdom! In the next session, Mei came in and announced that she wanted to draw pictures to show the therapist and her mother what her father had done to her. She had never told the incidents in full before. Mei was a bit embarrassed, but she felt proud of herself in being able to tell, through drawing, what had happened. Apparently, the happy identity had made it possible for Mei and given her strength to tell the abuse incidents. Kwan’s changed understanding of the meaning of Mei’s anger was also pivotal in changing the way she responded to Mei’s “uncooperative behaviours” at home. Kwan was more supportive, patient and understanding. Unfortunately, when things seemed to get better, the court requested the social worker to arrange for access of the father to Mei. Mei’s distress level intensified after she met the father under the social worker’s supervision. She was unwilling to go to school again, vomited if made to eat, shivered, was jumping around, and was unwilling to sleep. Eventually, Mei confided to her mother that she had to keep moving around and making sounds, because if she quieted down, she would see scary things. In the session, the therapist had some externalizing conversations with Mei on the scary things. Supported and encouraged by the mother, Mei was eventually able to tell them that she saw a dark human shadow with no hands and feet, usually before she went to sleep or when it was quiet all around. The therapist then asked Mei, “Where do the scary things appear, in your mind, or before your eyes like I am sitting in front of you now?” Mei replied that the scary things appeared inside her head. The therapist and Mei then had some discussions on whether the scary things were real or not since they only appeared inside Mei’s head, why they would want to keep Mei afraid, what they were up to by tricking Mei into believing that they were real, whether they had any real power to hurt Mei, etc. Instead of telling Mei not to be afraid since the scary things were only images in the head, the therapist gave Mei the space to figure out on her own that they were not real. The externalizing conversations also made it possible for Mei to discover that as long as she was not afraid, the scary things had no real power over her. With the assistance of her mother, Mei came to the conclusion that she must have a smart brain to be able to see through the tricks of the scary things and figure out that they were not real. This preferred identity of Mei, as someone with a smart brain, also made it possible for Mei to make the decision, at the end of the session, that she would not let something unreal mess up her life. Working with Familial Child Sexual Abuse 153 After this meeting, the scary things reduced their appearance in Mei’s life significantly, but Mei was still hitting her brother. At this point, Mei was able to articulate clearer what she was angry about. Mei asked forcefully why someone could do bad things and did not need to face any consequences, why she had to be good and considerate so as not to make others unhappy while that person (referring to her father) did not need to care for people, and what the point was for her to be a good kid. It was clear that Mei was angered by how unfairly she was treated. She was angry that her father denied the abuse, accused her of making things up, and even harassed her mother. She was also angry that not only did the adults and the police do nothing about her father’s abuse but they made her see him against her will. Having understood the meaning of Mei’s anger, the therapist was curious what might be important to Mei that was taken away by the abuse and by the way the abuse was handled, which led to her outrage. Kwan, at this point, was really good at reading beyond the problem and understanding the meaning behind the problem. She said that Mei really valued being fair and responsible, and the abuse violated these important values of hers. Kwan gave some daily examples of how Mei would keep her words, how she tried to play fair in games and treat her friends fairly, how she was willing to accept discipline when she did something wrong, etc. Kwan’s descriptions acknowledged Mei’s outrage. Kwan added that she and Mei’s teachers all liked these qualities of Mei and it would be a real pity if Mei let the Anger take away her precious qualities. With the help of the mother, a more preferred identity of Mei being a fair and responsible child was rediscovered and developed. Very amazingly, several days after this session, Mei told her mother that she would not be so stupid as to fall for the trap of Anger, and let Anger make her sick (vomiting, not eating or sleeping) and unhappy. She also would not let what her father did to her ruin her life and make her unable to do important things, such as going to school, taking care of her own daily routines, doing happy things, and being a nice sister. It seemed that Mei was able to use her smart brain to figure out ways to transcend the anger so that she could continue to have a happy life. She was living out the several preferred identities that she, her mother and the therapist had talked about — being a conscientious, caring, helpful and responsible child, being a happy person (“Smiley”), and being someone with a smart brain. Although the individual work with the mother is not the focus in this section, suffice to say is, Kwan came to realize that she had also let fear dominate her attitude towards her ex-husband. Fear had interfered with her commitment to protect Mei. Mei’s courage in telling the abuse incidents had also inspired Kwan to be courageous to fight for herself and her daughter if they wanted a happy life. She was determined to take action in the court to fight for a fair share of property (before, she had planned to ask for nothing from her husband) and to apply 154 Ellen Yee-man Ma and Delphine Cheuk-wai Yau for temporary suspension of her husband’s access, even though she knew that he would be angry and perhaps retaliate. As a passing note, the therapist also liaised with the social worker on the issue of the visitation. The therapist worked with the larger system to advocate for Mei’s interests. Eventually, the court granted temporary suspension of access. A few months later, Kwan succeeded in obtaining her ex-husband’s consent through the court and took the children abroad to study.
– Highlight Loc. 3435-38
Individual work with children whose relationship with the parent is strained For children whose parents do not fully give them support and blame them after the disclosure, and for children whose family members do not participate at all in therapy, the therapist has to face many challenges. The hardest challenge is how to work with these children, who are isolated, unsupported, and disconnected, in ways that would help to foster a greater sense of personal agency and reconnect them with supportive figures.
– Highlight Loc. 3441-46
Sui’s mother did not believe in Sui’s accounts. She believed that Sui had sex with her boyfriend and then made up a story of sexual abuse by the father to protect herself from being reprimanded or beaten up by the father. The mother and the two younger siblings were angry with Sui for accusing the father and believed that he was innocent. Sui was the only person whom the therapist could see because the family members refused to participate in therapy. After the disclosure, Sui had to live in a children’s home. She was under undue stress for being disbelieved and blamed, as well as having to leave home. Feeling lonely and rejected, Sui tried to kill herself by swallowing sleeping pills.
