The Role of Traumatic Experiences As Risk Factors for Sexually Abusive Behavior

Isr J Psychiatry Relat Sci - Vol. 49 - No 4 (2012) Victim and Victimizer: The Role of Traumatic Experiences as Risk Factors for Sexually Abusive Behavior

Lucinda A. Rasmussen, PhD, LCSW

School of Social Work, San Diego State University, San Diego, California, U.S.A.

ing. Although “there is widespread belief in a ‘cycle’ of child sexual abuse, there is little empirical evidence for Abstract this belief” (2, p. 482). The Victim to Victimizer paradigm purports to explain A more encompassing paradigm is the Trauma the connection between being a victim of sexual abuse Outcome Process Assessment (TOPA) model (3-7). and becoming a perpetrator, attributing sexually abusive In TOPA, outcomes of sexual abuse and other abusive behavior to a predictable cycle of cognitive distortions trauma and subsequent behavioral responses (i.e., self- and self-destructive and/or abusive behaviors. victimization and/or abuse) are viewed as a multidi- Integration of two ecological models, Trauma Outcome mensional process, intrinsically influenced by a priori Process Assessment and Family Lovemap provides a risk and protective factors in key ecological domains more comprehensive explanation of salient contributors (i.e., neuropsychological elements, family history and to sexually abusive behavior in youth (i.e., trauma). A case dynamics, community and cultural context). TOPA goes example illustrates the parallel Trauma Outcome Process beyond the Victim to Victimizer paradigm by including in a victim, and the victim’s perpetrator, identifying a “recovery” response involving salient predisposing protective factors beneficial for trauma recovery. variables present prior to trauma (i.e., self-awareness, protective factors mitigating negative outcomes). It is congruent with another ecological model, Family Lovemap (8, 9), and both models are consistent with Two decades ago a paradigm was proposed purport- validation findings on the MEGA risk assessment tool ing to explain why juveniles offend sexually: “Victim for youth ages 4-19 years (10-12). to Victimizer” (1). Its premise: both offenders and victims have “issues of power and control” that for the victim may be “the outcome of abuse” and for the Challenging the Victim to Victimizer offender “triggers for offending.” Traumatic situations Paradigm post victimization trigger “a progression of thoughts Examining the hypothesized connection between prior and feelings” which for some victims involves “a dys- sexual abuse and current sexual offending is daunting, functional response cycle” (e.g., drug/alcohol abuse, given little prospective research has followed samples eating disorders and suicide attempts). Others (those of sexual abuse victims over time. Studies have found who become offenders) enact a “sexual assault cycle” sexually abused children have a significantly higher (i.e., “a predictable pattern of negative feelings, cognitive percentage of sexualized (not abusive) behaviors than distortions, and control seeking behaviors” leading to a normative samples (13, 14). Engaging in sexualized sexual offense) (1, pp. 328-329). “Victim to Victimizer” behavior does not necessarily imply increased risk for became a popular term describing this purported link sexually abusive behaviors, and most victims of sexual between prior sexual abuse and youthful sexual offend- abuse do not become offenders. The Victim to Victimizer

Address for Correspondence: Lucinda A. Rasmussen, PhD, LCSW, School of Social Work, San Diego State University, 5500 Campanile Drive, San Diego, CA 92182-4119, U.S.A. [email protected]

270 Lucinda A. Rasmussen

Gender must be considered when considering the Figure 1. Trauma Outcome Process Assessment (TOPA Model) © 2010, L. Rasmussen, Ph.D., LCSW dynamics involved in a victim becoming a victimizer. Girls are much more likely to have experienced multiple sexual victimizations at younger ages (17), yet girls A Priori Risk & Protective Factors Recovery Neurobiological, Family Dynamics, & Integration account for only 2 to 10% of reported juvenile sex offenses Ecological & Cultural (18). Biological (as opposed to environmental) risk factors may better explain the difference between males Safety and females, whether the individual manifests sexually abusive behavior as a youth or eventually develops a Trauma paraphilia as an adult. The late sexologist Dr. John Money Outcomes asserted: “the biological complexities of becoming male, Self-perceptions Self- Self-regulation coupled with other crucial developmental events, may Awareness Neurobiological & Choice contribute to the organism’s developing a paraphilia later” (as cited in 8, p. 93). Although laudable in its attempt to explain behavior of sexually abused youth who become sexually abusive, the Victim to Victimizer paradigm frankly falls short in the face of the innumerable victims who, in fact, never Trigger Abuse perpetrate a sexual crime (9). The key question is: what is Self different about those victims that go on to sexually abuse Victimize others? A large descriptive study (N = 656, 72% of whom Denial were youth) provides informative clinical data. Findings showed sex offenders who were previously victims of sexual abuse experienced significantly more life stressors paradigm may inadvertently support the misconception than those without such histories (i.e., divorce/separation, that all sexual abuse victims are prone to developing trouble with the law, trouble with the law because of sex, sexually abusive behavior (15). This in turn may subject hospitalization, hospitalization due to psychiatric illness, victims to unfounded accusations related to subsequent sex difficulties, change in residence, relationship difficul- behaviors, eroding their self-esteem and increasing likeli- ties, and school difficulties). They were also significantly hood of negative outcomes. more likely to have a family member who committed Concepts of social learning theory (i.e., modeling [by suicide or aggression toward others or to come from a perpetrator] and reinforcement [for rule breaking]), families in which a member tried to kill someone (19). along with classical conditioning (related to orgasm), “Victims” who perpetrate sex offenses are different provide a more viable explanation for a youth’s sexually kinds of victims. Some do horrendous, vicious, violent, abusive behaviors, both the initial act and a continued heinous, cruel things to other humans, even though they pattern (16). Social learning theory takes into account themselves may have endured such trauma. The society the multiple factors influencing whether a sexual abuse at large does not want to recognize these individuals victim will become abusive, including specific behaviors as victims. They are rightly called perpetrators, as they that are modeled for the youth, then learned and rein- absolutely are, but they are also victims….distinctly dif- forced. Those few victims who go on to become sexually ferent from other victims. There is something about this abusive may tend to mirror their perpetrators, engaging kind of victim that may explain why they become sexual in behavior that “replicates the offender’s own experi- perpetrators. TOPA attempts to answer this question. ence of abuse” (2, p. 482). A study of male adolescent sexual abusers with histories of childhood sexual abuse found they were likely to utilize similar methods when Differentiating Responses to Sexual sexually abusing their victims as their perpetrators had Victimization: The TOPA Model used when molesting them (e.g., babysitting, giving The ecologically based Trauma Outcome Process favors, making threats, using physical force) (16), thus Assessment (TOPA) model presumes individuals have supporting a social learning paradigm. different behavioral pathways they may take subsequent

