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The Assessment and Treatment of Women who have been sexually abused An approach based on attachment research, psychoanalytic and systemic thinking. Child sexual abuse Rarely takes place on its own. It is usually accompanied by emotional abuse and neglect and sometimes physical abuse. It occurs in families without boundaries which are replaced by trans-generational secrets. 1/3rd of survivors don’t report long term negative effects Severe effects of CSA More likely if Abused by father or stepfather Abuse accompanied by violence or Penetrative sexual acts Ritual abuse Results: feelings of low self esteem, depression, guilt, anxiety disorders, sexual problems and a tendency to re-victimisation (domestic violence) Levels of childhood violence in the UK 91% of children are hit, particularly if under 1yr. 2 children die of child neglect of abuse in the UK every week (compared to none in Sweden where anti-smacking ban in place for 20 years). Levels of child sexual abuse involving contact are estimated at 16% for girls and 7% for boys and is usually carried out by close relatives (Cawson , 2000) What are the effects of such levels of violence? (Feletti, 1998) Looking at Adverse Childhood Experiences such as: Emotional abuse Physical abuse Sexual abuse Mother treated violently Household use of drugs or alcohol Presence of mental illness Parental Separation or Divorce Incarcerated household member ACE study findings The more adverse Childhood Adverse Experiences an individual had endured, the greater the incidence of: Smoking, Severe Obesity, Alcohol and Drug use, Ischaemic heart disease, stroke, chest diseases Diabetes, hepatitis, sexually transmitted diseases. Depression, attempted suicide. ACE score and the Risk of being Sexually Assaulted as an Adult 40 Women Men 30 20 10 0 0 1 2 3 4 >5 0 1 2 3 4 >5 ACE score and the Risk of being a Victim of Domestic Violence 15 Women Men 10 5 0 0 1 2 3 4 >5 0 1 2 3 4 >5 ACE score and the Risk of Perpetrating Domestic Violence 15 Women Men 10 5 0 0 1 2 3 4 >5 0 1 2 3 4 >5 The attachment perspective on family violence Bowlby defined violence in the family as a disorder of the attachment and caregiving systems (1984). Its manifestations will reflect the levels of social violence in which it takes place and the social role and status of the individuals involved: women and children more likely to suffer at level of the family. It will be related to the degree of damage experienced and transmitted by the family members’s attachment systems. Men and other mammals share the same emotions Attachment - Fear - Protection Human infants are genetically predisposed to want access or proximity to an attachment figure specially when they are frightened! When reunited with those we love, we have a nice warm feeling of safety and well being largely produced by endogenous opiates: separation leads to a miserable state. We are all ‘Opiate addicts’ Harlow’s monkeys Grossly abnormal and Self destructive and self antisocial behaviour in stimulating behaviour. adulthood. Failure to discriminate social cues, a deficit that Mutilation and killing persisted despite therapy of babies if artificially from young caregivers inseminated. (Suomi 1997). The Brain substrate of Attachment Behaviour Involves: Partly mediated by: A great part of the endogenous Opiates right hemisphere. and oxytocin (feel and part of the supra good factor) orbital area of the dopamine (energised brain which is crucial in state of feeling) enabling us to serotonin (linked to empathise with others. levels of dominance in hierarchy). Programming the Brain Without Mum or caregiver From birth to age 3 Infants are not capable of: At birth baby’s brain Regulating their hormones has 50 trillion synapses after birth. and by age 3 there are Soothing or comforting 1,000 trillion. themselves. During that time, new Regulating their arousal and synapses are formed emotional reactions - and ‘hard wired’ whilst whether positive or negative. unused ones are dissolved or ‘pruned’. ‘Attunement with baby’ Brain to brain communication The caregiver responds to the infant’s signals by holding, caressing, smiling, feeding, stimulating or calming, giving meaning. Her/his empathic interaction results in a child who can put himself in the mind of another and interact successfully This sense of Security protects him or her from the effects of trauma. Laying down the Templates for future interactions These daily interactions provide the memories that the infants synthesize into internal “working models” (Bowlby). These are internal representations or templates of how the attachment figure is likely to respond to the child’s attachment behaviour. Secure attachment (63%) A securely attached child has a mental representation of the caregiver as sensitive and responsive in times of need – emotional and physical. These chidren feel lovable and confident and are capable of empathy and good attachments The secure attachment is a primary defence against trauma induced psychopathology. Reflective Functioning The caregiver demonstrates reflective functioning by the capacity of giving meaning to the infants experiences, sharing and predicting his/her behaviour (Fonagy and Target, 1997). This enables people to understand each other in terms of mental states, to interact successfully with others and is key to developing a sense of agency and continuity. Empathic understanding from an outsider (teacher or relative) can compensate for effects of childhood abuse and protect against re-enactment and trauma. Insecure attachments An insecure attachment is one in which the infant does not have a mental representation of a responsive caregiver in times of need. These infants develop different strategies to gain proximity to their caregiver in order to survive. There are 3 types of attachment behaviour: Group C:Anxious ambivalent type (12%) Group A: Avoidant type (20-25%) Group D: Disorganised (15%) Insecure attachments: A and C Anxious ambivalent: Their carers are inconsistent and the children tend to develop anxiety disorders (Sroufe, 2005) Avoidant: rejected by their caregiver, these children tend to develop conduct disorders and deny the importance of attachments (Sroufe, 2005). Insecure attachment: Disorganised. These infants show a disorganised response in relation to their caregiver (A+C): they freeze in trance like states like sufferers of PTSD. Their caregivers are frightening or frightened, suffering from PTSD, which may be triggered by the child herself. This behaviour leaves the child in a state of fear without solution (Main and Hesse 1992, 1999). Their reflective functioning is severely impaired. The resulting sense of Self, of who we feel we are Our sense of self derives from 2 sets of experience. 