– Highlight Loc. 3467-3516
However, as the court date drew near and Sui had to take the witness stand since her father did not plead guilty, anxiety and guilt got an upper hand in Sui’s life. She had the dilemma of whether to withdraw from being a witness. On one hand, she felt worried and guilty upon seeing her mother’s and her siblings’ distress about the father’s possible imprisonment. Sui was especially worried about her mother who had weak health. On the other hand, Sui was also very angry at the father’s denial. She felt it was unfair that her father got all the sympathy while she was blamed and rejected by the family. She very much wanted to gain some justice through the court’s ruling. This time, although Sui was under a high level of distress facing the pending court hearing, she firmly told the therapist that she would not harm herself as a way out. Nonetheless, the high level of distress had real effects on Sui’s daily life. She had trouble sleeping at night and had bad dreams, felt she was stared at when she went out, and heard voices calling her name. Sui was worried that something might be wrong with her. She was most troubled by the “voices”, which disturbed her daily routines. Sui was referred for a psychiatric consultation. The psychiatrist reassured her that she was just being stressed because of the circumstances and there was no need for medication. This was relieving for Sui, but she still wished to discuss with the therapist how to deal with the voices. 156 Ellen Yee-man Ma and Delphine Cheuk-wai Yau Instead of giving advice to Sui on how to deal with the problem, the therapist tried to engage Sui in conversations that would assist her to discover her skills and strengths to cope with the problem (enhancing Sui’s personal agency and the belief that Sui was not just a passive victim). The therapist explored the effects of the voices on Sui’s life, her reactions to them, the times when the voices would be stronger or weaker, the power the voices had over Sui’s life, etc. Sui gradually realized that the voices were able to affect her because she chose to listen and attend to them. It came down to a matter of her choices of how she wanted to attend to the voices. She was certain that the voices were just inside her head and if she chose to ignore them, they would not affect her much in her daily routines. She felt that she could just treat them as noises. In the following session, Sui told a funny story of how she thought that the voices were calling her again while she was reading a book and therefore she ignored them, only later to find out that the houseparent was really calling her name from the living room. Sui had a good laugh together with the houseparent. Sui discovered that the voices could not disturb her when her mind was fully engaged, which was when she was solving mathematical problems. She even jokingly told the therapist that she had to thank the voices for helping her spend more time to study mathematics. After these conversations, the voices, though still present in Sui’s life from time to time, appeared less often, and were less disturbing. Sui also slept better at night. Sui still struggled with the dilemma of whether to appear as a witness in court. One week prior to the court date, Sui ran into her father when she went back home to get some personal items. The father scolded Sui and told her to leave. Sui was very angry and began to question whether it was worthwhile for her to make sacrifices for a man who had not showed the slightest hint of remorse. The therapist did not take Sui’s anger for granted, but explored with Sui the meaning of her anger in the hope of opening up conversations to rediscover Sui’s preferred life story alongside the story of abuse. For questions such as what made her so angry at her father’s response, why this would have her rethink about taking the witness stand and plan to withdraw as a witness in court, and whether the anger might be related to some important beliefs and values of hers that were being violated by her father’s act, Sui pointed out that it was important for her that people should be responsible for their actions. She continued to talk about why responsibility was important because her father had never been responsible to the family and he often put his own needs first. She saw how hard her mother’s life had been to support the family. Sui was able to acknowledge her mother’s contribution to the family by being a responsible wife and mother. She began to link the value of responsibility, which she held as important, to her mother’s influence on her. This subsequently had the effect of softening Sui’s anger towards her mother for not believing and supporting her. The therapist asked Sui Working with Familial Child Sexual Abuse 157 if the value of responsibility had any relationship with her belief that one should make choices for one’s life. Sui, after thinking for a while, agreed that the two were related. She explained that the true meaning of making choices for one’s life also included the notion of bearing responsibility for the choice one had made. The therapist and Sui had more conversations around this further reinforced preferred identity of responsibility and making choices for one’s life. As Sui talked more, she realized that actually disclosing the abuse was not the first time she made choices for her own life. She had a history of doing this, such as choosing to enroll in her present school despite her mother’s opposition, dating her boyfriend though her parents were opposed, opting for the science stream though her teachers thought that her grades were not good enough, etc. After a while, the therapist asked Sui this question, “So, you have made choices at different points in your life, and you have stood up to opposition and disapproval from others to live out your choice. You also value taking responsibility for one’s action. Now, what if you use this value and this belief as guidance in your dilemma about whether to be a witness in court next week? What are your thoughts?” Sui very quickly responded that her father should take responsibility for what he had done. Sui was still worried if her mother could take the blow of her father’s possible imprisonment, but she could better differentiate that it was her father’s actions which had caused her mother’s suffering rather than hers. Sui decided to take the witness stand. As an ending note, Sui took the witness stand, as she said. She was proud of her performance as a witness, especially her ability to outsmart the defense attorney without falling into the traps of his tricky questions. Eventually her father was sentenced to 4 years’ imprisonment. Sui also took a more understanding and compassionate stance towards her mother. She could appreciate what her mother had done for the family, and gradually was able to let go of her anger towards her mother. In a few months’ time, the mother also let Sui stay with the family for home leave.
– Highlight Loc. 3517-22
In working with children who struggle with significant level of distress as a result of sexual abuse and the disclosure, the first and foremost consideration is to build up a secure and safe care-giving environment for the child. This would enor-mously help the child recover from the trauma of the sexual abuse, and would also safeguard the child from being re-abused again. If the child is still at risk of abuse, there is no way she can overcome whatever difficulties she is experiencing. However, in the local setting, the non-offending family members are often not available for therapy. The therapist then has to explore, invite or invoke the presence of other supportive figures, and work to build up the child’s connection
– Highlight Loc. 3523-27
Secondly, the individual work has to address and enhance the child’s sense of personal agency. When the child sees herself differently in the preferred life story of resources, strengths and skills, there are more possibilities for change and for expanded meanings of the experience of abuse. The preferred life story then becomes a platform and makes it more possible for the child to break away from the distressing effects of the abuse. Thirdly, the therapist has to be flexible in working with children. For example, when working with young children, the therapist has to adapt his or her ways of working with more child-friendly methods so as to fit with the child’s developmental needs.
– Highlight Loc. 3528-32
Goals of family sessions The major goals of family work are, firstly, to strengthen the relationship between the child and her protective family members, such as the non-offending parent or other adults who assume the parental role in the child’s life, and secondly, to make safe the relationship between the child and the offending parent. When working with the family, it does not mean that the whole family has to be seen together in every session. Individual work with the non-offending parent is indispensable.
– Highlight Loc. 3533-38
Disclosure of child sexual abuse in a family can be equally shocking and confusing to the non-offending parent, usually the mother in most cases. The emotional turmoil around the abuse allegation, the protective role of being a mother, the attachment towards as well as the sense of betrayal by the partner, the possible split-up of the family, the financial and social changes, and the blame and pressure from relatives or family of origin are all real challenges to the non-offending parent. For a non-offending parent, a common response in hearing the abuse for the first time is shock and disbelief.
– Highlight Loc. 3547-49
The beliefs that “family matters should be resolved within family” and “one should never be involved with the court/legal system” are common among Chinese people. She was torn by the split loyalty between her daughter and her husband and the issue on whom she should believe and trust.
– Highlight Loc. 3568-69
To solicit the non-offending parent’s support for the daughter, the therapist has to validate her conflicts in facing the betrayal of her husband as well as her attachment towards him as her lived experience.
– Highlight Loc. 3569-77
For Li, it was difficult to share with others her concern for a man who sexually abused their daughter without anticipating shame and disrespect in return. If she told others of what had happened, she would likely get a story of shame, in that she had chosen a “wrong guy” as her husband, or she could not “satisfy” him as a wife. “Married to the wrong guy” is considered one big failure for women in Chinese culture. When sexual abuse occurs in family, one common attribution is that “the couple has problem in their sex life” or “the wife cannot satisfy her husband in sex”. The therapist has to be careful of beliefs that subtly justify men’s abusive behaviour by blaming women. In Li’s situation, the therapist and Li together explored and examined her beliefs in gender, family hierarchy, marriage and love; and how these beliefs were related to her sense of shame. Moreover, the therapist also worked with Li on issues of anger and shame in relation to her daughter’s disclosure to people outside the family, before Li were able to understand and support her daughter emotionally. All these issues are better worked with the non-offending parent individually.
– Highlight Loc. 3583-85
Another important area of therapy is to understand the non-offending parent’s childhood experience with her own parents. This helps the non-offending parent to understand how her parenting practices are affected by or modelled after her experience with her own parents, so that she can make a conscious choice in her current parenting practices.
