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Sorrow, shame, and self-esteem: Perception of self and others in groups for women survivors of child sexual abuse

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Abstract

Despite evidence that exists about the severity of impact of child sexual abuse (CSA), less has been published about treatment options. Much CSA is enshrouded in secrecy in the context of dysfunctional family dynamics, therefore group work is often recommended as a method of treatment. Although long- and short-term groups are seen as being equally effective, there are few published studies of long-term analytic groups for survivors of CSA. This study was designed to analyse the process of one long-term group. A case is made for using Core Conflictual Relationship Theme (CCRT), a method designed to analyse individual therapy, with reference to group theory. Shifts in self-perception and in relation to others are analysed from the beginning to the end of therapy.

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... Culturally sensitive, strength-based research on these populations is even less common. Research on couple relationships in general has suggested several important variables that are associated with relationship quality, including depression (Roberson et al. 2018;Rehman et al. 2015) and self-esteem (Doyle and Molix 2014;Valerio and Lepper 2009). Furthermore, adverse family of origin experiences have been found to be associated with poor adult relationship satisfaction for African Americans in particular (Chen and Busby 2018), and the way an individual comes to terms with past difficulties in their family of origin seems to be associated with relationship quality (Martinson et al. 2010). ...
... Self-esteem is an important construct for both individual and relationship functioning. Self-esteem may be threatened by self-criticism, which is vital to consider as those who experience childhood adversities are more likely to develop attitudes of self-criticism in adulthood (Pagura et al. 2006;Valerio and Lepper 2009). Some literature suggests this is because of negative self-attributions and blame that victims assign themselves after experiencing traumatic events (Littleton et al. 2007). ...
... These attributions seem to be pervasive throughout an individual's life. Less positive self-esteem has been associated with lower levels of romantic relationship functioning (Doyle and Molix 2014;Valerio and Lepper 2009). Long-term relational and personal implications for self-esteem issues vary by gender. ...
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Because adverse childhood and family of origin experiences may have implications for adult relationships, the current study was designed to understand the associations between childhood family of origin adversities, and adult romantic relationship quality for individual African Americans in relationships (N = 1286) considering the potential intermediary role of coming to terms, self-esteem and depression symptoms. A structural equation model was conducted using a selection of data from the RELATE assessment (see www.relate-institute.org). Results revealed no direct effect between family of origin adversity and relationship quality, however there were several indirect effects carried through coming to terms, self-esteem, and depression symptoms. Results also suggested that coming to terms associated with higher self-esteem and lower levels of depressive symptoms for the African Americans in the current study sample. Clinicians may find it useful to focus on assisting African American individuals in coming to terms with childhood family of origin adversity as part of treatment for depression, self-esteem issues, and adult romantic relationship problems. Additional clinical implications and directions for future research are discussed.
... In the field of group psychotherapies, while studies have been conducted on efficacy and effectiveness (Blackmore, Tantam, Parry, & Chambers, 2012;Burlingame, Fuhriman, & Mosier, 2003), as well as studies research focusing on such variables as therapeutic alliance, frequency and quality of participation by individuals, cohesion, group atmosphere, therapeutic factors, and feedback provided by the therapist (Bakali, Baldwin, & Lorentzen, 2009;Burlingame, Furhiman, & Johnson, 2002;Crits-Christoph, Johnson, Gallop, Gibbons, Ring-Kurtz, Hamilton, & Tu, 2011;Dierick & Lietaer, 2008;Lorentzen, Strauss, & Altmann, 2018), very few empirical studies have focused on the assessment of change in relationship patterns, and none have focused on psychotherapeutic techniques that use dramatization (Cappellucci, Ciavarella, De Coro, & Fusco, 2006;Gatta et al., 2010;McVea, Gow, & Lowe, 2011;Valerio & Lepper, 2009). ...
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In this exploratory study, the Core Conflictual Relationship Theme method was used to assess changes in interpersonal relationship patterns in a scenetherapy group based on dramatization and improvisation to facilitate the processing of conflicts. Four young adults with difficulties in interpersonal relationships participated in 32 scenetherapy sessions. Relationship episodes observed in the first eight and the last eight treatment sessions were compared using the CCRT-LU (Spanish version), a variant of the method with a logically unified category system to code patterns found in relational narratives. Outcomes indicate that scenetherapy contributes to modifying both the relationship patterns in sessions and reflections on the staged stories by individuals. Disharmonious interactions decreased and harmonious interactions increased, promoting a more positive vision among participants of themselves and others. Clinical implications, study limitations and further lines of research are also discussed.