271 Victim and Victimizer to a traumatic experience; two maladaptive (i.e., Self- Self-victimization and Abuse are immersed in “Denial” victimization and Abuse) and one adaptive (i.e., Recovery which in this context is a cognitive distortion used by the and Integration) (see Figure 1). The Victim to Victimizer individual to try to squash self-awareness. Diminished paradigm considers only the individual’s deficits that self-awareness, in a sense, is an oxymoron. Although potentially lead to dysfunctional and abusive behaviors. self-awareness may be impaired, it is impossible to not TOPA, on the other hand, affirms resilience in the face have some degree of self-awareness. of daunting challenges, both acute and ongoing. Many A well-known case of brutal sexual abuse that occurred victims cope effectively with their abuse and are neither in the United States helps demonstrate differences self-destructive nor sexually abusive. Protective factors between victims who become sex offenders and victims (e.g., family support, positive influences in school, work, who are “victims only,” as well as serves to illustrate neighborhood, and community) enable these victims the three responses in the TOPA model. The example to show “positive adaptation…..despite experiences of involves two qualitatively different victims: Elizabeth significant adversity or trauma” (20, pp. 739-740). Smart and Brian David Mitchell. The TOPA model will Figure 1 illustrates the Trauma Outcome Process examine these victims at post-victimization, considering pathway from experiencing a trauma to engaging in developmental variables that come into play. maladaptive or adaptive behavior. A priori risk and protective factors within the individual (e.g., inheritable Case Example: Overview characteristics, neuropsychological elements) and the At approximately 2 a.m. on June 5, 2002, Elizabeth Smart, environment (i.e., family dynamics and community and age 14, was kidnapped at knifepoint from the bedroom cultural influences) are represented by the oval shape she shared with her 9-year-old sister. According to her shown at the top of the Figure. They invariably affect testimony at the trial of her abductor (Brian David (positively or negatively) outcomes of trauma and the Mitchell, age 49 at the time of the kidnapping), Mitchell individual’s responses. Trauma outcomes (illustrated by forced her to hike through 4 miles of rough terrain in the first circle in the middle of Figure 1) are observed in the hills behind her home until they arrived at his camp- three areas: self-regulation, expressed self-perceptions, site. There (in the consenting presence of his wife) he and neurobiological symptoms (e.g., Posttraumatic Stress performed a “marriage ceremony” after which he raped Disorder [PTSD]). Self-awareness (the second circle) Elizabeth; then shackled her ankle to a heavy metal cable consists of thoughts, feelings, sensations, motivations, between two trees, where she was tied for 6 weeks (22, and actions (21) and is a key variable in the model. 23). Mitchell and his wife Wanda Barzee (age 57 at the Impaired self-awareness creates vulnerability to self- time) held Elizabeth captive for 9 months, during which destructive and/or abusive behaviors, both at the time time Mitchell raped her “on a daily basis up to 3 to 4 of the traumatic experience, but also to later “trigger times” (24, p. 11). Elizabeth reported she was forced to events” reminiscent of the trauma. watch Mitchell and Barzee engage in sexual acts, and then Trigger events (depicted as a “star” at the bottom repeat them with Mitchell. She claimed Mitchell forced of Figure 1) may involve any of the senses (i.e., sight, her to drink alcohol, take drugs, and smoke cigarettes, hearing, smell, taste, touch); as well as actions of others; and once allowed her to lie in her own vomit following body states (e.g., hunger); and/or cognitive associations drinking (22, 23). (e.g., the anniversary of a loss). Failing to connect a cur- Brian David Mitchell, like Elizabeth, also experienced rent trigger event to a past trauma may reflect impaired severe trauma as a child. Per the report of his siblings, self-awareness (perhaps associated with a dissociative there was significant parental discord and “all of the process), making it more likely the individual will follow children were exposed to physical and verbal abuse” (25, a maladaptive pathway. The three behavioral pathways p. 51). In one instance, Brian’s father allegedly beat him of the Trauma Outcome Process are illustrated by the with a garden hose (26). His father once left him in an large circles on the right side of Figure 1. The pathways unknown location, several miles from home, telling him of Self-victimization and Abuse overlap, indicating that that “if he didn’t like where he lived, he could live on his an individual can sometimes be self-destructive and own” (25, p. 51). Brian, about 9 or 10 at the time, bor- abusive at the same time. A circle of “Safety” surrounds rowed money from a passerby, and found his way home Recovery and Integration, signifying a safe environ- (27). Shadows of this experience were perhaps evident ment is needed for trauma to be integrated. In contrast, some 37 years later when Brian Mitchell kidnapped