– Highlight Loc. 3596-3606
In working with the non-offending parent, we find that asking “If” questions are helpful to bypass the denial or the minimization, to expand the mother’s perceptions and to assist her to get in touch with her emotions that are difficult to express. For instance, instead of falling into an argument with the mother, the therapist may ask “If the abuse had really happened, what do you think would be the consequences? How would you and your daughter be affected?” Sometimes, not all non-offending parents are like Li, ready to make a moral choice. Some simply refuse to trust their daughters and participate in therapy. When working with the non-offending parent is impossible, other supportive adults have to be identified so that there is still someone in the child’s life with whom she can develop a trusting relationship. Lastly, the impact of sexual abuse on the child vary depending on her age and development. Sometimes, it may be helpful to assist the non-offending parent to realistically understand the impacts of the abuse on her child in light of her age and development. The non-offending parent may be so overwhelmed by the disclosure that she loses sight of the needs of her child. When the mother is able to understand her child’s reactions and to relate with the child in ways that support her developmental needs, this helps to strengthen their mutual trust and lessen stress and conflicts.
– Highlight Loc. 3616-19
The therapist needs to discuss with both parties on what materials they want to bring from their individual sessions to the joint sessions. Such discussion is called Decision Dialogue (Sheinberg and Fraenkel 2001). It is important in the sense that both can participate in the decision on when to talk what, which is empowering to families who, having gone through the experience of sexual abuse, are often left with a sense of powerlessness and helplessness.
– Highlight Loc. 3628-39
In summary, in the story of Li and Ling, the therapist chose not to confront the mother about her disbelief of abuse in the first place, but rather tried to understand what might be contributing to her dilemmas and struggles. The therapist then heard a story of love and the importance to find one’s own happiness, as well as an alternative story of strength in mothering practices that had existed Working with Familial Child Sexual Abuse 163 in generations. The therapist was thinking beyond the problem narrative of the mother’s disbelief and blame and rediscovered in her preferred stories of strength and finding one’s own happiness. This became a different platform in the joint session in which Li was able to support Ling and the two were able to connect emotionally. The mother could also make a moral choice. Both Li and Ling were no longer dominated by the story of shame around the abuse. The rediscovered stories and the values that they treasured helped to build up their preferred identities and their connections to one another. This made it possible for Ling to change her perception towards her mother. Li was no longer a primitive mother, but a mother committed to her family and children. Listening to her mother’s story and the strength that the three generations of women possessed, Ling felt proud and connected with the women in her family line. In the individual sessions with Ling, she showed more capacity to understand her mother’s conflicts and to let go of her anger towards her mother for not believing her in the first place. Ling became less irritable at home.
– Highlight Loc. 3661-63
Being influenced by the traditional Chinese values about the different roles of men and women, and the importance of the firstborn son in a family, he worked hard as the sole breadwinner of the family, and he often favoured the elder son,
– Highlight Loc. 3664-65
Preoccupied with both shame and fear of losing his son, Wong was depressed and irritable.
– Highlight Loc. 3668-82
With this understanding of how the abuse incident had affected the family members’ relationships by locking them in a cycle of negative interactions, and with the knowledge of Wong’s values of honesty and responsibility which he took pride in, the therapist first showed respect for the contribution he had made to his family, as well as acknowledged the expectations he had for his son and the attempts he had made to approach Fong. The idea of manhood and what constituted a responsible man in a family and society were then raised with Wong and Chun. Wong took pride in having treated his wife well and in having provided the family with a secure living. He spoke of what he believed a responsible man should be like, in which one of the qualities was to know how to respect women. When asked what he meant by respecting women, he replied, “Such as not to touch them indecently.” “So, how would you help your son grow up to be a responsible man so that he knows how to respect women?” the therapist asked. This opened up a dialogue that changed the meaning of his son’s removal from Working with Familial Child Sexual Abuse 165 one of losing him to one of helping him to learn to be a responsible man through the programs and counselling offered by the social worker. It also helped Wong see the importance for his son to take responsibility for the abuse, if he was to learn to be a responsible man. With this changed perspective, both Wong and Chun were able to recognize each other’s contribution in raising their children and establishing a family together. Through the conversations, the father’s life story and identity were no longer dominated by a story of shame and loss, but were expanded to include a story of pride and responsibility. With this expanded perspective, he had more capacity to understand the impact of abuse on Fong and to show more patience of Fong’s need for personal space at home. “Let me die!” was no longer heard in the family. Quarrels between the couple were much reduced.
– Highlight Loc. 3687-95
she would do her best to protect Fong in future. With this reassurance, Fong then told her mother why she did not disclose the abuse earlier. She was worried that her parents would not believe her, as she perceived that they had favoured Wai over the years. She then let her mother know her need for personal space at home. With the help of the therapist, she told her mother the stress she had during the disclosure and she reassured her mother that she would not hurt herself again. All these issues had actually been discussed in the individual sessions with Fong prior to the joint session, and Fong had agreed to tell these to her mother in the joint session with the therapist’s assistance. The mother and the daughter then had a discussion on what to do in their daily life so as to regain and rebuild their confidence towards one another. When the mother and the daughter were connected through their shared pain and reassurances of support rather than fear and blame, their perceptions of the relationship and their interactions changed. They were less irritated, fought less and had more understanding of each other.
– Highlight Loc. 3695-3700
In short, the primary goal of joint sessions with the child and the non-offending parent(s) is to strengthen their relationship and to rebuild trust between them, so that they can dissolve the difficulties brought by and heal from the negative 166 Ellen Yee-man Ma and Delphine Cheuk-wai Yau effects of the sexual abuse. To achieve this, the therapist has to work on the blocks that hinder the non-offending parents’ capacities to be empathic with the abused child. The non-offending parents’ overwhelming emotions towards the abuse, their fears and worries, their dilemmas and conflicts, their life experiences, their beliefs that affect the ways they respond, and the values that they cherish despite the abuse, all need to be explored and addressed.
– Highlight Loc. 3704-7
the therapist has to stand on a clear moral position that the perpetrating family member has to take total responsibility for the abusive acts. Other family members, including the child, are not to be blamed for the abuse. The therapist has to be conscious of the exercise of power by the perpetrating family member, usually the father or the father figure, over the child and how other factors such as gender beliefs and family roles help to maintain the power distribution in the family.
– Highlight Loc. 3708-25
we would state only the criteria that the offending family member has to meet before a joint session with the child and the non-offending parent is held. The first and foremost criterion is that the perpetrating family member takes total responsibility for the abuse. He makes no excuses, which sometimes can be subtle, for the abusive acts. An example of subtle excuses would be for a father12 to say, “I’m sorry for what I did. I was abused as a child, and I think I was messed up. I would never do this to you again.” For the apology, he can either apologize in the form of writing if he and the child cannot meet; or face to face with the child and the mother in an apology session if the child is ready to accept his apology. He has to learn to be empathic to the impact of abuse on the child and other family members. He also needs to be aware of how he has made use of his position in the family to exert his power in an abusive way. Furthermore, he has to commit himself to what he would do to ensure that he would not offend again. Secondly, it is important that he does not pressure or induce the child to feel pity for him and thus to forgive him. The distinction between a self-centred apology and an other-centred apology is important (Jenkins, Joy and Hall 2002). When the father focuses on his own suffering or apologizes for a particular end result, even though he admits his abusive behaviour, he is still prioritizing his own interests and needs over the child’s needs. In a self-centred apology, a father subtly puts pressure on the child and the partner to pity or forgive him, perhaps Working with Familial Child Sexual Abuse 167 by saying how miserable or painful he has felt, for example, “I know I do not deserve to be forgiven, and I cannot forgive myself too. I would carry the pain for the rest of my life.” Another example of a self-centred apology would be a father who apologizes as a means to achieve reconciliation. “I am very sorry for having hurt you. I promise I will change myself and never do this again. I hope we will work together for a better family.” If the perpetrating family member truly owns up total responsibility, he will prioritize the child’s best interests over his, and there are no strings attached to his apology. He understands and accepts that his apology does not entitle him to any specific responses he desires to have from his family members.