... This is therapeutic for those with complex trauma because it serves to remove a sense of social isolation, reduces shame and raises self-esteem, as will be seen in the clinical vignettes below. Other useful studies from group therapy are Kanas (2005), Seager and Thummel (2009), and Valerio and Lepper (2009). Literature from the PTSD field distinguishes between groups which focus on symptom management or stabilisation, and those which involve trauma disclosure. ...
Article
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The concept of complex trauma has been around for a long time and in 2018, it’s expected to become a new diagnosis in the International Classification of Diseases eleventh revision, ICD-11, the World Health Organisation, WHO, manual used formally in the NHS. Psychiatric diagnosis often does not sit well with psychoanalysis, which is at least as interested in unconscious phantasy as it is in symptoms. But as psychodynamically-trained practitioners in the NHS we need to engage with ICD-11 and apply our own understanding to service design so that patients have access to treatment which works for them. The service where I work (a secondary mental health team in the London borough of Lewisham) has already been receiving referrals for ‘complex trauma’ for some time, despite its not being formally classified. Patients so described are most often those with a history of childhood sexual abuse, and refugees with a history of brutality and torture. Differential diagnosis includes personality disorder since many have difficulties with interpersonal issues. In this paper I want to discuss how we might understand the new diagnosis of complex Post-traumatic Stress Disorder, PTSD, and its implications for treatment in the NHS.
... The CCRT method has been used in the past as a measure of changes in treatment (Jarry, 2010) or of relational experience (Bourke & Grenyer, 2010). Valerio and Lepper (2009), in particular, made a case for using CCRT as a method of evaluating individual psychotherapy. An expert trained two independent judges in the use of CCRT's cluster method, according to the training manual (Luborsky & Crits-Christoph, 1990). ...
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Despite the identification of many factors that play a central role in the development of the psychotherapy process, there is still a lack of evidence about the basic relational mechanisms that pave the way to its working. In this pilot study, we focus on nonverbal microprocessual attunement as the basic mechanism grounding the displacing of discrete factors in shaping the clinical process. Two single sessions of two short-term psychodynamic treatments, selected respectively from a good- and a poor-outcome treatment, have been coded in terms of patient and therapist speech rate, coordination in ruptures, resolution of the therapeutic alliance, and patient's displayed thinking processes. Two dynamic structural equation models focusing on clinical attunement as a factor able to activate the interplay of the assessed clinical dimensions have been theoretically designed and tested in both cases. The driven theoretical structural equation models fit the data, suggesting a different role of nonverbal attunement as a moderating factor. The obtained results are consistent with the hypothesis claiming that a good-outcome psychotherapy session is characterized by a mechanism of clinical attunement that enforces the therapist–patient relationship and promotes the integration of formal thinking processes that affect emotional and cognitive domains.
... Previous studies estimated that two-third of children experience early traumatic events before age 16 (7). Further, a substantial body of literature has suggested that those who experienced traumatic events, in comparison with those control groups without experiencing such an adverse background, are more likely to exhibit low self-esteem (8-10), higher stressful states and use more avoidant coping mechanism (8,9). ...
... These methods have been used in various areas of psychotherapy research such as in understanding change in psychotherapy (e.g. [5, 6]), psychotherapy process [7, 8, 9] , childhood trau- ma [10], dreams [11] , and Axis I psychopathol- ogy [12, 13, 14]. Specific personality disorders, including borderline personality disorder (BPD) have also been investigated. ...