272 Lucinda A. Rasmussen

Elizabeth Smart and took her to his isolated campsite. profoundly affect outcomes of traumatic experiences, Thus a “victim” became a “victimizer.” and as seen in the MEGA data, perhaps relate to an Elizabeth Smart and Brian David Mitchell share many individual’s vulnerability to engage in the Abuse response characteristics. Both grew up in Salt Lake City, Utah, in of the TOPA model. intact two-parent Caucasian families with multiple sib- Many youth develop Posttraumatic Stress Disorder lings; and both families were practicing members of the (PTSD) secondary to sexual abuse and other severe trau- Church of Jesus Christ of Latter Day Saints (Mormons). matic experiences, manifesting clinical symptoms of: (a) As children, both were involved in activities outside of reexperiencing (e.g., flashbacks, nightmares, reenacting school (i.e., Cub Scouts and Little League for Brian, and the trauma); (b) avoidance of cues associated with the playing a musical instrument [harp] for Elizabeth). Both trauma; and/or (c) hyperarousal/physiological responses fathers were professionals who dealt with the public, (i.e., increased heart rate, blood pressure, respiration, and although their professions reflected differences in socio- muscle tone) (33). Victims who experience symptoms economic status. Elizabeth’s father was a successful real of PTSD typically have difficulties in self-regulating estate developer and the Smart family lived in a million emotions, sometimes alternating between being: (a) dollar home in an affluent area of the city. Brian’s father emotionally overwhelmed by symptoms of intrusive- was a social worker and the Mitchell family frequently ness and hyperarousal; or (b) emotionally shut down changed residences (i.e., living in four or five apart- and detached, as seen in avoidance, numbness, and in ments, with the paternal grandmother, and in a house some cases dissociation. the father constructed) (27). Despite their similarities, Symptoms of PTSD are often part of the TOPA Self- the a priori risk and protective factors of Elizabeth and victimization response and relate to the individual’s Brian were distinctively different, perhaps accounting awareness of feelings, thoughts, and body sensations for their divergent outcomes and contrasting behavioral associated with a particular trauma (see Figure 1). The responses post trauma. Self-victimization response is characterized by problems in self-regulation and distorted self-perceptions Biological and Neuropsychological Risk Factors for including: suppression and avoidance of feelings; possible Sexually Abusive Behavior explosive episodes (directed toward self, not others); The effects of traumatic experiences on the brain are well deteriorating self-esteem; and self-destructive behaviors documented, affirming the brain is “the organ mediat- (i.e., suicidal gestures or attempts, substance abuse, eating ing the adaptive – and maladaptive – responses relating disorders, placing self in dangerous situations) (3, 7). to traumatic stress” (28, p. 1). Negative outcomes of PTSD is hypothesized to be frequently present for traumatic experiences are integrally linked to neuro- sexually abusive youth who have histories of significant psychological risk factors that may include, but are not trauma. Rates of prior sexual abuse vary considerably limited to distorted self-perceptions and impaired self- across studies (0 to 80%) but “are almost always found regulation (29-31). Difficulties in executive function- to be higher than the general population” (16, p. 277). ing often seen in sexual abusers (e.g., attention deficits, Likewise, up to two thirds have histories of physical abuse poor self-regulation, impulsivity) may have little to do and/or histories of domestic violence (34). Hunter asserted, with the “dysfunctional response cycle” (1) of Victim “PTSD in juvenile sex offenders appears to be high and to Victimizer, but rather reflect biological complexities its presence very likely directly or indirectly impacts the affecting brain functioning, including inheritable charac- behavior and treatment outcomes of afflicted youth” (34, teristics (30, 32). The MEGA risk assessment validation p. 368). However, to date, only one study has provided studies found a good percentage of youths in the samples incidence data of PTSD; of 40 adolescent sex offenders, (N = 1184 and N = 1056) had neuropsychological dif- two thirds met diagnostic criteria for PTSD. For 85% of ficulties (e.g., low intellectual functioning, impulsivity, these youth, triggers for sexual offending were reportedly attention problems, learning disabilities), variables found related to factors associated with their trauma (35). to be associated with risk for coarse sexual improprieties History of sexual abuse specifically “may play a direct and/or sexually abusive behaviors (10-12). The MEGA role in the emergence of sexual behavior problems in research empirically supports the TOPA premise that some youth, and very likely exacerbates the sexual behav- a priori ecological risk factors are related to the victim ior problems of many others.” (34, p. 368). A review of to victimizer dynamic. Neuropsychological difficulties 45 studies comparing sexually abused and non-abused

