Treating Sexual Abuse Through the Transtheoretical Model

As we progress ever further in understanding the scientific and sociological implications of our neurological processes, the human mind continues to be a difficult vault to unlock due to the complexities associated with its development and functioning. In spite of the leaps and bounds we have made, there still exists an ideological canyon in the field of psychology over the perspective which we should take in understanding the conditions of individual subjects. The division between those of a clinical disposition and those from the psychoanalytic school of thought, for instance, tends to direct the discourse over all manner of issue concerning the human emotional condition. With clinicians being only assured of a principle through empirical research and psychoanalysts engaging the philosophically instructed theorems of the likes of Sigmund Freud, (the father of psychoanalysis and a physiologist who brought forth and developed the concepts of the unconscious, childhood sexuality and repression and a way of understanding an individual’s psychological development and treating abnormal mental situations) the differences between the schools are significant enough to cast doubt on complete principles. This will drive the discussion hereafter, which concerns trauma relating to sexual abuse and the resultant psychological complexes that might emerge. Indeed, in contexts where sexual abuse has been a presence or in contexts where this persists with regularity, there are various schools of thought on how to approach its control and treatment. There is also a need to use various appropriate therapeutic tactics for instance the utilization of the steps advocated for in the transtheoretical model which are; precontemplation, contemplation, preparation, action, maintenance, and termination on the victims to help them move and recover from the harmful effects of sexual abuse. In order to examine these needs, this paper will consider the social cognitive theory, the health belief theory and the transtheoretical theory as ways of approaching treatment where sexual abuse is present with much emphasis being given to the transtheoretical model and theory as it is considered the most appropriate one for utilization in treatment of sexual abuse.

Before proceeding to a more detailed discussion of these theoretical constructs as they relate to the subject, it is appropriate to assess some of the psychological conditions that pertain to sexual abuse for instance fears, panic attacks, nightmares, irritability, sleeping problems, lots of anger among others. Though much of this discussion revolves from an examination of sexual abuse between adults—and characteristically perpetrated by a male against a female-it is also appropriate to draw some connection between sexual abuse of minors and resultant psychological conditions in adulthood. To this latter point, we are inclined to consider Freud’s body of work more directly.

Though Freud is considered one of the preeminent thinkers in our progress toward perceiving accurately the realities of the human brain, he is also an extremely controversial figure whose ideas have been held as much up to scrutiny as they have been praised. His conceptualization of repression is a primary example of this circumstance, with parties differing vehemently on whether or not this phenomenon is one that could be considered possible. Loosely, repression is the willful dis-acknowledgment of traumatic events during one’s lifetime which result later in psychological problems. Given that psychoanalysis, the process of therapy that asks the subject to sweep his or her own psyche for ingrained reasons for psychological distresses, is the likeliest route to eliciting the recovery of repressed memories, there is a general lack of empiricism in the discussion on the topic. And the clinical history of the topic suggests that it is very difficult to establish a sound methodological approach to proving its presence.

In absolute certainty, there is a relevance to memories which may have been forgotten by the recipient of abuse; while events may not be in the forefront of one’s consciousness or even directly accessible without reminders it is still possible for them to play a part in one’s life and emotional stability. This will be a prominent point of consideration especially as we make acknowledgement of the social cognitive theory of treatment. However, this does not necessarily illustrate that repression is the correct diagnosis to cast on every circumstance in which memory lapses are evidenced to have taken hold. This is a circumstance which can make psychological conditions beholden to repression extremely difficult to prove, diagnose and treat. Indeed, the most taxing element of contending with repression in a subject is in actually bringing to the conscious surface any memories which could be responsible for debilitating internal conflicts. Even here though, the elaboration of lapsed memories does not in itself warrant the use of the repression term. By its nature, repression is rarely a label which can be applied to one’s case without first an intensive exploration of the subject’s background and condition. Even then, revealing memories which have been repressed and properly assimilating them into one’s recollection of his own biography is a process that may illustrate that the trauma in question is in fact only elemental to a set of negative environmental experiences which may have led to one’s lack of emotional soundness. Sexual assault is specifically a topic that is fraught with a great variance of psychological responses among victims. Repression is often the most attractive label to apply to those suffering the long-term emotional repercussions of vaguely recalled or completely forgotten trauma, but this might be a flawed approach to treatment of an emotional condition.