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Aim. It is common knowledge that disturbed interpersonal functioning is a key feature of borderline personality disorder (BPD). However, it remains uncertain whether patients with BPD have specific interpersonal behaviours that can be validly and objectively identified. This study examined the interpersonal behaviours of patients with BPD. Method. The narratives of interpersonal interactions of the 66 participants were rated using the Core Conflictual relationship theme (CCrt) method. Results. results showed that once other Axis II disorders were controlled for, only three CCrt components significantly predicted scores on the borderline personality Disorder Scale: not wishing to be good as a CCrt Wish component, others not being untrustworthy as a response of other component, and not being open to others as a response of self component. However, while these findings were significant, the percentage of variance explained remained low. Conclusions. the authors argue that future research will need to examine subgroups within bpD if specific interpersonal behaviours are to be reconsidered.
... Survivors generally do not feel they have had any power or control in their lives and many consequently have low self-esteem (Valero and Lepper, 2009). They have the right to be treated with respect and dignity, and to feel that they are worthy of this. ...
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Childhood sexual abuse remains a taboo subject and requires sensitive handling by committed and caring services (Scottish Executive, 2004). By introducing a training programme, Safe to Say, the Scottish Association of Mental Health aims to improve the confidence and competence of healthcare workers when faced with the sensitive disclosure of childhood abuse. This article aims to explore the effects of childhood sexual abuse and the attitudes of health professionals when faced with adult survivors disclosing such abuse. Despite Government strategies, there still appears to be a lack of suitable services for adult survivors of childhood sexual abuse, even though health professionals have an essential role in supporting disclosure and promoting recovery (Read et al, 2005).
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This paper describes and explores a racial conflict that occurred in a mixed race, sexual abuse survivors’ group. Curiosity and productive dialogue surrounding race faces inherent difficulties and evokes powerful feelings that are often defended against through unconscious dissociative processes. This does not only lead to the denial of the traumatic impact of racism and racist acts, the denial in and of itself is traumatizing. I emphasize both the challenges and benefits that occurred in the processing of a group enactment around a racial conflict. The analysis of the group process is supported by psychoanalytic ideas surrounding the impact of racism and prejudice, contemporary relational theories of dissociation, the significance of witnessing and repair, and intersectional theory as it relates to race and gender. A discussion of the parallel processes between the group process and systemic racism in our society is interwoven as an important theme in the paper. This discussion demonstrates how the psychoanalytic process, whether group or individual, can be applied to our understanding of unconscious dynamics underlying the current divisiveness in our socio-political environment.
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In the wake of child abuse allegations surrounding Pennsylvania State University and Syracuse University, there has been renewed interest in the ways that organizational structures allow this type of abuse to occur. Within the Black Church, the child abuse allegations against Bishop Eddie Long, leader of New Birth Missionary Baptist Church, has led many scholars and members of the lay community to wonder whether the contemporary Black Church has the same relevance as in decades past. The purpose of this paper is to highlight how Black Churches consciously and unconsciously heighten feelings of shame among victims of child abuse and discourage these children and their families from seeking help. We integrate components of Reuben Hill’s [1]. ABC-X model, Derrick Bell’s [2] Critical Race Theory (CRT), and Black Feminist Theory as our foundation. In particular, we offer a theoretical framework that demonstrates and explains suspicion and/or knowledge regarding abuse (A), the resources to which the child and his/her family can rely (B), the meaning that the child and his or her family attributes to the abuse and abuser (C), as well as how race, power, oppression, and church teachings directly and indirectly endorse shame among child victims and their families and maintain and solidify power hierarchies within Black Churches (X). In addition to providing various conceptualizations of shame among victims of child abuse, we define “The System of Black Religious Privilege” and provide recommendations regarding how Black Churches can simultaneously protect the well-being of Black children without sacrificing the primary goals of the Black Church.
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abstractThe impact on individuals of severe and early trauma is looked at from an integrative perspective that seeks to combine the growing body of evidence and literature from psychoanalysis and from an attachment perspective, which emphasizes the centrality of the relationship in which the trauma occurs. As much sexual abuse happens without the opportunity for communication, it is suggested that what is most traumatic about the trauma is its lack of shareability. This is exactly what group psychotherapy can promote. Through cohesiveness the group can create a secure base through which to explore the world of inner objects and interpersonal relationships and, specifically, the traumatic responses of the self. The majority of groups in non-forensic settings are for women only and short-term specifically in order to prevent the tendency of the women to get stuck in an identity of being victims. The author discusses the literature that addresses differences in the way in which men and women respond to childhood sexual abuse. As the group functions as a microcosm of society, it is suggested that mixed groups enable cultural stereotypes, or the social, to enter the group room where it can be shared and illuminated, and as further demonstrated through clinical material, the presence of the ‘other’ facilitates an interplay between the male/female/abuser/victim poles leading to an opportunity to work with more perverse attachments and identifications.
