CME

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Assisting sexually
I
aduOtt

)l

Practical guide to interviewing patients

MARK M. LEACH, PHD

CHERI BETHUNE, MD, CCFP

SUMMARY
Millions of adults have been
sexually abused. Patients
often confide in their family
physicians concerning their
abuse. Physicians must
understand their own issues
surrounding sexual abuse and
its sequelae before they
attempt to treat sexually
abused patients. The PLISSIT
model offers a practical guide
for assisting abused adult
patients.

RESUME
Des millions d'adultes ont et6
victimes d'abus sexuel.
Les patients confient souvent
a leurs medecins de famille
les circonstances de ces abus.
Les medecins doivent
comprendre leurs sentiments
personnels entourant les abus
sexuels et leurs sequelles
avant de s'impliquer dans le
traitement des victimes
d'abus. Le modele PLISSIT
offre un guide pratique pour
venir en aide aux adultes
victimes de ces abus.
Can Fam Physician 1996;42:82-86.

ILLIONS OF TODAY'S NORTH

experienced unwanted sexual encoun-

American adults were

abused during childhood.
Many experienced sexual
abuse. Statistics indicate that one in
three girls and one in eight boys under
the age of 18 will be involved in an
unwanted sexual experience with an
adult. We think that most of these
cases go unreported and undetected.",2
This article discusses how the
PLISSIT (permission, limited information, specific suggestion, and intensive therapy) model, originally
designed to treat sexual dysfunction,
can be adapted for treating survivors
of sexual abuse. It also discusses physicians' concerns about disclosure of
sexual abuse.

ters at some time. This has two oppo-

Physicians' responses
The prevalence of sexual abuse,
indicated by the statistics cited above,
suggests that many physicians and
mental health practitioners must have
0 0 @

@-*-

*-

@ 0
@

*e

Dr Leach is an Assistant Professor in the

Department of Psychology at the University of
Southern Mississippi in Hattiesburg, Miss.
Dr Bethune is an Associate Professor in the
Discipline of Family Practice at Memorial
University ofNewfoundland in StJohn's.

82 (anadin, Eandil P/lv.vi(ian1* li Aldecin defamnille canadien *:O

Vol 42: JANUARY * JANVIER 1996

site implications. The fact that they

share this experience with their sexually abused patients might interfere
with physicians' ability to empathize
as their own agendas and memories
surface or, conversely, might enhance

empathy through understanding.

The capacity to get in touch with
the basic human experience of powerlessness, vulnerability, and humiliation
that is integral to the experience of
sexual abuse might help doctors
appreciate the experience of abuse
survivors more fully. Physicians must
become aware of their own feelings,
attitudes, and beliefs regarding sexual
abuse because they have direct implications for their treatment of abused
patients.3 For example, what is your
first thought when you suspect abuse?
Do you feel competent and confident
that you can handle any situation
stemming from disclosure? Do you
dread opening a "can of worms?" Is
your biggest fear, "What am I going
to do if she does disclose?" Your
answers to these difficult questions
will affect both the verbal and nonverbal cues that you give patients and,
hence, affect the dialogue that follows.