According to a set of recent studies (e.g., Briere & Conte, 1993; Feldman-Summers & Pope, 1994; Herman & Schatzow, 1987; Loftus, Polonsky & Fullilove, 1993; L. Williams, 1994, 1995; for a recent review, see D. Brown, Scheflin, & Whitfield, 1999), “amnesia and/or subsequent recovery of memories have been found to be relatively common in studies of clinical populations that experienced childhood sexual and physical abuse.” (Gleaves, 4) This is indicative of the long-standing relationship between trauma such as sexual abuse during childhood and psychological conflicts later in life. There are a broad range of resolutions or evasive tactics which individuals might employ to contend with the presence of such experiences in their past. And there is an illustrated pattern wherein memories of such occurrences may be obscured over time. It has been even further argued by advocates of the repression theory that individuals subjected to recurrent abuse may adapt dissociative skills to contend with untenable emotional conditions, thus obscuring such experiences within the adult psyche. Thus, in a circumstance that would appear as counter-intuitive, most advocates of the theory of repression believe that repetition of traumatic atrocities is likely to increase the presence and cosmetic pervasion of repressive tendencies. Habitual sexual abuse is in particular a matter in which victims may be vulnerable to developing the coping mechanisms that banish such experiences to the periphery of the consciousness. The victims involved may find themselves accepting the situation and taking sexual abuses as normality and hence may not take any necessary precaution or action that may avoid such incidences in future making its effects more adverse. Clinicians have consistently engaged in controversial discourse over the parameters by which repression is more or less likely under such a condition.

However, through a review of the clinical history and the semantic debate over the relationship between trauma–especially sexual abuse–during childhood and the surfacing of psychologically distressing consequences in adulthood, it is evident that the diagnosis of repression is often misapplied. “The term ‘dissociative.’’ as applied to these disorders, is better construed as a descriptive label (referring to loss of conscious access to memory) than any pathological process instigated by trauma.” (Kilstrom, 36)

This helps to initiate interest in such approaches as social cognitive theory, developed by Albert Bandura. According to Bandura (1989), “social cognitive theory favors a model of causation involving triadic reciprocal determinism. In this model of reciprocal causation, behavior, cognition and other personal factors, and environmental influences all operate as interacting determinants that influence each other bidirectionally.” (Bandura, 2) Indeed, this is a model for therapeutic treatment which argues that some cognitive dissonance such as a sexual trauma during one’s childhood will have lasting and perhaps seemingly unrelated consequences. Bandura argues that one’s cognitive development is impacted by the experiences and stimuli to which one is exposed during the process of maturation. Any dissonance during this developmental process can have the impact of damaging or distorting one’s cognitive impressions even in future.

To this perspective, there are distinct formative conditions which help to mold one’s cognitive understanding of the world and, conversely, this cognitive understanding will shape behaviors, decisions and one’s comprehension of their impact. Thus, where some trauma such as sexual abuse has occurred, one’s cognitive response may take on the disassociative tendencies that lead to a perception of memory repression. This can make it difficult where such abuses are essentially unknown to both the client and the therapist to diagnosis the root causes of dissonance in one’s adult life such as incapacity to establish a stable romantic relationship, an unhealthy relationship with sex, defensive social posturing or general paranoia. Bandura (1989) warns that normal, healthy cognitive development will require the establishment of certain competencies, with undue trauma sometimes functioning to obstruct the full formulation of said competencies. Bandura (1989) warns that “learning how to deal with sexual relationships and partnerships becomes a matter of considerable importance. The task of choosing what lifework to pursue also looms large during this period. Self-judged capabilities influence the range of career options seriously considered, the degree of interest shown in them, and the vocational paths that are pursued (Betz & Hackett, 1986; Lent & Hackett, 1987). These are but a few of the areas in which new competencies have to be acquired.” (Bandura, 1989 p.67)

Another manner in which the Bandura theory applies to the present discussion is as it relates to adult self-actualization. Often, this is an element of cognitive development which has been clouded by emotional dissonance in those who remain in relationships where sexual abuse is persistent. Women who are subjected to repeat patterns of sexual abuse within the confines of a relationship may reveal patterns of developmental or emotional trauma during childhood.

This is not always the case though, as a preliminary discussion on the Health Belief Theory and a more extensive examination of the Transtheoretical Model will reveal. In some instances, the negative patterns which enable continued sexual abuse may develop as a result of adult-co-dependencies, insecurities or perspectives. On this point, research tends to demonstrate that for adults who are victims of sexual abuse, this will usually occur in patterned ways and in connection with other levels of abuse. The Minnesota Advocates for Human Rights (MAHR) (2003) points out those patterns of physical, emotional and sexual abuse are commonly repetitive. A child, women or even man who is vulnerable to such abuse in the home or within the confines of a negative relationship may often find it difficult to break away from the environment and emotional state which both help to reinforce such patterns as the perpetrator of the sexual abuse has no point of stopping the behavior since the victim seems to be taking no constructive step towards stopping it for instance reporting the matter to the responsible authorities or moving out from the abusive relationships. This is why evolving approaches to counseling for rape victims, and the expansion of such counseling for victims of violence, are geared toward offering victims ways to extricate themselves from circumstances where patterns of violence and abuse are likely to continue or even worsen.