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The present naturalistic study examined the relation between core interpersonal patterns measured by the Core Conflictual Relationship Theme (CCRT) method and psychopathology in 55 patients selected for long-term dynamic psychotherapy. Psychopathology was assessed by the DSM-III-R, symptom self-report, and the Karolinska Psychodynamic Profile (KAPP). Patients with different DSM-III-R diagnoses did not differ in their CCRTs abstracted from the Relationship Anecdote Paradigm interview. Furthermore, lack of flexibility (pervasiveness) in the use of different CCRT components was not associated with psychiatric symptoms. Only one significant correlation between character pathology and the CCRT was found: problems concerning the patients' experience of social significance were associated with more negative responses of other. Limitations of the CCRT method and the sample used are discussed.
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In Part I, the authors provide a survey of the basics of the Core Conflictual Relationship Theme (CCRT) method, including its history, scoring, standard categories, and detailed illustrations of the CCRT scoring of patient narratives obtained during psychotherapy, psychoanalysis, and other talking therapies. The Relationship Anecdotes Paradigm, a versatile new method for obtaining narratives told on request, is described. The authors delve deeper into the multiple facets of the CCRT in Part II, where they explore nine directions to find the meaning of the CCRT measure. Also included in this section is a newly expanded study of the parallel of the CCRT within waking and dream narratives. There are also two new explorations of the consistency of the CCRT across time—from age 3 to 5, and from before psychotherapy to during psychotherapy. In Part III, the book turns to more clinical applications of the CCRT method, including the everyday uses of the CCRT in practice. In the book conclusion, the authors reflect on the convergence of many CCRT findings with Freud's observations about transference and a set of prescriptions for the continued healthy growth of the CCRT method. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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The current study investigates the hypothesis that psychiatric patients display consistent interpersonal themes in narratives across different important interpersonal relationships. In response to a revised Relationship Anecdote Paradigm interview, 93 patients with a diagnosable disorder, based on Diagnostic and Statistical Manual of Mental Disorders (third edition, revised) criteria, were asked to give 5 narratives about each of the following significant people in their lives: mother, father, same-sex best friend, and romantic partner. From the transcribed interview material, independent judges reliably rated the intensity of wishes, responses of others, and responses from self associated with a modified Core Conflictual Relationship Theme (CCRT) method (Luborsky & Crits-Christoph, 1990). Consistency of specific relational themes was assessed across multiple interactions with the same person and across different relationships. Although only 1% to 3% of the variance was explained by an individual's consistency, there vas substantial variability in specific interpersonal themes across narratives, both across and within relationships (explaining 27% to 30% of the variance). The discussion addresses methodological issues that may have contributed to the current findings and the implications of these findings for the CCRT method, psychodynamic theory and practice in general, and the psychodynamic concept of transference in particular.
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We explored the relationship between the consistency of relationship patterns and the severity of psychopathology. Relationship patterns were assessed by means of Relationship Anecdote Paradigm interviews rated according to the Core Conflictual Relationship Theme (CCRT) method. The repetition of the same type of CCRT components across relationship narratives indicated stereotypical patterns. Subjects treated in an inpatient setting (n = 25) told narratives with more consistent patterns than subjects in an outpatient setting (n = 32). Relationship episodes of normal adults (n = 23) were more flexible compared with the two clinical groups. Especially repetitions of the wish component were closely associated with the severity of psychopathology assessed by SCL-90R. The consistency of relationship patterns seems to be connected with the severity of psychopathology.
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To compare the effectiveness of 10 sessions of group therapy with that of 10 sessions of individual therapy in a sample of 86 adult women seeking treatment for the effects of childhood sexual abuse. Participants were randomly assigned to the 2 treatment modalities and tested at assessment, pretherapy following a 10-week wait condition, posttherapy, and 6-month and 12-month follow-up. Participants had fewer symptoms and better psychosocial functioning posttherapy and were further improved at the 6- and 12-month follow-up. Neither treatment modality was superior to the other. Approximately one-half of the sample sought further treatment during the follow-up periods. Improvement in symptoms and functioning was associated with short-term treatment in both modalities, but many patients remained distressed and required further treatment. Future research should investigate whether sexually abused women who meet criteria for specific diagnoses require more focused and/or longer-term therapy.