– Highlight Loc. 3725-31
In preparing for an apology session, the therapist has to make sure that the offending family member, the child, and the non-offending parent are all ready for the meeting; and that they are ready to talk about how to build safe relationships in the family. The child also participates in the decision whether to forgive or not and whether she wants such a session. The goal of an apology session is not for family reunion, but for the interests of the child. The therapist needs to be sensitive to the child’s voice on this issue, since usually children lack the negotiation power to assert their preference in the family. Sometimes, a child says yes for family reunion simply because she knows that her mother wants it, and she does not want to risk losing the mother’s love by opposing her wish.
– Highlight Loc. 3749-51
Chun shared that although there were some adjustment and embarrassment at the beginning, Wai kept his word on what he had committed to do, such as not staying alone with Fong and not going into her room.
– Highlight Loc. 3752-56
In cases where the offending family member denies the abuse or is imprisoned, or where the non-offending parent decides to separate from her partner, apology from the offending member is not likely. Under these circumstances, the therapist has to work with the child on how she perceives the offending family member’s denial or justifications, how to separate herself from self-blame, as well as how she can regain justice and a positive sense of self with the support of other persons in her life.
– Highlight Loc. 3756-65
From the above stories, it can be seen that each family and each person makes meaning of the experience of sexual abuse differently, and hence is impacted differently. The therapist needs to understand how beliefs in gender and family roles, family interactions, and the meanings constructed about the abuse influence the family’s perceptions and responses to the sexual abuse. Bearing these in mind, the therapist engages the non-offending parent(s) to explore their dilemmas and clarify their confusions, invites them to expand their capacities to understand the child’s feelings and needs, and facilitates them to make a moral choice. In addition, the therapist also has to work on changing any negative patterns of interactions among family members so as to restore a safe and nurturing family relationship for the child. Last but not the least, work with the offending family member is of salient importance in the safety and recovery of the child and the non-offending family members. Although this work is currently very difficult Working with Familial Child Sexual Abuse 169 to be implemented because of limitations in the social and legal systems in the local context, wherever possible, the offending family member should be invited and engaged in therapy.
– Highlight Loc. 3766-69
Bringing children who are rejected by their families together in groups helps to break down their sense of isolation, disconnection and stigmatization. In the earlier sections, we have talked about the importance of fostering supportive and nurturing relationships for the sexually abused children with other significant figures if family members are not available. Groups are another valuable option here.
– Highlight Loc. 3770-79
In facilitating groups for sexually abused adolescents,13 the same core ideas that are discussed in the earlier section apply. One central principle in the family-based relational approach is for therapists to interweave information among different therapy modalities (individual, family and group sessions) when working with sexually abused children/adolescents and their families. It is therefore preferable that the same therapists who see the adolescents individually act as therapists for the group. We find that it is also easier for the adolescents to speak up as they already have some familiarity with the therapists. It also seems to work best if the group members share common experience, such as being rejected and blamed by the family, being close in age with one another, and experiencing similar severity in the abuse. Where possible, it is helpful to recruit some group members who have already reclaimed some aspects of their lives from the effects of the abuse, so that they can share stories of hope and strength with those who are still in the turmoil and struggling with difficulties. In addition, ensuring certain degree of structure and predictability of the group helps the members to feel safe. Safety is fostered through regularity of time and place to meet, clear guidelines of conduct for group members, and similar structuring of each group meeting into components such as checking in, discussion of a particular theme, and closure.
– Highlight Loc. 3783-89
Artwork can be a useful adjunct for discussion of the difficult subject of sexual abuse. In one group, the members found art activities like making collages to introduce themselves and to express their feelings and thoughts about the abuse in the early meetings helpful both as an icebreaker and also to lessen the initial anxiety. Sometimes artwork helps to instill a sense of cohesion and shared purpose in the group. One group came up with the idea of having a symbol of a Flying Heart to represent the primary group value of “Love, Hope and Freedom”. This group, with a member talented at needlework, made the Flying Heart to be displayed in every meeting. The therapists often make sure that an array of art materials is available for use in the group meetings. Group members are given the option of using artwork as an alternative medium of expression in addition to the use of language.
– Highlight Loc. 3789-94
The use of food Food is another important element that the therapists include in every group meeting. Food is a symbol of nurturance and sharing. In the Chinese culture, families and friends enjoy the sharing of food to enhance the sense of mutuality and togetherness, whether on daily occasions or during special times. In our groups, the adolescents usually sit at a round table, sharing snacks while talking about the difficult topics. They also participate in deciding the snacks they would like to have. Sometimes, some group members brought food they made to share with the others. The therapists always take care to instill an atmosphere of care and mutuality in the group sessions when difficult topics are being brought up for conversations.
– Highlight Loc. 3795-3801
Inclusion of the larger context One important topic that is usually brought up for discussion in the groups is: how the larger context has made the group members’ experiences more difficult (the core idea of “social context in the life of problems”). The group members are invited to reflect and discuss how the negative societal responses and gender beliefs influence them to think negatively of themselves. Some examples of the negative social and gender beliefs that were discussed in the groups are: women are responsible for the sexual assault because of the way they behave and dress; or sexually abused girls are inferior or damaged. The group members are invited to discuss the effects of these beliefs on them, what positions they want to take, how they want to respond to these societal responses and beliefs, and whether they find these beliefs helpful to them.
– Highlight Loc. 3801-17
Discussing the effects of abuse: the use of metaphors and thinking beyond the problem narratives The other topics often brought up for discussion in the groups are self-blame, guilt, shame, confusion, fear, anxiety, anger and self-harm, namely the many difficult effects of the abuse and of disclosure the group members struggle with. The therapists facilitate the groups to speak of the difficulties in an Working with Familial Child Sexual Abuse 171 externalized way, as in Mei’s story in the section, “Individual work with young children”. Metaphors and symbols are used to represent the different topics for conversations. Some of the metaphors that we have used in the groups include: a dumping ground in which the members put down the burden of secrecy, a swamp in which the group talked about ways of getting free from the quicksand of self-blame, a dense forest in which the group found their ways out of confusion, a big hand that represented conversations about breaking free from the tight grip of guilt and shame, a candle that symbolized hope against fear, and a “wonderland” that represented the end stop where the group would find new skills and abilities and new preferred stories of strength. Externalizing the problems by speaking in metaphors puts a distance between the adolescents and the difficulties they are struggling with. In turn, this makes it easier for them to notice ways and steps that they have used or can use to overcome the problems. It is important that the therapists think beyond the problem narratives and listen to the group members on a double level. The therapists not only listen to the group members’ painful experience of the abuse, but also take note of how the group members have struggled and taken steps to stand up to the effects of sexual abuse. The therapists enquire the values, beliefs, hopes and commitments that have supported the adolescents in taking those steps to reclaim their lives from the effects of the sexual abuse. These values, beliefs, hopes and commitments speak to the adolescents’ more preferred stories of strengths, resources and pride. Connecting the group members’ lives through shared values, beliefs and hopes help to reduce their sense of isolation tremendously and enhance their sense of personal agency.