MAHR indicates that, increasingly, in legal contexts, first-responders are provided with more effective education in approaching live situations of abuse, which can be difficult to negotiate and even potentially dangerous to intervening parties. This training is intended to help initiate this process of extrication immediately and to “change attitudes toward other violent crimes including dating violence, sexual assault, and stalking.” (MAHR, 1)

This underscores the argument that drives the remainder of this discussion. Namely, the account is influenced by the view that for those persisting in a state of ongoing sexual abuse, there is a need to employ counseling as a way of moving the victim toward the psychological and emotional decision to be extricated from this situation. One way of clarifying this subject matter is through examination of the values of the health belief model. This is an appropriate way to gain a better understanding of what causes people to make certain health behavior decisions, such as those which are likely to incline individuals who have been subjected to sexual abuse for an extended period of time to remain in demonstrably dangerous circumstances. It seems reasonable to deduce that a perspective through this model might help to reveal such possible causes for one’s continued presence in a relationship marked by sexual abuse. The use of the health belief model should contribute to the construction of an examination that seeks to alter negative health behavior by isolating such root causes and establishing empirical connections for subjected individuals between patterns and consequences.

Our research finds that the health belief model bases its approach on the premise that the individual will tend only to take preventative healthcare actions or positive health if certain conditions are present. Namely:

  • The individual must believe that it is feasible to avoid the negative health condition at issue
  • The individual must believe that by taking an action which has been recommended by a public health campaign, that it will be likely that he or she can avoid this condition.
  • The individual must believe that the recommended action can be adhered to successfully. (TCW, 1)

This sequence of conditions may be useful in a discussion on how to remove individuals in abusive relationships from harm’s way. And ultimately, the realization of such conditions would be a crucial step in making some potentially life-altering or life-saving changes. It also forms one strand of the Transtheoretical Model, which is ultimately considered the most directly pertinent to our area of consideration. Namely, its conditions demonstrate the model to take a direct interest in health behavior changes but with a greater emphasis on individuality as part of the health decision-making progress. This differs from the health belief model by removing the focus on social pressures and external conditions, instead investing the power for health behavior change in the individual. As we apply this to a consideration of sexual abuse, it becomes increasingly clear that such is the emphasis which is most likely to empower one to be extricated from a harmful situation. According to CZ (2004), the Transtheoretical Model “focuses on the decision making of the individual. Other approaches to health promotion have focused primarily on social influences on behavior or on biological influences on behavior.” (p. 1)

With respect to sexual abuse, this seems to acutely recognize the helplessness which is often assumed by a victim of sexual violence and to take steps to undo this perspective. Indeed, research demonstrates that sexual abuse carries a number of psychological consequences for instance fear and panic which can make it inherently difficult for a victim to remove him or herself from dangerous circumstances that are presented by the sexual assault. Most studies on this subject show compelling and statistically lopsided evidence that women who are victims of abuse are likely to experience some degree of psychological distress or disorder in the long-term. A study by Butter (2006) uses a literature review compiled of statistical evidence which helps to reinforce the primary argument of this proposal. Namely, Butter finds that “women who live in violent households experience intense feelings of fear, panic, and anxiety (Jones 87). Many experience feelings of depression and shame, because they feel guilty about staying in their current situation yet they can not get themselves out of the situation (Jones 87).” This contributes an important point concerning the cyclical nature of sexual abuse and psychological distress, with the victim often retreating into a depressed and insecure emotional state that will prevent her from extricating herself from the situation. This, in turn, becomes a cause for a further sense of isolation. A limitation of this study is its reliance upon a bulk of research which is driven by anecdotal and discursive rather than quantitative literature.

This means that it is best supplemented by such studies as that provided by An Abuse, Rape and Domestic Violence Aid and Resource Collection (2008), which employs statistical findings from prior research to further its claims as to the direct connection between sexual abuse and psychological trauma. As this source denotes, among those surveyed in prior studies, “depression remains the foremost response, with 60% of battered women reporting depression (Barnett, 2000).” (AARDVARC, 2008 p. 1) These statistical claims are supported by the indication that there is also a heightened risk of suicide in women who have suffered thusly, with 25% of suicide attempts by Caucasian women and 50% of suicide attempts by African American women preceded by abuse (Fischbach & Herbert, 1997).” (AARDVARC, 2008 p.1) These are compelling statistical claims which provide a firm empirical backbone to the claims of the proposed research.