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Article
discuss a significant connecting link between these two central areas of inquiry, that is, an association between unresolved loss of attachment figures (or other attachment-related trauma) as experienced by the parent, and the infant's failure to fit to one of the traditional, organized Strange-Situation response categories / this is in essence the discovery of a second-generation effect of unresolved loss of attachment figures, with the infants of parents who are judged unresolved with respect to this potentially traumatic experience being found to fit to a new (fourth) infant attachment category now termed "disorganized/disoriented" (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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All psychotherapists know that narratives are often told during psychotherapy sessions and that they are clinically very informative. Although the special clinical values of narratives are evident, the narrative as a unit in psychotherapy has never been systematically investigated before; until the launching of the CCRT, its exact formal characteristics (e.g., frequency, length) remained unexplored territory. Because narratives are the database for the CCRT, focus on the CCRT requires scrutiny of the narratives themselves closely. This chapter sketches a few features of narratives that are important to the studies in this book, such as the number and completeness of narratives, the length of the narratives, and the main other people in the narratives. This chapter also examines the frequency of the types of CCRT components, such as the types of standard category CCRTs within narratives, the sequential versus the regular CCRT, the positive versus negative responses within CCRTs, and the possible significance of the diagnosis of dysthymia for CCRTs. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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This study takes as a starting point the need for further observational research in identifying the phenomenon of cohesion in group psychotherapy. The purpose is to test the possibility that there are relevant observational technologies that, like the microscope, can reveal phenomena that cannot be perceived directly but that underpin events at the perceptual level. Two text analytical approaches will be applied to mutually support possible findings: conversation analysis as a qualitative tool and quantitative computer-assisted text analysis following the therapeutic cycles model (TCM). The text to be analyzed is a transcript of Session 9 of a psychodynamic psychotherapy group for seven women diagnosed with an eating disorder. Within the cycles there is higher category density, higher levels of coherence, and tying across turns. The TCM reliably can identify features of the therapeutic process that are of clinical interest.
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This study compared interjudge agreement in 2 sample cases in which both experienced as well as inexperienced scorers were used. Scorers were given only a single page of core conflictual relationship theme (CCRT) instructions to help them learn the method. The results in both cases suggest that there was significantly greater interjudge agreement among experienced CCRT scorers compared with inexperienced scorers.
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Being raped generates an enormous amount of anxiety in the victim. This anxiety is the basis for an acute traumatic reaction called the rape trauma syndrome 1 The nucleus of the anxiety is the impact of the life-threatening or highly stressful experience on the individual.
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We randomly assigned 65 women who had been sexually abused by a father, stepfather, or other close relative to 1 of 3 treatment conditions: a 10-week interpersonal transaction (IT) group, a 10-week process group, or a wait list condition. Subjects were evaluated at pretreatment, posttreatment, and (if assigned to a group) a 6-month follow-up on measures of social adjustment, depression, fearfulness, and general distress. Results suggested that both the IT and process group formats were more effective than the wait list condition in reducing depression and in alleviating distress; changes were maintained at follow-up. Subjects in the process group format exhibited improvement in social adjustment, whereas subjects in the wait list condition actually deteriorated.
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Two long-term analytic inpatient groups comprised of severely disturbed neurotic and personality disordered patients were intensively investigated through process ratings and therapist and patient reports with regard to five therapeutic factors: cohesiveness, self-disclosure, feedback, interpersonal learning-output, and family re-enactment. The process variables were correlated with outcome assessments at 12 and 18 months following treatment. The study applied a single case (group) approach with replication to cross-validate the findings from one group to the next. Results demonstrated that all five therapeutic factors were meaningfully associated with clinical improvement. Although different treatment groups may generate unique psychological climates for producing change, the findings suggest that group cohesiveness is an important ingredient for effective group process to occur. The multimethod, multiperspective nature of this study lends considerable credence to the findings, despite the small sample size.