CME

Assisting sexually abused adults

Caregivers, both during abuse or later during

healing, must be constantly vigilant that they do
not participate in the victim-blaming that frequently occurs.4 Much of the work will be to
counter the consequences of this common attitude of victim culpability. It is essential, therefore, that caregivers entering professions where
sexual assault and its sequelae are encountered
must work on the personal perceptions, stereotypes, and experiences that could colour their
treatment.
PLISSIT model
The variety of interactions with patients' past
abusive experiences calls for a model, or framework, of interaction to guide caregivers in assessing and treating survivors of sexual abuse. The
PLISSIT model was originally designed as a
framework for engaging patients and physicians
in discussions about sexual concerns. It can be
adapted to assist us in our approach to survivors
of sexual abuse.5
The PLISSIT model has been used in a variety of settings and for varying durations. Annon5
reported that each level of treatment requires
caregivers to have a greater degree of knowledge,
skill, and training. Therefore, caregivers must feel
comfortable with the type and amount of therapy
given and also be perceptive enough to understand patients' covert needs. Caregivers must also
recognize their individual limitations regarding
therapy and should know local referral sources in
case they are needed.
The model uses four levels of therapeutic
approach. The model is founded on the belief
that patients' needs vary and understanding those
needs will assist physicians to engage and help
patients. However, understanding these needs is
often difficult and might be limited by lack of
expertise, the professional setting, or physicians'
own discomfort with presenting or underlying
concerns. If physicians feel uncomfortable, it is
unlikely that they will be "available" to patients
who want to disclose. The model provides a flexibility that permits patients and physicians to
interact with varying depth and intensity based
on their shared agenda.5

This expanded model is based not only on the

desires and needs of patients but also on physicians' ability to determine these needs and their
own attitudes, feelings, and biases. The first three
levels of the model are best described as a brief
therapy format. The final stage is a longer, more

intensive approach.
It would be presumptuous to assume that all
abused patients place equal emphasis on the
abuse. It would also be incorrect to assume that
all sexually abused people need intensive psychologic or psychiatric therapy. Some suggest that the
most powerful determinant of psychologic harm
is the traumatic event itself, particularly for the
more extreme psychologic diagnoses, such as
multiple personality disorder." These authors suggest the more severe the trauma, the greater the
possible psychologic impact. Sexual assault ranks
as one of the traumas with the most enduring
psychologic effects.7
However, our experiences indicate that the
perception of the abuse is more important than
the event itself. Caregivers must understand the
meaning of the experience for each patient as
well as what effect patients believe it has had on
past and present functioning. For example, some
patients display severe posttraumatic reactions to
what might seem only mildly offensive behaviour.
The opposite also occurs. Patients who initially
seem to need more intensive therapy have confided
that the abusive acts have not caused them severe
stress. Some of these patients, upon further discussion, appear accurate in their perceptions. Many
patients have been working on healing themselves
for years in their own ways without caregiver assistance. "Treatment should be based on the issues
raised by the nature of the experience and on the
victim's unique response pattern."8
Permission. Case history:
A 48-year-old woman visited her family doctor for a checkup. TIhe doctor asked when she had her last Pap smcar. She
said she had never had a Pap smear. When asked why, she
said she was afraid because she feared that she was somehow different "down there" (her genitals) and that the doctor would automatically know she had been sexually
abused when she was a teenager. She said that she had
never told anyone before and wanted assurance that no one
else would find out.

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Assisting sexually abused adults

Becoming comfortable: Research and clinical reports

indicate that many patients avoid or are hesitant to
discuss sexual abuse issues."') Physicians should be
comfortable with the topic and should have a compassionate, nonjudgmental attitude.""2 The first
step is to permit patients to express concerns. This
treatment level is essential because patients must
be comfortable enough to discuss issues before they
can enter more in-depth treatment.
Much has been written about patients disclosing personal information to health professionals.'' For many, simple disclosure has
profound healing power. Physicians, by nature of
their profession and the position they hold in
society as healers, can offer opportunity for healing by acting as "confessors."'4 5 The concept of
"bearing witness," although liturgical in nature,
describes the phenomenon of giving meaning to
people's experiences and has tremendous therapeutic power.`9'6-'9
Patients often just want to know that they are
normal, that their experiences are common to
others, and that nothing is wrong with the way
they think or feel. They want to know they are
not considered bad or sick if they engage in particular thoughts or acts. People generally have
some distorted ideas about "normal" and abnormal behaviour; it is the professional's job to rectify these misconceptions. Patients often want to
talk to relieve tension associated with withholding
information. Patients' fear of reprisal or deviancy
demands that the doctor's attitude be accepting
and nonjudgmental.
Permission is the first step to recovery, yet it is
often the mnost difficult step for both patients and
physicians, particularly if they are of opposite
sexes. Many of the first author's (M.M.L.) female
patients attest that they have difficulty discussing
sexual abuse issues with him because he is a man.
Some physicians are uncomfortable with sexual
issues or simply are not trained to assist patients
with these concerns.
Gaining trust and respect is not easy. The
secrecy prevalent in many abusive households has
many causes. Victims might want to protect
themselves or family members from additional
emotional pain and societal rejection because of