The subject is also provided with a useful definitional framework for abuse and its relationship to emotional trauma. Here, Belmonte (2007) denotes that “domestic abuse, also known as spousal abuse, occurs when one person in an intimate relationship or marriage tries to dominate and control the other person. An abuser doesn’t ‘play fair.’ He or she uses fear, guilt, shame, and intimidation to wear you down and gain complete power over you.” The victim therefore has no power or control over the issue and is left to suffer from the abuser’s or perpetrator’s behavior (Belmonte, 2007p. 1).

And beyond this, victims of abuse will tend to suffer many practical difficulties in being removed from such circumstances as well because of difficulties associated with adapting to the changes involved. In the confines of a marriage or other shared-living situation, sexual abuse can be the cause of uncommonly regular absentee from work for medical leave, with the victimization of women often compounded by dismissal from jobs where they cannot maintain suitable attendance. This adds to the problem of depression of the victim as he or she finds it difficult to deal with both the problem of sexual abuse and loss of employment. This is a crisis which is mirrored in housing for abused women. Another difficulty which this demographic has faced is eviction from the home, with urban landlords often showing a decisively low tolerance and pragmatism for domestic violence or the frequent presence of police officers resulting there-from. However, such threats as the loss of livelihood, residence or spousal support structure are all real stumbling blocks for women who find themselves restrained within abusive relationships in an effort to save themselves from the agony of shame and embarrassment. This leads to further execution of sexual abuse which leads to greater physical and emotional effects that could be avoided through quitting the abusive relationships.

The result of these findings is a further endorsement for the transtheoretical model, which boasts at its greatest therapeutic strength of the use of incremental steps driving the subject to make healthy decision and healthy behavior improvements of his or her own volition. It is clear from the findings discussed here throughout that patterns of continued sexual abuse do no inherently provide sufficient motive for lifestyle change on the part of the victim. A sense of both emotional helplessness and economic fear may prevent the individual from taking the necessary psychological steps to begin the process of separation from the abusive and harmful situation. This is why the Transtheoretical model imposes a process of gradual movement toward the eventual goal of optimal health behavior. According to Prochaska & Velicer (1997), “the Transtheoretical model posits that health behavior change involves progress through six stages of change namely: precontemplation, contemplation, preparation, action, maintenance, and termination.” (Prochaska & Velicer, 1997 p.38)

These stages seem to provide evidence of graduating efficacy for those restrained to negative health behavior patterns such as remaining in a relationship tainted with demonstrated patterns of sexual abuse. The stages provided by the model in question provide a realistic framework for making the emotional and practical preparations which are required to remove one’s self from such a situation. Consideration of these stages demonstrates that those suffering from sexual abuse must be moved only gradually into the direction of making life-altering decisions, and that pushing for these changes too aggressively might lead to defensiveness and relapse on the part of the client making the process of change and recovery more difficult. This justifies the ‘pre-contemplation’ stage of therapy, in which the focus is driven not by making change in the individual’s life or circumstances but by identifying the conditions which have produced distress or trauma in order to take appropriate measures. During this stage, the individual will likely be unaware that the level of change which is required—in this case, extrication from the abusive relationship and placement in safe physical circumstances—will be sought by the therapeutic process. It is instead more essential to incline the subject to begin to consider her situation as it relates to personal distress and cognitive dissonance. (CZ, 2006 p.1)

It is during the next stage that more direct consideration of the implications and harm levied by patterns of sexual abuse are explicitly addressed. The phase called contemplation requires the counselor to move the subject to consider the real dangers—both physical and psychological—which are connected to the decision to remain in an abusive relationship as opposed to moving out. This phase should also provide the subject with the capacity to make more explicit recognition of the irrational nature of the relationship, as well as to consider the ways in which she has rationalized remaining in this relationship. The contemplation stage should help to reveal to the victim the degree to which she is truly in control of the decisions and behaviors that will remove her from a harmful situation.