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Surveys of child sexual abuse in large nonclinical populations of adults have been conducted in at least 19 countries in addition to the United States and Canada, including 10 national probability samples. All studies have found rates in line with comparable North American research, ranging from 7% to 36% for women and 3% to 29% for men. Most studies found females to be abused at 1 1/2 to 3 times the rate for males. Few comparisons among countries are possible because of methodological and definitional differences. However, they clearly confirm sexual abuse to be an international problem.
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Long-term process-oriented psychotherapy groups for adult survivors of childhood sexual abuse allow an in-depth exploration of both the individual meaning of traumatic experiences and the subsequent effects on current adult life functioning. It may not be curative just to tell the traumatic story. Therapists must also pay careful attention to unconscious reenactments by examining the process of interpersonal relating between and among group members and their therapists. Rather than avoidances, these reenactments are better viewed as a necessary form of remembering and can contribute to the understanding of the past trauma and recognition of current, previously unconscious manifestations in maladaptive behaviour. Such therapeutic benefit began to be evident in some members within 6 months in the group; for others, more time was necessary, often a year or more. Additional study and understanding of the role of reenactments in trauma treatment may lead to more effective intervention strategies that can further elucidate the complexity of this form of memory.
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This article presents a psychoanalytically oriented model of group treatment for female adult survivors of childhood sexual abuse. Two key treatment issues--the survivor's struggle to trust her own mind and her tenacious allegiance to an omnipotent, all-bad self-representation--are used to illustrate ways in which the transference/countertransference matrix of the group permits members to enact, identify, and work through central internalized relational configurations. The group therapist's role is to maintain transitionality, a focus on process, and the capacity for play.
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To assess the effectiveness of a new model of group treatment for sexual abuse survivors over individual therapy alone. In this quasi-experimental design, 32 women were in either group treatment (N = 22) or a wait-list comparison group (N = 10). They completed standardized measures on depression, self-esteem, and trauma symptomatology at pretest and after completing the 10 to 12 week group. All were in concurrent individual therapy. On average, both groups of women decreased depression and trauma symptoms as well as increased self-esteem. However, the clients in the treatment group improved their depression and anxiety to a statistically significantly greater degree than clients in the wait-list comparison condition. Improvement approaching statistical significance was found in levels of self-esteem in the treatment as compared to the wait-list condition. The group intervention was significantly more effective than individual treatment alone on depression and anxiety. The inclusion of the wait-list comparison group was critical in interpreting the improvement noted by all of the women in treatment.
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This review examines the current literature on individual psychotherapy outcomes with adult survivors of childhood sexual abuse. As compared to the literature on treatment with victims of sexual trauma in adulthood, fewer researchers have explored the field of psychotherapy outcome with this population, particularly with regard to individual treatments. For this reason, a review of psychotherapy outcome for adult survivors of child sexual abuse is needed. This review first presents issues salient to the study of treatment with this population, such as prevalence, short-term impact, and long-term sequelae of childhood sexual trauma. Next, the eight studies that have been published on individual psychotherapy for this population are presented and evaluated according to both efficacy and effectiveness criteria for a methodologically sound study. Last, directions for future research with this population include continued integration of efficacy and effectiveness methodology, use of multi-method/multi-rater assessment data, as well as further investigation of interpersonal variables such as the therapeutic alliance.
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This retrospective study explores, through quantitative and qualitative methods, the relationship of two variables (perpetrator relationship and perpetrator methodology) to posttraumatic and dissociative symptomatology. The quantitative sample comprised a nonpsychiatric group (N = 39) of Australian adults reporting sexual abuse histories. A MANOVA revealed that current levels of posttraumatic and dissociative symptomatology were significantly higher in the group reporting sexual abuse by a perpetrator in a relationship of trust, guardianship, or authority. The qualitative sample comprised a purposively selected subgroup of the quantitative sample (n = 20). Thematic content analyses of perpetrator methodology suggest that perpetrator strategies involving emotional manipulation, rather than the perpetrator relationship per se, appear to differentiate between groups with clinical or nonclinical levels of post traumatic and dissociative symptomatology. The combination of qualitative and quantitative methods provides integrated, contextualized data with implications for future research and clinical practice.
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