the "taboo" of sexual abuse." '2'1 Many patients

are ashamed and embarrassed after disclosure, so
physicians must help establish a commitment to
treatment and engage patients in the therapeutic
process. 1 1
Associated with secrecy is the issue of disclosure. Many patients are unclear about the law
and the limits of confidentiality. Once they have
disclosed, patients often feel they have lost control
because someone else (ie, the physician) might
make decisions regarding "treatment" without
their explicit permission. Patients whose disclosures are received positively by caregivers are
more likely to feel better and return for future
appointments than those who experience negative reactions.'
We believe that full disclosure is not mandatory for working through abuse, but some authors
suggest that it enihances the healing process.2'
Immediate full disclosure need not be physicians'
primary concern at this point, but they must be
willing to understand the value that patients place
on their experience. At the permission stage
physicians should acknowledge to patients that
they have been understood.

Limited information. Case history:

A 21-year-old man arrived at his doctor's office for -what
appeared to be a minor illniess. WVhen given anl opportunity
to ask questions, he inquired wvhether a scare in one's life
could affect one's sex drixe. The pliysiciall acknovvlcdged
that this could happeni, particularly if the scare was caused
by a bad sexual experience, especially abuse. W\hen asked if
he wvas experiencing problems with his sex drive, the patienit
stated that his close fricnd wsas. The physician sensed the
paticnt's reticence to disclose more and rcstated that an
uninvited sexual experience could affect ainyonie's sex drive.
He suggested professionial help for the frienid.

Addressing immediate concerns: The concept of "limited information" can address the immediate and
most pressing concerns that validate patients' experience and fill in gaps in knowledge and understanding. It focuses on the patient's agenda, not the
physician's agenda. Patients might need to disclose
only a limited amount of information at a given
time. Physicians can provide a limited amount of
information regarding the problem disclosed.
Patients often feel relieved when they realize that

84 Canadian Fanilv Pl/sician * Le AIMecin defatmille canadiei .+ VOL. 42: JANUARY * JANVIER 1996

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Assisting sexually abused adults

others have shared similar circumstances. The critical component at this stage is that survivors get validation and reassurance from caregivers.
Caregivers must be aware of common themes
reported by survivors describing their reactions to
unwanted experiences. However, each patient is
also unique and has individual needs. Physicians
should ask whether patients recognize correlations
between past abuse and current symptoms. Some
patients have determined this connection, but others do not realize the possible relationship.22
Physicians should be aware that a perceived relationship between physical symptoms and abuse
might make patients defensive, particularly if
symptoms were previously discounted as being "all
in her head." However, negative reactions do not
prevent patients from further considering the idea.

Specific suggestions. Ciase history:

A 20-year-old woman disclosed her experience of sexual
abuse and said she vanted to cngage in group therapy. She
had heard that this type of therapy vas best and requested a
referral. A group was not available for several months but
her need to talk and discuss issues wvas critical and she did
inot rvant to xvait.