– Highlight Loc. 3824-29
Some more examples of the values, beliefs and hopes shared by the group members are: the belief of the importance of connections, the commitment in fairness, the belief to hang on even though things are tough, the hope to live their lives free from the effects of abuse one day, and the value of compassion and 172 Ellen Yee-man Ma and Delphine Cheuk-wai Yau empathy arisen from their suffering. After these conversations, the group members gave the feedback that they felt stronger, freer, happier, less lonely, more hopeful and more confident that they would overcome the difficulties brought by the sexual abuse.
– Highlight Loc. 3835-42
The importance of creating hope To instill a sense of hope, as aforementioned, it helps to have some group members who have already established some aspects of their life free from the effects of abuse to share their stories with those who are currently in struggles and turmoil. From our experience, we also find that the journey metaphor is useful in creating hope (McPhie and Chaffey, 1998; White, 2002). The group is likened to a journey. The members set off on a journey to explore different places (the discussion topics) and they all share a common hope that they will reach the “wonderland” where they will find new skills and knowledge about themselves, as well as strengths and resources that help them survive and surpass the negative effects of abuse. As a note of caution, we do not want to give the wrong impression that the process of traveling to this “wonderland” is easy and smooth, as our writing may sound. The process is full of setbacks and difficulties instead.
– Highlight Loc. 3844-46
The journey metaphor makes it easier for the group members to notice the steps they have taken, however small, when they compare the place they are currently at to the place they start off initially. The steps they have taken become the foundations to open up conversations for more preferred stories of strengths and pride.
– Highlight Loc. 3848-52
Rituals help to Working with Familial Child Sexual Abuse 173 build up group solidarity and also help to consolidate and strengthen the preferred identities and stories. Sometimes, it is in the format of an award presentation cer-emony (for example, an award may be presented to congratulate a member for her bravery in standing firm on her belief in fairness and in taking the witness stand in court), or a feast celebration. All members participate in deciding what they feel would be a meaningful ritual for them.
– Highlight Loc. 3871-72
in most cases of familial child sexual abuse, the offending family member is usually a male. When the offending person is a parent, it is usually someone in the father role, while the non-offending parent is usually the mother.
– Highlight Loc. 3876-77
“Collaborative Therapy: Relationships and Conversations That Make a Difference”.
– Highlight Loc. 3883-85
The externalizing way of talking about problems is a skill in narrative therapy. Readers who are interested can read more about the skill of externalizing conversations in Alice Morgan’s book “What is Narrative Therapy”
– Highlight Loc. 3974-83
In an attempt to differentiate the heterogeneous batterers population, Holtzworth-Munroe and Stuart (1994) have identified three dimensions which are found consistently to differentiate among subtypes of batterers: severity of violence, generality of violence, and psychological functioning. On the basis of these dimensions, three main types of male batterers are suggested, namely, (1) family-only, (2) dysphoric/borderline, and (3) generally violent/antisocial. The “family-only” batterers, estimated to constitute 50% of batterers, engage in the least severe violence and show little evidence of psychopathology or personality disorder. The “dysphoric/borderline” batterers, estimated to constitute 25% of the batterer samples, engage in moderate to severe wife abuse and in violence outside the family; they are involved in other criminal behaviour and likely to have borderline and schizoid personality features. Finally, “generally violent/antisocial” batterers are estimated to constitute the remaining 25% of batterers who engage in moderate to severe violence to their partners as well as outside their family; they have extensive criminal records and are likely to have substance abuse problems, antisocial personality, or psychopathology.
– Highlight Loc. 3986-87
There is also apparent consensus in the literature that partner violence is a very complex problem which indicates the need for a multidimensional explanation
– Highlight Loc. 3989-95
According to the theory, there are four levels of analysis for the characteristics of batterers, namely, the macrosystem, which refers to broad cultural values and belief systems such as patriarchal values; the exosystem, which refers to the formal and informal social structures (such as job stress, low income, unemployment, and the presence or absence of social support systems) imposed on the immediate settings of an individual and thereby influence his behaviour; the microsystem, the immediate context in which wife assault takes place and factors such as the couple’s communication and interaction pattern, their conflict issues, their power differential, and the process of assault; and ontogenetic factors, which refer to the individual’s developmental experiences with violence that shape his responses to the three-level social context.
– Highlight Loc. 4000-4005
The “internal experiences point of view” examines the men’s expectations and frustrations in intimate relationships; violence is believed to be used by the men as an attempt to protect themselves from being overwhelmed by emotions arising from the frustrations (Goldner et al. 1990; Chan 2000). The “interpersonal point of view” studies the men’s violence in the context of relationship conflicts and power struggle between the partners (Chan 1996). Finally, the “interventionist point of view” focuses on combating the men’s violence and proposes various strategies to change the men (for example, Emerge 2000; Pence and Paymar 1993; Geffner and Mantooth, 2000).
– Highlight Loc. 4020-22
It consisted of two stages: the first stage was a seven-session psycho-education which aimed at educating the batterers on the nature and consequences of partner violence and motivating them to take up the responsibility for change; the second stage consisted of 14 sessions and aimed at a more in-depth review and management of the men’s individual and marital problems underlying their violent behaviour.
– Highlight Loc. 4052-53
The focus here was on the men’s physical violence.
– Highlight Loc. 4069-78
These intermarriages have also been fostered by the men’s difficulties or reluctance in finding partners in the city and the women’s expectation to seek a better life in Hong Kong, an expectation that was somehow shared by the men or their parents in the past. These men and women were therefore joined by their wish for a family and their idealistic expectation to have a way out and improve their living standards. A typical marriage between a Hong Kong man and a Mainland woman in this sample was a blitz union between the partners who were introduced to each other and then got married within days or weeks. There was no dating or courtship, not to mention any romantic love, between them. After their marriage, they lived separately, with the man working in Hong Kong and the woman looking after the children in the Mainland. They were then united in Hong Kong after some three to ten years after their marriage. However, in spite of their union, they were yet to be united in many other ways ― their daily routines including their financial management and family roles differentiation, their own relationship and father-child relationships, their culture, and so on. Indeed, these men and women have a huge variation in their cultural or ethnic background. They had different family origins
– Highlight Loc. 4079-82
Such a difference represented, among other things, the men’s variation in their male-dominated kinship system and patriarchal values which are still prevalent in many rural parts of the Mainland, the women’s attachment with their own kin, and their exposure and openness to Hong Kong’s relatively modern values in gender equality and social justice. At a micro-level, the difference also had an effect on how the men and women manage their personal and family problems in their everyday life.