273 Victim and Victimizer children found two symptoms consistently differentiated (i.e., aggression, luring a child, exposing himself, and the two groups: sexualized behaviors and PTSD (36). It kidnapping and sexually assaulting Elizabeth Smart). may be that the two symptoms are interrelated, that is, Elizabeth Smart. There was an absence of psychiatric children who are sexualized may manifest underlying illness and/or hospitalizations in Elizabeth Smart’s family. PTSD (intrusive symptoms) which may then manifest There were no reports that Elizabeth had any problems as “repetitive reenactment of their victimization experi- prior to her kidnapping. She was described as a “kind, ence” (34, p. 368). smart, shy and obedient child” and “an intelligent and Brian David Mitchell. A priori neuropsychological diligent student” (37). Elizabeth was an accomplished risk factors are evident for Brian Mitchell, whose family harpist, an avocation requiring intense focus, concentra- history reflects serious mental illness and an obsessive tion, and the self-discipline of daily practice sessions, thus focus on religion. Brian’s paternal grandfather report- demonstrating she had a good ability to self-regulate. edly had a mental disorder and history of psychiatric She was also skilled in horseback riding and was a long hospitalization. His father, Shirl Mitchell, reported having distance runner who was training to compete in cross- unusual spiritual experiences (e.g., hearing a voice when country racing (37), activities that likewise required he was a boy saying “You are Christ”) (27). Shirl Mitchell focus, concentration and self-governance. spent over 50 years writing a “1066 page tome” entitled At first glance, Elizabeth Smart appears to have escaped Spokesman of the Infant God or Goddess. He claimed having PTSD, self-destructive behaviors or other indi- to be the “divine emissary” spoken of in the tome and cators of the Self-victimization response, despite the quit his employment in order to work fulltime on the terrible nature of her trauma. She did not report any document (25, p. 51). PTSD symptoms (e.g., intrusive thoughts, nightmares, Brian Mitchell began to show signs of serious mental hyperarousal) and, surprisingly, did not avoid cues illness by age 32, and at age 49, when he kidnapped associated with the horrendous things she endured. Elizabeth, Mitchell was a self-proclaimed prophet, On the night of her rescue from her perpetrators and unkempt with long beard and dressed in a white robe. reunion with her family (after 9 months of captivity), she He claimed he was called by God to reform the Mormon elected to sleep in the bedroom (and same bed) where Church (referring to himself as Immanuel David Isaiah). she was kidnapped, remarkably telling her family “don’t Like his father, he wrote a spiritual manifesto (i.e., the worry; I’ll be here in the morning” (38). A few weeks 27-page Book of Immanuel David Isaiah), which con- after her return home, she hiked with her family to the tained a purported commandment from God for him to campsite where Mitchell had taken her and later said, forcibly take “seven times seven” sisters to be his wives. “It felt triumphant!” (38). Elizabeth’s initial comment His obsession with polygamy appears to be the primary (“don’t worry; I’ll be here in the morning”) is perplexing. motivator for his kidnapping Elizabeth Smart (25, p. 51). Does it reflect Elizabeth’s resilience in the face of severe According to the TOPA model, Mitchell’s mental ill- trauma? Does it evidence aspects of family intimacy, ness put him at risk for distorted self-perceptions (i.e., that is, Elizabeth’s trust that her parents will protect her? grandiose religious delusions) and poor self-regulation, Or is her comment reflective of denial, that is, lack of and impaired his self-awareness. Evidence of problems self-awareness of the egregiousness of her trauma and in self-regulation is clear in Brian’s history. Shirl Mitchell its profound emotional effects? Does it represent deficits described his son as physically aggressive to his siblings, in Elizabeth’s ability to be self-nurturing, sensitive and frequently truant from school and “isolated…in his attentive to the emotional wounds from her trauma? own world” (27). As an adolescent, Brian abused drugs Over the years of Elizabeth’s recovery, there were and alcohol, which continued throughout his adult life, no reports of emotional outbursts, problems with self- including during the 9 months when he held Elizabeth esteem, or anger problems or abusive behaviors. On the Smart captive. At age 16, Brian began to manifest sexu- contrary, in an interview with Oprah Winfrey 6 years ally abusive behavior when he was arrested for luring a after her kidnapping, Elizabeth stated, “I’m doing great. I 4-year-old girl to his home, exposing himself and ask- don’t see myself different than anybody else” (39). Some ing her to touch his penis (25). Brian’s responses to his adult sexual abuse survivors have challenged the validity childhood trauma include behaviors characteristic of of Elizabeth’s statements, claiming Elizabeth could not the TOPA Self-victimization response (i.e., substance possibly have endured the atrocities she reported (e.g., abuse), as well as behaviors that were clearly abusive being raped over 1000 times in a 9 month period) without

274 Lucinda A. Rasmussen subsequently showing emotional distress and PTSD TOPA and another ecological model, the Family symptoms. They speculate Elizabeth has either denied Lovemap (8, 9), emphasize that both internal and envi- or repressed her feelings (possibilities in the TOPA Self- ronmental factors must be considered when assessing victimization response), or is hiding something and lying youth who have coarse sexual improprieties and/or about what happened to her (40). These survivors assert are sexually abusive. The Family Lovemap paradigm that Elizabeth’s claim of a relatively quick and purportedly describes how intimacy is expressed or not expressed in complete recovery (without having therapy) (38) does a family. Family Lovemap includes “a family’s hereditary a disservice to the thousands of rape victims and other predispositions or manifestations of inheritable charac- sexual abuse survivors who suffer years of emotional pain teristics, its history of romantic bonding, erotic bonding, and PTSD symptoms subsequent to traumas similar to reproductive bonding, and the products of such (i.e., the those Elizabeth experienced. The TOPA model would sexualities)” (9, p. 96). Traumatic abusive experiences support that it is possible, albeit very rare, for a trauma occurring within the family impact the youth’s Family victim to emerge relatively unscathed from extreme Lovemap. This can be seen in two important areas, first trauma, provided there are protective factors in a priori the degree of attachment, love and caring between chil- neuropsychological functioning, family dynamics and dren and their parents (4, 41); and next, the children’s community support. However, the TOPA model would ability to make and sustain relationships (8,10,11) and also support that it is possible to deny the effects of one’s relate socially with their peers (45, 46). trauma, to hide or suppress one’s feelings, thereby increas- The TOPA model asserts sexually abusive behavior ing one’s vulnerability to maladaptive self-destructive may emerge, not only subsequent to sexual abuse, but and/or abusive responses later on (3, 7). also when violence in the home is coupled by a high degree of sexual awareness engendered by a sexualized Family Risk Factors for Sexually Abusive Behaviors environment, although not necessarily sexual abuse The Victim to Victimizer paradigm explores the internal (47). Children may be “eroticized,” that is, “prematurely motivators (i.e., feelings and thoughts) of a sexually exposed to sexual material through any media form abusive youth’s behavior, but fails to consider how envi- (e.g., TV, Internet, still photos, DVD/video recordings ronmental influences affect the youth’s motivation. of movies, writings, tapes, songs) beyond their sexual Severely disturbed sexually abusive children typically developmental readiness age (Miccio-Fonseca, 1993)” come from chaotic family environments characterized (48, p. 89). This may include “actual sexual behaviors, by enmeshed or disengaged relationships, role rever- either observed, or participatory” (48, p. 96). Seto and sal between parent and child, and/or loss of a parent Lalumière’s meta-analysis (45) is also relevant here: the through death, separation, or divorce (41, 42). The great study not only found that adolescent sex offenders were majority of sexually abusive youth have experienced more likely to be sexually abused than adolescent non- some type of abuse (i.e., sexual, physical, exposure sexual offenders; they were also more likely to be socially to domestic violence, neglect) (10-12, 32, 43). Many isolated, have early exposure to pornography, and show sexually abusive youth have also been subject to other more atypical sexual interests. types of trauma (e.g., serious life threats and/or injuries, Brian David Mitchell. Brian Mitchell’s history is witnessing injury and/or death of another, involvement replete with risk factors related to the Family Lovemap. in gang violence, and/or family criminal lifestyle) (44). Abuse and/or neglect often impair erotic and romantic A meta-analysis of 59 studies compared 3,855 adju- development and contribute to “a ‘vandalized Lovemap’ dicated male adolescent sex offenders and 13,393 adju- (Money, 1986a, 1986b)” (8, p. 96). For Brian, this is seen dicated male adolescent nonsexual offenders (some of in physical aggression between him and his mother and whom may have been sexually abusive) (45). They found alleged emotional abuse and neglect from his father (i.e., the adolescent sex offenders were more likely to have being left in an unknown area to find his way home). been sexually abused, exposed to sexual violence in their Although he grew up in a two-parent home, there was family and/or experienced other types of abuse or neglect conflict in his parents’ marriage and they eventually (consistent with the research reviewed above). They divorced. His father’s testimony at his trial indicated had more anxiety and problems with low self-esteem. Brian’s physical aggression toward his mother and sister All of these variables are important when assessing the resulted in him being sent to live with his paternal grand- outcomes of prior trauma for sexually abusive youth. mother. Brian had difficulty engaging in and maintaining