Thereafter, preparation and action denote that change will not come about without first identifying the challenges to be faced and instructing one’s self on the steps which will be necessary to best deal with these challenges. These stages have been demonstrated through empirical research to have a direct impact on the health behaviors pursued by individuals who have suffered sexual abuse. While many victims did not report relief from the emotional trauma of sexual abuse under this model, it has proven effective in helping women to make informed decisions and engage in behaviors that do lessen or remove the continued threat of abuse. This is particularly so, the article by Koraleski & Larson (1997) shows, during particular stages of changes. Accordingly, Koraleski & Larson report that “participants in the contemplation, preparation, and action stages reported significant differences in use of behavioral processes of change but no difference in their use of experiential processes. The pattern of change reported by these participants lends some support to the applicability of the transtheoretical model to this population and supports prior clinical description of therapy with sexually abused clients.” (Koraleski & Larson, 1997 p.302)

This suggests that the transtheoretical model has been instructive in guiding women to take the practical steps to remove themselves from patterned and harmful situations. Indeed, its focus is largely similar to the health belief model in this respect, suggesting that those who engage in patterned negative health behaviors must first be educated on the implications of these decisions. However, the emphasis in the transtheoretical model on individual empowerment through gradual movement toward a specific change goal seems the proper fit for the conditions which are often attendant to repeated sexual abuse. Particularly, the degree to which this model acknowledges the practicalities which often prevent abused women from taking these steps renders it a realistic approach to a complex social and public health issue.

Another degree to which its value in the area of sexual abuse recommends the transtheoretical model is in its demonstrated success as an outreach approach. Where sexual abuse is concerned, one of the greatest difficulties to intervention is the reluctance of many victims to come forward. Fear of the social and economic stigma that may accompany the involvement of law enforcement and the courts, as well as shame over one’s persistence in an abusive situation, often leave many women to languish without any detection. The transtheoretical model, however, has proven effective in treating those who might not have voluntarily sought such counseling. According to the research conducted by Prochaska & Velicer (1997), “one of the most striking results to date for stage-matched programs is the similarity between participants reactively recruited who reached us for help and those proactively recruited who we reached out to help. If results with stage-matched interventions continue to be replicated, health promotion programs will be able to produce unprecedented impacts on entire at-risk populations.” (Prochaska & Velicer, 1997 p.38)

This suggests that the transtheoretical model may be ideal as a way of bringing comfort and support to those who might otherwise neglect to seek this. To this extent, it may be argued that the transtheoretical model is the most inherently valuable approach here examined to helping women take the emotional and practical steps to remove themselves physically from sexually abusive relationships and situations without the fear of the immediate shame but rather by considering the long term benefits. That said, we also note the limitations to this approach as a mode of therapy. In many ways, we are inclined here to refer back to the discussion on Bandura’s social cognitive theory, which seems more concerned with addressing the emotional and cognitive dissonance associated with such trauma. It is thus that while the transtheoertical model carries some of the strongest practical implications to our research, it is not to be considered in itself as a therapeutic solution to the repercussions of patterned sexual abuse.

For women, children or men who have suffered this, practical change are only an initial step. Thereafter, the process of therapy must focus on the emotional trauma and its potential long-term consequences. This denotes the need for some supplemental theoretical approach to treatment that continues to empower the individual but which does not shy away from confrontation of the trauma and its consequences to the individual psyche.

That said, the transtheoretical model seems a powerful first step in helping those otherwise incapable of removing themselves from abusive circumstances to gain the freedom, distance, and perspective needed to engage the healing process.

Reference List

An Abuse, Rape and Domestic Violence Aid and Resource Collection (AARDVARC). (2008). Long Term Effects of Domestic Violence.

Bandura, A. (1989). Social cognitive theory. In R. Vasta (Ed.), Annals of child development. Vol. 6. Six theories of child development (pp. 1-60). Greenwich, CT: JAI Press.

Belmonte, J. (2007). Domestic Violence and Abuse.

Butter, V. (2006). The Physical and Psychological Effects of Domestic Violence on Women. Web.

Change Zone (CZ). (2004). The Transtheoretical Model. The Change Zone.

Gleaves, D.H., Smith, S.M., Butler, L.D., & Spiegel, D. (2004). False and recovered memories in the laboratory and clinical: A review of experimental evidence. Clinical Psychology: Science and Practice, 11, 3-28.

Kilstrom, J.F. (2004). An unbalanced balancing act: Blocked, recovered and false memories in the laboratory and clinic. Clinical Psychology: Science and Practice, 11, 34-41.

Koraleski, S.F. & Larson, L.M. (1997). A Partial Test of the Transtheoretical Model in Therapy with Adult Survivors of Childhood Sexual Abuse. Journal of Counseling Psychology, 44(3), 302-306.

Minnesota Advocates for Human Rights (MAHR). (2003). Stop Violence against Women. Minnesota: University of Minnesota.

Prochaska, J.O. & Velicer, W.F. (1997). The Transtheoretical Model of Health Behavior Changes. American Journal of Health Promotion, 12(1), 38-48.

TCW. (2006). Health Belief Model. Web.

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PsychologyWriting. "Treating Sexual Abuse Through the Transtheoretical Model." September 6, 2022.