– Highlight Loc. 4197-98
TIN’s case illustrated one phenomenon that was clearly evident in this research, namely, the men’s longing to establish their own family.
– Highlight Loc. 4203-4
However, the male batterers in this research sample clearly subscribed to a family culture in the sense that they had been striv-ing to find their family, although the subjective meaning of family may vary from one man to another.
– Highlight Loc. 4205-11
In the majority of the cases, the men’s longing for family could be traced to some miserable personal and family experiences in their past, which had fostered in them a heightened and reparative wish to find their own family. In TIN’s case, he had endured a lonely childhood, rejected by others because of his psoriasis, and a failed marriage in the past. In KEN’s case, during his childhood he had been severely abused by his stepfather and frequently bullied by schoolmates of Triad backgrounds; when he entered adolescence, he went through a long and lonely struggle to wean himself from the habit of seeking sexual gratification by groping girls while in crowded places. For another man LIU, he came from a poor family in a Mainland village, which was labelled as having a “bad element” ― his father being a veteran from the Kuomintang. His family was victimized and LIU used to be bullied and hit by others, and his arm was once broken in a fight.
– Highlight Loc. 4217-23
From the outset, the men’s endeavours to establish their own families was an attempt to fulfill their reparative wish. But on a deeper level, they were apparently hoping that the intimate relationship could provide a healing to their emotional wounds and suffering that they endured in the past. For example, TIN was expecting from his wife an exclusive relationship in contrast to his childhood loneliness and rejection; KEN was expecting his girlfriend to provide him with a kind of unconditional acceptance and support in contrast to the childhood abuse and social judgment for his offending behaviour in his adolescence and early adulthood; and LIU was expecting from his wife intimacy and care to compensate 190 Chung-ming Chan for his prolonged victimization by the political movement. In other words, the men were seeking closeness, acceptance and recognition, care and support from their partners.
– Highlight Loc. 4229-36
the blitz union for some of these men and their emotional needs to heal their wounds and sufferings defy the account of using “romantic love” or “companionship marriage” as the norm or model to explain the relationship expectations of them. The romance and mutuality suggested in such accounts are to a large extent compromised by the functional union of these men with their partners and their internal quest for healing of their emotional wound and suffering. Their “romance” lies more with their unilateral, idealistic wish for “family” rather than in the couple’s relationship, and there is certainly little ground for “love” or “companionship” in their rushed, functional union. Instead of romantic love, the idea of “family” appears to be the core value of their relationship development; and instead of mutual care and support, their unmet emotional needs could, at least in the early stage, dominate in the partner relationship.
– Highlight Loc. 4237-55
Although they managed to find their marriage through a “blitz” union or otherwise, these men had endured a great deal of frustrations in their subsequent family development, and there were three main sources of their frustrations. First of all, they were in the past five years impacted by various life events or stresses such as serious health deterioration, unstable jobs or loss of employment owing to their health deterioration or economic downturn, financial loss due to gambling or business failures, death of close family members, being arrested and put on trial, and so on. Secondly, as with all other families, these men had encountered frustrations in managing the family finances, child behavioural problems, and in-law conflicts. Half of the men received or were still receiving public assistance; all of them Wounding and Being Wounded 191 (including TIN) were in the past five years under a great deal of financial stress because of their unstable jobs or loss of employment. In terms of child supervision, three of the men had problems in supervising their children who warranted their special attention; in TIN’s case, his two adolescent daughters were on the verge of delinquency. In terms of in-law conflicts, five of the men (including TIN) reported having conflicts, either between them and their partner’s parents or between their own parents and their partner. Finally, the men were greatly frustrated by the relationship with their partners. It should be noted that their frustrations were not so much directed towards the partner’s household and childcare responsibilities, although many of them did have constant arguments with their respective partners in the latter area. Instead, they were frustrated by the way their partners related to them especially when they were faced with their life events and family problems. In other words, they were frustrated because their partners had violated their expectations of her role in the intimate relationship. In TIN’s case, he felt being treated as an outsider by his wife. Moreover, some men were seriously wounded by their own partner’s provocative response at a time when they were agonized by some personal or family crises: for KEN, his girlfriend used to threaten separation when he was awaiting trial for his sexual offences; for TANG, his wife had used an allegedly bogus extramarital affair to avenge her suffering in the relationship; and for TUNG, his wife refused to attend the funeral of his ninety-year-old mother, thus avenging her hurt at his refusal to attend her father’s funeral many years ago.
– Highlight Loc. 4256-60
The many frustrations were apparently an assault both on the men’s sense of identity and in particular on their reparative wish to fulfill their unmet emotional needs in the intimate relationship. When faced with the many frustrations in their family life, they were confronted with a multitude of emotions which could be intense and overwhelming: sadness, loneliness, fear, anxiety, resentment, dissatisfaction, hopelessness, loss of control, being attacked or wronged, being trapped, being betrayed, being threatened, being neglected, being shamed or humiliated, being rejected, and so on.
– Highlight Loc. 4263-72
my view, the vulnerabilities of these men can be categorized into the following four types or sources. 192 Chung-ming Chan 1. Vulnerability to unhealed emotional wounds from past experiences ― Owing to their miserable personal and family experiences, the men carried heightened and reparative expectations in their intimate relationships and they were easily harmed by re-invoked feelings of the past wounds. 2. Vulnerability to the impact of life and family events ― The various life events in relation to one’s loss of health, employability, money, death, freedom, children’s well-being and so on were certainly an assault to an individual’s self-esteem or identity. 3. Vulnerability to the frustrations in an intimate relationship ― Their partner’s provoking responses in their daily interactions and especially at times of critical situations presented another assault to their self-esteem. 4. Vulnerability to jumbled, overwhelming emotions ― When the emotions arising from the various frustrations were jumbled together, they could be overwhelming and presented a serious challenge to the men’s emotional integrity.
– Highlight Loc. 4283-90
According to the attachment theory (Feeney 1999; Hazan and Shaver 1987; Shaver et al. 1988; Mikulincer et al. 2002), couples in intimate relationships have an internal working model of the relationship and how they expect to be treated. Couples typically expect their partners to be attentive, responsive and supportive especially in times of stress. In handling a negative emotional experience, an individual develops different strategies as a result of past attachment experience and repeated experiences of regulating distress with the partner: handling negative Wounding and Being Wounded 193 feelings in a relatively constructive manner by acknowledging distress and turning to the partner for support (referred as secure attachment); resorting to self-reliance as a way of reducing conflict with the rejecting or insensitive partner (referred as avoidant attachment); heightened awareness and expression of negative feelings as a way of maintaining contact with the inconsistent partner (referred as ambivalent attachment).
– Highlight Loc. 4299-4301
The above analysis suggests that the male batterers were exposed to a number of vulnerabilities or injuries and had difficulties in managing the emergent emotions which at times threatened to overwhelm them. These overwhelming emotions may then fuel their aggression towards their respective partners or explode occasionally into extreme violence towards the partners.