275 Victim and Victimizer relationships, as evidenced by his father’s statements that absent. In the TOPA model, inconsistent emotional support Brian’s childhood and adolescence were characterized erodes the sense of “safety” needed to facilitate the adap- by “alienation” (27). As an adult, his ability to relate to tive response of Recovery and Integration (see Figure 1). others was skewed, as evidenced by poor reality testing, religious delusions, and erratic and bizarre behaviors. In Community and Cultural Influences aggregate, these behaviors reflect an inability to relate to, Cultural factors are important to consider when assess- or have concern or empathy for others. According to the ing trauma outcomes and responses post trauma. The Family Lovemap model, the degree of sexual violence role of community and cultural factors is not taken into that Brian perpetrated against Elizabeth (i.e., using a account by the Victim to Victimizer paradigm; rather, weapon, making lethal threats, raping her on multiple all victims of sexual abuse are assumed to be vulnerable occasions) reflects an individual with profound intimacy to similar cognitive distortions and predictable patterns deficits, coupled with a history of problems in expressions of dysfunctional behavior. Both TOPA and the Family of intimacy within his family (9). Lovemap consider these ecological factors to be integral in When interviewed following his son’s arrest for the influencing trauma outcomes and individuals’ responses kidnapping of Elizabeth Smart, Shirl Mitchell reported (particularly when abuse or other trauma occurs within the that Brian “was a latchkey kid” who had access “to books family). According to TOPA, a specific culture’s view on of an erotic nature maybe too much – novels that I’d bring abuse may adversely impact youths who have experienced into the house” (49). The author of the Family Lovemap sexual abuse and contribute to maladaptive responses, model asserts that sexually abusive individuals “often to include self-victimizing or abusive behavior (3, 5). come from unorthodox, unconventional families, having Likewise, the Family Lovemap paradigm considers the sexually deviant proclivities or unorthodox lifestyles individual’s culture among “the fundamentals of a family’s traceable from prior family generations (Miccio-Fonseca, combined biological, physiological, psychological, sexual, 1994)” (8, p. 96). There are indications in Mr. Mitchell’s social, and cultural history” (8, p. 96). history that he, like his son, had unconventional sexual A youth’s relationship with the social environment interests. In Spokesman for the Infant God or Goddess, includes immediate connections with neighborhood the senior Mr. Mitchell ruminated on sexual topics (e.g., and community, that is, “those entities with which the erotic play by children, sex between teens) and disclosed individual has direct communication, involvement, and having “an addictive voyeurism” (i.e., he fondled young some degree of influence (e.g., school, work, church con- girls as a child and peeped in women’s windows as an gregation, clubs, and medical, mental health, and social adult) (50). services)” (51, p. 26). Aspects of the family’s environment Elizabeth Smart. Family Lovemap centers on the capac- (e.g., poverty, unemployment, instability of residence) ity for intimacy in a family as it is played out through a create ecological risk factors that impact children’s abil- family’s previous generations, ultimately influencing a ity to form stable interpersonal relationships, inhibit youth’s ability to have and sustain trusting, close and inti- formation of a positive support system, and place them mate relationships with the world at large (10). Elizabeth at greater risk for sexually abusive behavior and mal- Smart’s history appears on the surface to be absent major adaptive responses to trauma (3, 5, 41). A supportive problems in family relationships. She came from an intact environment in a youth’s immediate social connections family (no separation from parents) and was not a victim within a culture is an essential component for promoting of physical or emotional abuse or sexual abuse or neglect. adaptive coping with the effects of abuse trauma (52). Her parents have appeared caring and supportive; her Brian David Mitchell. Brian’s family reportedly made relationships with her four siblings were harmonious; several changes of residence during his childhood and and she has had a network of close friends, both before adolescence (27). The family was described by neighbors and after her kidnapping. Support from family and close as “Mormon, frugal, and a little weird,” perhaps due to friends is a protective factor that may mitigate negative their unusual dietary practices (i.e., eating only wheat outcomes of traumatic experiences, as it apparently did products and vegetables) and the fact that all children for Elizabeth. However, the long-term effectiveness of were born at home (26). Other reports indicate Brian’s support as a protective factor is contingent on whether parents “were not especially active in the [Mormon] it is consistently rich and sustaining, or infrequent and church” (25, p. 51). From these statements, one may sporadic, with extended periods when support is largely infer that the family may have been somewhat lacking