Suggesting changes: At this stage physicians can

make a direct attempt to suggest changes in
patients' behaviour in order to reach stated goals.
It would not be therapeutically appropriate to
provide specific suggestions until an understanding of an individual's unique situation is reached.
Provided the patient does not require intensive
psychotherapy, it could be useful to find out the
age at which the abuse occurred, how long it lasted, the perceived severity and frequency of the
abuse, past treatment, the patient's current
understanding of the cause of the abuse, and the
patient's expectations of you as a helper.
Family physicians can offer specific suggestions
for alleviating negative symptoms. Physicians can
offer continued support through discussions and
suggest that the patient start a diary. The diary
allows patients to express themselves immediately
by writing down thoughts and feelings. Reading
certain books can help survivors learn how to
articulate feelings, particularly negative feelings
that are too difficult to verbalize. These techniques

and others allow patients to progress in the healing

journey.13,17 Once patients begin to express ideas
and feelings about abuse, they sometimes become
overwhelmed. Close monitoring is essential.
Many patients improve without full disclosure.
Some patients never disclose all information, either
through conscious reluctance or as a consequence
of incomplete recall of events resulting from years
of competing and confusing thoughts. If caregivers
probe for details, patients might become frightened
or resistant. Therefore, immediately requesting
W
details is potentially countertherapeutic.9 iVhen
details gradually emerge, physicians sometimes feel
voyeuristic. Stories of abusive situations might be
difficult to process, and we should be honest with
ourselves and our patients regarding our capacity
to hear all the details.
In this stage of the application of PLISSIT,
patients and physicians could discuss more effective ways of managing the abuse now that it has
been disclosed. Physicians must have a firm
understanding of the psychologic effects of sexual
abuse and recommend a treatment plan that
agrees with current knowledge. Because office visits are time-limited, it might be necessary to rely
on a "maintenance" plan instead of a "healing"
plan. Coping strategies include setting goals, bibliotherapy, and keeping a diary. Keep in mind
that, between appointments, patients are still living and working through the abuse in their own
unique manner. Possible future interventions and
referral options can be discussed.

Intensive therapy. Case histoiy:

A 28-year-old woman disclosed abuse by her father and was
compelled to deal with it immediately. The physician sooIn discovered that she had been drinkinig heavily for about 6 years,
had been oni aind off antidepressaint medication, and often felt
like giving up and driving her car off the road. She had two
small children she believed she was neglecting due to her current preoccupation and a spouse who was very demanding.
TFhc overwhelming needs of the patient and concerns about
her addiction, her depressive mood, and vulnerable children
encouraged the physician to negotiate an immediate plan for
her. TIhe plan inicluded a psychiatric assessment with possible
admission to a hospital, social services support, and a nonthreatening way of informing her husband about the situation.

Understanding referral: Only some patients

require intensive therapy, and usually only after

\VOI 42: JANUARY * JANVIER 1996 .. Canadian Family Phlurician Le Afedcill defamille canadien 85

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Assisting sexually abused adults

brief therapy modalities have been tried. Given

the potentially highly volatile nature of intensive
therapy with sexual abuse survivors, it is mandatory that physicians treat patients only to the
extent of their comfort and competence. During
this stage, a thorough understanding of referral
sources is needed, because the pursuit of healing
is often all-encompassing in the patient's life. If
family physicians do not feel qualified to handle
the potentially long, arduous, and emotionally
draining task, referral to resources that have
greater skills in the treatment of abuse is merited.
Questions to ask yourself include: Are referral
individuals any more competent in this area than
I am? Am I perhaps the only alternative or the
last alternative? Will the patient only confide in
me because of the ongoing professional relationship I have with him or her? Only physicians with
special interests, skills, and training should venture into intense therapeutic relationships with
survivors of abuse. Family physicians should continue to provide supportive psychotherapy while
their patients pursue intensive therapy elsewhere.

Conclusion
The PLISSIT model offers family physicians a
strategy for connecting in a variety of ways with
survivors of sexual abuse that is responsive to
patients' needs and physicians' skills and
resources. Because family physicians are available
and trusted by patients, they are in a unique position to hear and help patients disclose their innermost secrets, including experiences of sexual
abuse. All physicians must recognize their
strengths and limitations as resources to people
who have been abused.
0
Correspondence to: Mark M. Leach, Department of
Psychology, University of Southern Mississippi, Box 5025,
Hattiesburg, MS 39406-5025 USA

References
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2. Farmer S. A1dult children of abusive parents. New York:

Random House, 1990.

86

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