– Highlight Loc. 4302-13
Goldner et al.’s theory rests on the premise that the construction of gender and gender difference is a universal principle of cultural life that manifests itself in the individual psyche, the metaphysical framework, and the ideologies of a society. There is a taboo against the similarity between men and women and the dread of the collapse of gender difference operates silently and powerfully in all relations between men and women. These fears are normatively central to the development of men’s masculinity and they are socialized to be different and stronger than woman, to control and overpower, and to deny their dependency needs and weak, “feminized” feelings. However, in the romantic alliance between a man and a woman, there is an illusion of a collapse of gender 194 Chung-ming Chan differences in their love relationship ― men are allowed to express need or vulnerability without dishonour and women are allowed respect and dignity to their voice. But when the man is pushed to an intolerable feeling of similarity to the woman, he is terrorized by the weak, “feminized” feelings and will reassert his masculine difference and dominance by resorting to violence. Regarding men’s reparative expectations that the intimate relationship might provide healing to their emotional wound and suffering, Goldner et al.’s postulation regarding the men’s illusion about the collapse of gender differences between the couple has gained some support in the men’s cases.
– Highlight Loc. 4319-31
Goldner et al.’s theory. First of all, as discussed earlier, the majority of couples did not develop an intimate relationship based on romantic love. Instead, in their mostly functional union with their partners, it was “family” that played the significant role of tying them together and fostering the couple’s expectations towards each other. Family played a significant role in these men’s self-development such that it became part and parcel of their identity. Secondly, in addition to the four sources of vulnerabilities for these men, Goldner et al.’s postulation points to another type of vulnerability harboured by the men at a deeper, unconscious level ― vulnerability to being similar to women. But important as the role of this gender-based vulnerability in male battering behaviour may be, the role of other more generic vulnerabilities should not be overlooked. More importantly, when they are exposed to life and family events in an intense intimate relationship, how much difference is there between members of the opposite sex? Could there be more similarities than differences? Could there be a wide variation even within members of the same sex? Thirdly and finally, contrary to Goldner et al.’s postulation, some men in this research sample were not in denial about their weak feelings and need for support in front of their partners. Instead, it seemed to be their partners who did not acknowledge or even reject their expressed feelings and emotional needs. Therefore, in my view, as much as there are gender differences in the men and women’s acceptance and expression of their feelings and needs, there are also important differences in how their expressed feelings are accepted or rejected by their partners.
– Highlight Loc. 4342-56
For those men who held explicit and strong patriarchal values, they on the one hand felt justified in asserting domination and control in the relationship and, on the other hand and perhaps more importantly, hinged their emotional comfort upon their wife’s subservience. However, like any other man in the research sample, these patriarchal men were prone to various vulnerabilities in their personal and family development; and their patriarchal domination provided a deadly cover for their vulnerabilities. Contrary to their wish to find emotional comfort in the intimate relationship, their gender superiority beliefs made them more vulnerable in several ways. First of all, when faced with rejection and challenges from their wives, they were susceptible to feeling that their leadership was threatened and themselves being humiliated. Secondly, since their emotional comfort hinged upon the care and subservience of their partners, they were further alienated and wounded at times of confrontation with their partners who could hardly be caring and subservient to them at times of confrontation. Thirdly, when these men were struck by jumbled, overwhelming emotions and therefore came close to their weak, “feminized” feelings such as sadness, inadequacy and shame, the similarity with women posed a great threat to these men who believed that they were superior to women (Goldner et al. 1990). Moreover, in dealing with their emotional frustrations and vulnerable feelings, instead of advancing their self-understanding and self-care, they tended to adopt a moralistic view and focus on the wife’s violation of their relationship virtues (不守婦道、唔識做人老婆), and their 196 Chung-ming Chan patriarchal beliefs provided them a dominant justification to release their anger and other emotions through aggression towards their partners. But their aggression could hardly provide any comfort but only further alienated their wives from them, therefore aggravating the marital conflict and leading to further frustration.
– Highlight Loc. 4362-64
To understand male battering and thus design the appropriate treatment strategies for the male batterers, the findings of the men’s vulnerabilities and emotional injuries in this research study demand us to go beyond the focus on the male batterers’ “violent face” and touch on their “non-violent faces” in the context of their personal and family development.
– Highlight Loc. 4364-73
These men may have a number of vulnerabilities as mentioned earlier ― vulnerability to unhealed emotional wounds from the past experiences, vulnerability to the impact of life and family events, vulnerability to the frustrations in the intimate relationship, vulnerability to jumbled and overwhelming emotions, and vulnerability to being rejected in expressing their “feminized” feelings ― which operate through the men’s developmental experiences in the past, values attached to family, expectations of the intimate relationship, and management of emotional frustrations. Owing to these vulnerabilities, the men may feel being wronged during confrontation and their violent outburst is an attempt to protect themselves from being wounded emotionally by their partners or otherwise. In this act of protection, they are likely to be immersed in their hurtful feelings, seeing themselves as being wounded and justifying their violent reaction as an inevitable self-defense. As a result, it would be difficult for them to look at or experience their behaviour from another angle, that is, the violent and controlling side of their self-protective behaviour as well as reparative expectations in the relationship.
– Highlight Loc. 4377-81
In my view, in order to establish the connection and therefore the basis for intervention with these men, we need to adopt a “both-and” approach: While their aggression is not to be accepted and themselves not to be exonerated from the responsibility, their miserable experiences and resentment should be heard with empathy and with a view to understanding the vulnerabilities that may under-lie their violence. Such empathic understanding may provide not only ventilation of their pent-up emotions but also space for the men to reflect on their own experiences.
– Highlight Loc. 4384-86
The questions are: Which types of anger are particularly prone to violent outbursts? What are the roles of other emotions (such as shame, jealousy, hatred, depression) in contributing to these angry emotions and/or violent outbursts in an intimate relationship? Finally and most importantly, what is an effective, alternative management of these emotions?
– Highlight Loc. 4387-88
Moreover, in relation to the men’s emotions, it was found in this research that certain types of issues may be particularly volatile and hurtful to the men.
– Highlight Loc. 4476-77
Though no group differences were found in the cognitive test performance, patients with subjective memory complaint reported a higher level of anxiety than those without.
– Highlight Loc. 4481-85
post-trauma experiences as an internal event to the person caused by the onset of severe physical illness. The onset of physical illness may be sudden, unexpected and immediately life-threatening like stroke or myocardial infarction. The potential for psychological reactions to these events can be comparable to other traumatic reactions. Post-trauma reactions often include intense feelings of helplessness and high levels of anxiety and uncertainty about the future (Tedstone and Tarrier 2003). It is important to understand these reactions as they can act as a trigger for a range of responses which in turn will affect interventions and rehabilitation (Alonzo 2000).
– Highlight Loc. 4486-90
Severe acute respiratory syndrome (SARS) was the name given to this disease at that time because patients suffering from SARS had flu-like and respiratory symptoms; for example, fever, cough and difficulty in breathing (Donnelly 204 Alma Au, Iris Chan, Patrick Chung-ki Li and Kam-mei Lau et al. 2003; Lee et al. 2003). SARS attacking human lungs has been considered as atypical pneumonia; tomography and chest radiographs of the SARS patients disclosed multiple areas with peripheral ground-glass appearance and consolidation on the lung, causing different degrees of lung injury (Lau et al. 2005). This disease was later found to be caused by a novel coronavirus (SARS CoV) (Peiris, Yuen, Osterhaus, and Stohr 2003).