276 Lucinda A. Rasmussen in community support, which may have contributed to family and community, consistent with other authors Brian’s own isolation. who have stressed the importance of protective fac- Elizabeth Smart. Community and cultural support are tors and influences in mitigating effects of trauma (20, seen in the strong connection of Elizabeth Smart and 55). The keys for opening the door of Recovery and her family with their faith, the Church of Jesus Christ Integration are self-awareness and safety (see Figure of Latter Day Saints (Mormon) and its social network. 1). An emotionally supportive environment creates a Over 700 of the Smart’s neighbors in their predominantly safe therapeutic space wherein the traumatized victim Mormon neighborhood showed up to help search for can sort through the conflicting thoughts and feelings Elizabeth in the days following her kidnapping (53). In associated with the trauma, take responsibility for his an interview 10 years after her kidnapping, Elizabeth or her recovery, and grieve the losses engendered by the attributed her survival and her remarkable recovery traumatic experience (3, 7). to: “my family, and to my friends and community who After being rescued by police from her kidnappers, really supported me, who really loved me and who never Elizabeth Smart successfully reunited with her parents treated me any different” (54). and five siblings, reintegrated socially with a network The community support evident in Elizabeth’s experi- of positive friends, and resumed her school activities, ence (i.e., 700 people searching for her) is atypical and horseback riding, and harp performances and recitals. unprecedented. Victims of sexual abuse typically do not She went on to major at music performance at Brigham experience such an outpouring of support from their Young University, then completed a successful missionary families and communities. Support and/or community experience in France for the Church of Jesus Christ of resources may be absent altogether – or intermittent Latter Day Saints. She testified articulately at her abduc- and inconsistent. For many victims, messages received tor’s trial and spoke to the United States Congress at from others are not helpful or encouraging, but rather the signing of the 2006 Adam Walsh Child Protection blaming and discounting. Victims may encounter such and Safety Act (i.e., a U.S. Federal statute that imposed statements as: “It’s your fault because of the way you lifetime registration on the most serious sex offenders dressed”; “What happened to you is no big deal; other [56]). An advocate for victim rights, Elizabeth has made people have had it much worse”; and “Why don’t you just numerous appearances at child abuse conferences across get over it?” Such statements may echo similar statements the country and discussed her trauma and recovery. She made by the perpetrator at the time of the abuse (3). recently married a young man she met on her Mormon Events that occur once abuse is discovered (i.e., negative mission to France, and was hired by ABC news as an reactions from family members, inadequate interven- expert on missing persons' cases (57). tions from law enforcement and child welfare) can be All reports indicate Elizabeth has made an extraordi- almost as traumatic as the abuse itself. Victims are often nary recovery from the egregious long-term trauma of isolated and feel alone, making them vulnerable to TOPA’s being kidnapped at knifepoint, held captive for 9 months, Self-victimization response. Contrary to the experience and repeatedly sexually assaulted. Remarkably, Elizabeth’s of many victims, Elizabeth Smart was enthusiastically recovery was accomplished without therapy. She declined welcomed home after her captivity, then sheltered by therapy, although her parents offered it. In an interview 6 her parents and nurtured by her family and friends, years following the kidnapping, she explained, “I don’t feel thus enhancing the possibilities of recovering from and the need to talk about what happened to me, but if I do, I moving beyond the horrific trauma she experienced. know my family is there” (38). Elizabeth Smart evidently was able to find a therapeutic space of safety through Recovery and Integration the emotional support of her family, her music and her The ecologically-based TOPA model helps explain why religion. Unlike many sexual abuse victims, Elizabeth was some victims like Elizabeth may not evidence PTSD able to see her perpetrator arrested, charged, and ultimately symptoms or other behaviors indicative of the Self- brought to justice, which was perhaps vindicating and victimization or Abuse responses. Such victims remain allowed her to move on. At the time of Mitchell’s sentenc- relatively intact and are able to engage in a process of ing, Elizabeth proclaimed, “I have forgiven him…..I am Recovery and Integration of their traumatic experi- at peace with what’s happened” (58). ences. According to TOPA, such recovery is facilitated by Elizabeth’s story causes pause. Her courage – in facing protective factors, particularly emotional support from her perpetrator and testifying for several days against