– Highlight Loc. 4851-53
Although cancer is the major cause of death, these patients also had other comorbid chronic illnesses at the time of death. Cancer, together with other chronic debilitating diseases of the heart, lung, kidney and the neurological system, accounted for half of the deaths in Hong Kong (Tse 2007a).
– Highlight Loc. 4886-87
According to another local qualitative study on thirty-three Chinese palliative care patients by Mak (2001), awareness of dying was identified as the foremost element of a good death.
– Highlight Loc. 4895-4900
When thinking about suffering due to cancer, patients are often overwhelmed by the anticipatory or existing pain, as if pain is the hallmark of cancer. Studies have shown that cancer patients suffer from multiple symptoms in addition to pain. Pain, dyspnoea, fatigue, anorexia, nausea, vomiting, constipation, weight loss, cough, insomnia are among the common ones (Lo et al. 2002). In a local study on advanced cancer patients at the last week of life (Kwok, Tse and Ng 2005), patients reported multiple symptoms and among all, fatigue, cachexia and anorexia were among the most distressing ones. Indeed, these are often regarded as the triad of symptoms in patients who are imminently dying.
– Highlight Loc. 4903-4
The overall distress as experienced by the patient is subjected to his or her own appraisal as affected by multiple internal and external factors. It
– Highlight Loc. 4905
In addressing the distress and suffering from the symptoms, a multidimensional approach is required.
– Highlight Loc. 4908-13
I did not expect his lung lesion to cause any significant pain, and indeed, he rated his pain over the right chest (where his lung tumour was lying in) as very mild in intensity, of grade 1 out of 10 in a numerical rating scale. The pain was also transient, and would subside spontaneously. However, the impact of this “mild” pain actually lasted for a disproportionate duration of at least 4 to 6 hours. Every time the pain occurred, Chong would fantasize about his cancer growing bigger. Instead of carrying out his social activities that he was perfectly able to do so, he would rather be alone at home, perplexing about his cancer.
– Highlight Loc. 4913-15
The suffering of those dying is far beyond that of symptoms or the disease itself. The “disease” itself is not the focus of care, but should be the person living with the illness and dying from the illness.
– Highlight Loc. 4915-17
The idea that humans are dichot-omized into “body” and “mind” (Descartes, 1596–1650), has deep-rooted influence on development of Western medicine. With this dichotomy, the body was left to medicine. We keep on fixing the body, with little awareness of the suffering of the whole person. Helping the dying involves recognizing the patient as whole person.
– Highlight Loc. 4923-26
in the book The Nature of Suffering and the Goals of Medicine (2004), Dr Eric Cassell described a whole person as one consisting of the dimensions of physical body; behavioural pattern; roles and functions; relationship with self, others, and his/her god; past life experience and transcendence.
– Highlight Loc. 4950-52
Ming carried with him a strong sense of aloneness and loneliness as he appeared before our palliative care team. He could feel no one understanding him, as if he was disconnected from this world. The family was so valuable to him, and his act of doing something for his family had given him strength to live.
– Highlight Loc. 4954-55
The Modern Palliative Care Movement The rise of palliative care in medicine is responding to a call for alleviating the suffering of the dying.
– Highlight Loc. 4957-59
Palliative care, as defined by the World Health Organization (WHO), integrates physical, psychological and social care and provides relief from pain and other distressing symptoms. Palliative care affirms life and regards dying as a natural process; it neither hastens nor postpones death. Patients with life-limiting illnesses are supported to live as actively and fully as possible.
– Highlight Loc. 4959-64
Instead of the traditional biomedical model adopted in modern medicine, palliative care is characterized by a paradigm shift to the biopsychosocial and spiritual model. In order to relieve suffering, patient should be seen as a whole person, who has own experience of suffering as a spiritual being. Therefore spiritual care is an integral part of palliative care. And therefore in the presence of an incurable illness and a decaying physical body, therapeutic activities are still possible. This is mediated by professionals with skill and knowledge, who can establish a therapeutic relationship with the dying through acceptance and compassion.
– Highlight Loc. 4964-66
Compassion is not pity and sympathy. Compassion compromises of three active steps (Sulmasy 1997): firstly, to recognize the contents of suffering objectively; secondly, to understand the experience of suffering subjectively; and thirdly, to help the one who suffers by words and deeds actively.
– Highlight Loc. 4993-97
In one study on advanced cancer patients (McCarthy, Phillips, Zhong, Drew and Lynn 2000), they increasingly preferred not to have CPR and life-extending treatment as they approached death. They would prefer to die than spending time in coma or on ventilator. In one more recent study on 440 patients (Heyland et al. 2006) with advanced cancer and non-cancer illnesses, 55.7% of patients opined that “not to be kept alive on life support when there is little hope for recovery” as an important factor of quality end-of-life care.
– Highlight Loc. 5087-88
A hospital is never like home. Rules and regulations, routines, and lack of privacy contribute to depersonalization of death and dying.
– Highlight Loc. 5137-43
Illness is a family matter. While the patient suffers, the family members also undergo a painful journey, which will continue as they grieve after patient’s death. The dying journey is then one of saying goodbye to possessions, achievements, and relationships with the loved ones. While patients are facing the pain and suffering as the diseases progress, the caregivers are continuously adjusting to the burden of care giving. The importance of the palliative home-care service cannot be over-emphasized in this difficult journey. It facilitates continuity of care after patient’s discharge from hospital, and supports patients to stay at home for as long as possible. In delivering a home visit, the palliative home-care service will perform assessment of the patient and family and provide on-site intervention and appropriate bridging and referral if necessary.
– Highlight Loc. 5165-66
Although dying at home may not be preferred by some patients or families, it is important that home death is an option when so desired.
– Highlight Loc. 5171
A good death is a consolation not just for the dying, but also for the living.
– Highlight Loc. 5195-96
Care for the dying is not just a family matter, or just a part of the medical care, but also a matter that concerns the society by large.
– Highlight Loc. 5206-8
As palliative care workers, the encounters with our patients teach us not so much about how to die, but more importantly how to live even when the end is expected to be near. It is the present where we live, not the past, not the future.
– Highlight Loc. 5319-21
There are four key features in the international disaster management scene: mitigation, preparedness, response and recovery (Coppola 2007). Mitigation refers to the reduction or elimination of the likelihood of disasters. Preparedness refers to readiness of people to cope with the disaster and their chance of survival. Response means actions to reduce or eliminate the impact after the disaster.
– Highlight Loc. 5322-23
Recovery is about rebuilding and returning victims to the normal state of life.
– Highlight Loc. 5324-28
As we can see from the UN resolution, while advances have been made in international disaster management in the past decade, there has been little or no reference to post-disaster psychological support. The emphasis is still on saving of lives, replacement of damaged property, and restoration of the economy. Behind this is perhaps the still unresolved conflict among mental health professionals regarding when or if psychological support services should be provided.
– Highlight Loc. 5351-52
Experience shows that psychological needs permeate and affect all other aspects of relief such as shelter, food and basic health care.
– Highlight Loc. 5429-30
In the development of psychological services in response to disasters, the consensus is more important than the differences.
– Highlight Loc. 5441-43
The consensus is a compromise of a kind that seeks to circumvent the debate on what types of specific interventions are useful. It emphasizes the basic principles or philosophies and allows flexibility in the development of specific strategies. This is perhaps the most sensible and pragmatic approach to solve the problem.