277 Victim and Victimizer him – and her resilience – in embracing her life and References moving forward – are admirable. Her recovery, however, 1. Ryan G. Victim to victimizer: Rethinking victim treatment. J Interpers provokes lingering questions. How does one recover from Violence 1989; 4: 325-341. the terror of being kidnapped at knifepoint and 9 months 2. Glasser M, Kolvin I, Campbell D, Glasser A, Leitch I, Farrelly S. Cycle of abuse: Links between being a victim and being a perpetrator. Brit J of captivity and repeated and brutal sexual assault? The Psychiat 2001; 179: 482-494. answers are perhaps found in the TOPA model. 3. Rasmussen L A. The trauma outcome process: An integrated model for guiding clinical practice with children with sexually abusive behavior problems. J Child Sexual Abuse 1999; 8: 3-33. 4. Rasmussen L A. Integrating cognitive-behavioral and expressive therapy Summary interventions: Applying the Trauma Outcome Process in treating children The overall conclusion of this review is that the Victim to with sexually abusive behavior problems. J Child Sexual Abuse 2001; 10: 1-29. Victimizer paradigm, while it perhaps explains sexually 5. Rasmussen L A. Differentiating youth with sexual behavior problems: abusive behavior in some youth, is restrictive, attributing Applying a multidimensional framework when assessing and treating sexually abusive behavior solely to distorted patterns of subtypes. Special Edition, J Child Sexual Abuse 2004; 13: 57-82. 6. Rasmussen L A. Trauma Outcome Process Assessment (TOPA Model): thinking and patterned behaviors. Responses to traumatic An ecological paradigm for treating traumatized sexually abusive youth. experiences (as demonstrated by the Elizabeth Smart J Child Adol Trauma 2012; 5: 63-80. case) are inherently more complex, influenced by the 7. Rasmussen L A, Burton J, Christopherson B J. Precursors to offending and the Trauma Outcome Process in sexually reactive children. J Child neuropsychological workings of the executive functions Sexual Abuse 1992; 1: 33-48. of the brain and environmental context of family, culture, 8. Miccio-Fonseca LC. Challenging the myths about sex disorders: and community. The Victim to Victimizer paradigm Understanding the role of bio-physio process, family lovemaps, and paraphilic fugue states. In: Prescott DS, editor. Knowledge & practice: does not consider these complexities. Challenges in the treatment and supervision of sexual abusers (pp. 91- Two contemporary ecological models provide com- 107). Oklahoma City, Oklahoma: Wood ‘N’ Barnes, 2007. prehensive and multidimensional explanations of the 9. Miccio-Fonseca LC. Family Lovemap, eroticized children and a constellation of sexually related risk variables. Manuscript submitted relationship of prior sexual abuse and sexually abusive for publication. behavior: Trauma Outcome Process Assessment (TOPA) 10. Miccio-Fonseca LC. MEGA: A new paradigm in protocol assessing sexually and Family Lovemap. These models are supported by abusive children and adolescents. J Child Adolesc Trauma 2009; 2: 124-141. contemporary empirical research on sexually abusive 11. Miccio-Fonseca LC. MEGA: An ecological risk assessment tool of risk and protective factors for assessing sexually abusive children and adolescents. youth (10-12) and thus provide a more evidence-based J Aggression Maltreat Trauma 2010; 19: 734-756. explanation of sexually abusive behavior than the Victim 12. Miccio-Fonseca LC. MEGA: A new paradigm in risk assessment tools for to Victimizer paradigm. sexually abusive youth. Manuscript submitted for publication. The above case example of Elizabeth Smart and Brian 13. Friedrich WN, Grambsch P, Damon L, Hewitt S K, Koverola C, Lang R A, et al. Child Sexual Behavior Inventory: Normative and clinical David Mitchell serves to illustrate how TOPA can dif- comparisons. Psychol Assessment 1992; 4: 303-311. ferentiate between victims of abuse who cope effectively 14. Gale J, Thompson R J, Moran T, Sack WH. Sexual abuse in young children: with their trauma and those who manifest maladaptive Its clinical presentation and characteristic patterns. Child Abuse Neglect 1988; 12: 163-170. behaviors that may be self-destructive and/or sexually 15. Johnson TC. Understanding your child’s behavior: What’s natural and abusive. A notable limitation of the case example is that it healthy. Oakland, Cal.: New Harbinger, 1999. is part of the public domain and well known throughout 16. Burton DL. Male adolescents: Sexual victimization and subsequent sexual the U.S. Information about such cases is often inflated abuse. Child Adolesc Soc Work J 2003; 20: 277-296. 17. Miccio-Fonseca LC. Adult and adolescent female sex offenders: Experiences and possibly peppered with inaccuracies. The author compared to other females and male sex offenders. Special Edition, J took steps to ensure that information about the case was Psychol Hum Sex 2000; 11: 75-88. well documented and cross-checked. Official sources 18. Finkelhor D, Ormrod R, Chaffin M. Juveniles who commit sex offenses against minors. Office of Juvenile Justice and Delinquency Prevention (court records, psychiatric evaluations) were utilized Juvenile Justice Bulletin 2009, December: 1-11. whenever possible. Other sources utilized were reputable 19. Miccio-Fonseca LC. Research report: On sex offenders, victims and their and respected news organization generally recognized families. Special Edition, J Offender Rehabil 1996;23: 71-83. as a reliable news sources. Included in the information 20. Luthar SS. Resilience in development: A synthesis of research across five decades. In: Cicchetti D, Cohen D, editors. Developmental reviewed were direct interviews with Elizabeth Smart psychopathology: Risk, disorder, and adaptation, Vol. 3, 2nd ed. New (including some that were videotaped).The result is York: John Wiley & Sons, 2006: pp. 739-795. a case study that provides an in-depth analysis of the 21. Miller S, Nunnally E W, Wackman DB. Alive and aware: Improving communication in relationships. Minneapolis, Minn.: Interpersonal dynamics of victim to victimizer in a sexual abuse case Communications Programs, Inc., 1975. and serves to show the application of the TOPA model. 22. Salt Lake Tribune Utah News (November 8, 2010). Nov. 8 transcript:

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Elizabeth Smart. Retrieved May 7, 2012 from: http://breaking.sltrib.com/ trauma and never needed therapy? Evil sits at the dinner table. Retrieved mitchell/nov8elizabethsmarttranscript.php May 7, 2012 from: http://ordinaryevil.wordpress.com/2010/11/18/ 23. Salt Lake Tribune Utah News (November 9, 2010). Nov. 9 transcript: elizabeth-smart-raped-at-least-once-a-day-forced-into-sex-with-a- Elizabeth Smart. Retrieved May 7, 2012 from: http://breaking.sltrib.com/ woman-and-tied-to-a-tree-but-shows-no-sign-of-having-suffered-trauma- mitchell/nov9elizabethsmarttranscript.php and-never-needed-therapy/ 24. United States District Court for the District of Utah Central Division, 41. Friedrich WN. Psychological assessment of sexually abused children and Case 208CR125, October 1, 2009, Elizabeth Smart testimony. their families. Thousand Oaks, Cal.: Sage, 2002. 25. Welner M. Forensic psychiatric evaluation submitted to Brent Tolman, 42. Hall DK, Mathews F, Pearce J. Factors associated with sexual behavior U.S. Attorney. Salt Lake City, Utah: The Forensic Panel, June 16, 2009. problems in young sexually abused children. Child Abuse Neglect 1998; Retrieved May 4, 2012 from: http://www.forensicpanel.com/data/Unsorted/ 22: 1045-1063. BDM_CST_Report.pdf 43. Righthand S, Welch C. Characteristics of youth who sexually offend. J 26. Griggs B. Tribune archive: Mitchell’s journey to “Immanual”: His life Child Sexual Abuse 2004; 13: 15-32. changed dramatically from diligent family man to delusional vagabond. 44. McMackin RA, Leisen MB, Cusack JF, LaFratta J, Litwin P. The relationship Salt Lake Tribune Utah News, November 1, 2010. Retrieved May 4, 2012 of trauma exposure to sex offending behavior among male juvenile from: http://www.sltrib.com/sltrib/home/50581425-76/story.csp offenders. J Child Sexual Abuse 2002; 11: 25-40. 27. Salt Lake Tribune Utah News, November 17, 2010. Nov. 17 transcript: Shirl 45. Seto M C, Lalumière ML. What is so special about male adolescent sexual Mitchell, defendant’s father. Retrieved May 4, 2012 from: http://breaking. offending? A review and test of explanations through meta-analysis. sltrib.com/mitchell/nov17shirlmitchelltranscript.php Psychol Bull 2010; 136: 526-575. 28. Perry B. Stress, trauma, and post-traumatic stress disorders in children: An 46. Letourneau E, Schoewald SK, Sheidow AJ. Children and adolescents with introduction. Child Trauma Academy Interdisciplinary Education Series sexual behavior problems. Child Maltreatment 2004; 9: 49-61. 1999; 2(5). Retrieved February 21, 2010 from: http://www.childtrauma. org/ctamaterials/ptsd_interdisc.asp 47. Araji SK. Sexually aggressive children: Coming to understand them. Thousand Oaks, Cal.: Sage, 1997. 29. Creeden K. Trauma and neurobiology: Considerations for the treatment of sexual behavior problems in children and adolescents. In: Longo 48. Rasmussen LA, Miccio-Fonseca LC. Paradigm shift: Implementing MEGA, RE, Prescott DS, editors. Current perspectives in working with sexually a new tool proposed to define and assess sexually abusive dynamics in aggressive youth and youth with sexual behavior problems (pp. 395-418). youth ages 19 and under. J Child Sexual Abuse 2007; 16: 85-106. Holyoke, Mass.: NEARI, 2006. 49. CNN.com (March 15, 2003). Father describes Brian David Mitchell’s 30. Miccio-Fonseca LC. Somatic and mental symptoms of male sex offenders: behavior. CNN Access. Retrieved May 5, 2012 from: http://edition.cnn. A comparison among offenders, victims, and their families. J Psychol com/2003/US/West/03/14/cnna.shirl.mitchell/index.html Hum Sex 2001; 13: 103-114. 50. Carrier S. The ongoing mysteries of the Elizabeth Smart case. Mother Jones. 31. Streeck-Fischer AS, van der Kolk BA. Down will come baby, cradle and December 14, 2010. Retrieved May 5, 2012 from: http://www.motherjones. all: Diagnostic and therapeutic implications of chronic trauma on child com/politics/2010/12/elizabeth-smart-verdict?page=2 development. Aust N Z J Psychiatry 2000; 34: 903-916. 51. Miccio-Fonseca LC, Rasmussen LA. Implementing MEGA, a new tool for 32. Venziano C, Venziano L. Adolescent sex offenders: A review of the assessing risk of concern for sexually abusive behavior in youth ages 19 literature. Trauma Violence Abuse 2003; 3: 247-260. and under: An empirically guided paradigm for risk assessment: Revised 33. American Psychiatric Association. Diagnostic and Statistical Manual of Version. 2006. Available from California Coalition on Sexual Offending Mental Disorders Fourth Edition Text Revision (DSM-IV-TR). Washington, Web site, http://www.ccoso.org DC: Author, 2000. 52. Sinacore-Guinn AL. The diagnostic window: Culture- and gender-sensitive 34. Hunter J. Prolonged exposure treatment of chronic PTSD in juvenile sex diagnosis and training. Couns Educ Superv 1995; 35: 18-34. offenders: Promising results from two case studies. Child Youth Care 53. ABC News. Neighbors help in hunt for Utah girl. June 6, 2002. Retrieved Forum 2010; 39: 367-384. May 5, 2012 from: http://abcnews.go.com/US/story?id=91586&page=1 35. McMackin RA, Leisen MB, Cusack JF, LaFratta J, Litwin P. The relationship 54. KOAA.com. Elizabeth Smart shares her story of survival, and hope. of trauma exposure to sex offending behavior among male juvenile March 13, 2012. Retrieved May 6, 2012 from: http://www.koaa.com/news/ offenders. J. Child Sexual Abuse 2002; 11: 25-40. elizabeth-smart-shares-her-story-of-survival-and-hope/ 36. Kendall-Tackett KA, Williams LM, Finkelhor D. Impact of sexual abuse 55. Katz M. On playing a poor hand well: Insights from the lives of those on children: A review and synthesis of recent empirical studies. Psychol who have overcome childhood risks and adversities. New York: W. W. Bull 1993; 113:164-180. Norton, 1997. 37. Bio. True Story. Elizabeth Smart. Biography. 2012. Retrieved May 5, 56. U.S.Legal Adam Walsh Child Protection and Safety Law and legal definition. 2012 from: http://www.biography.com/people/elizabeth-smart-17176406 2012. Retrieved August 3, 2012 from: http://www.definitions.uslegal. 38. Free C, Tresniowski A. Heroes of the year. People 2008; 69. Retrieved May 6, com/a/adam-walsh-child-protection-and-safety-act/ 2012 from: http://www.people.com/people/archive/article/0,,20207194,00. 57. Deseret News. Elizabeth to join ABC for missing person insight. July html 7, 2011. Retrieved: May 7, 2012 from: http://www.deseretnews.com/ 39. Oprah. Elizabeth Smart, John Ramsey: The stories that captured the article/700149961/Elizabeth-Smart-to-join-ABC-for-missing-persons- nation. September 10, 2008. Retrieved from: http://www.oprah.com/ insight.html showinfo/Elizabeth-Smart-John-Ramsey-Stories-That-Captured-a-Nation 58. Smolowe J. Elizabeth Smart “I forgive him.” People 2011; 75(22). 40. Alethea, blog (n.d.). Elizabeth Smart raped up to 1,000 times, forced into Retrieved May 5, 2012 from: http://www.people.com/people/archive/ repugnant sex acts and tied to a tree; but shows no sign of having suffered article/0,,20498386,00.html

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