1) Our intimate attachment experiences in the family > “I feel - therefore I am”, a sense of Self closely intertwined with what our parents made us feel ie lovable and capable or bad or dispensable and/or fragmented. 2) What our community reflects back to us “You are what others make you feel you are”. This view of the self is important in the development of gender identity. 3) In some societies (Muslim or black communities) shame plays a big role in reinforcing an individuals sense of identity. 1. Attachment and Dissociation The infant’s psychobiological response to such states comprises 2 response patterns: 1. ‘Fight-flight’ response mediated by the sympathetic system. This blocks the reflective symbolic processing with the result that traumatic experiences are stored in sensory, somatic, behavioural and affective states. 2. If ‘fight-flight response is not possible, a parasympathetic dominant state takes over and the infant ‘freezes’ in order to conserve energy, feign death and foster survival.Vocalisation is inhibited. In such traumatic states of helplessness, both responses are hyper-activated leading to an ‘inward flight’ or dissociative response. 2. Attachment and dissociation Children in fear of their care-giver’s hatred and violence will: A) Maintain their attachment to their desperately needed caregiver by resorting to splitting, creating different representations of themselves and their caregiver resulting in a lack of self continuity in relation to the other as in BPD (Fonagy and Target,1997). B) The Moral Defence: by blaming themselves for their suffering, they retain power and control as well as hope for a better parenting future (Fairbairn 1952). This reinforces the identification with the the abusing parent and reinforces the need for an idealised caregiver. The traumatic attachment Pathology clearly linked to attachment events ie seperation or fear of loss of partner. Often high levels of dissociation using Dissociation Evaluation Scale. Idealisation of a caregiver, usually mother. The intense need to maintain the often unconscious traumatic attachment prevents change and increases risk of violence: case example. 1. The Psycho-biology of child neglect and abuse The loss or inability to regulate the intensity of feelings is the most far-reaching effect of early trauma and neglect (Van der Kolk, 1996). This leads to: A limited capacity to modulate sympathetic dominant affects like terror, rage and elation, or parasympathetic- dominant affects like shame, disgust, and hopeless despair. Shame: the emotional reaction to a Self that has been totally invalidated is extremely important in triggering violent reactions in victims of chronic neglect and abuse: ‘ I was disrespected’ says a murderer; ‘Better be bad than not be at all’. 2. The Psycho-biology of child neglect and abuse Changes in the HPA axis in response to stress or separation with reduced levels of cortisol and increased glucocorticoid receptors--> PTSD vulnerability Release of endogenous opiates in stressful conditions to produce analgesia leading to cutting or self harm as self medication. Transgeneration transmission Non-genetic transmission 75% correspondence found between parents’ mental representation of attachment and the infant’s attachment security (Van Ijzendoorn, 1997). Transmission of mother’s low levels of cortisol when suffering from PTSD to her infant (Yehuda et al., 2005) Traumatised individuals who respond to stress with lower levels of cortisol than normal develop PTSD (Yehuda, 1997). important implications in terms of genetic evidence and anti-social behaviour transmission. ASSESSMENT The ASSESSMENT is carried out In relation to the external system of social attachments In terms of the internal system of working models and resulting cognitions and behaviour and levels of dissociation. Need for a potential SECURE BASE to be established BEFORE starting treatment. Assessment of the external attachment system Social network in community and in mental health services ie levels of family support, social support and involvement of Community Mental Health Teams. Genogram to spot deaths in family and important information left out of interview. Bubble chart of services and people involved with client to pre-empt problems due to ‘splitting’, failure of communication etc Assessment of the external attachment system (cont) Cultural issues need to be taken into account: Eg: Bangladesh family Respect for parents in many cultures in Africa, Middle East Implications of rape in similar cultures Important in relation to patients involved in domestic violence or sexual abuse or when patient’s illness is systemically reinforced by the family. Eg of assessment failure Eg domestic violence treatment problematic Assessing the Internal Attachment system Internal world of working models (object relations) and security of attachment: Use of questions in AAI: ie. when you were little whom did you go to when you were hurt or upset? Incoherence in time: use of present when talking of somebody who has died. Capacity for reflective functioning ie putting him or herself into mind of the other Assessing the Traumatic Attachment For ‘moral defence’ and its accompanying features - idealisation and splitting, resistance to change – read traumatic attachment bonds to parental figures. Prevalence linked to levels of dissociation: > Use of DES with patient in the room. Importance of mother in survivors of CSA. Defences linked to the Traumatic Attachment Self medication: drug or alcohol abuse. Opiate abuse in terms of cutting or other forms of self abuse. Suicide: issue of control or traumatic attachment: Example: the price of joining mum. Eating disorders to maintain control > ? need for medication > ? Need for other service input Importance of Shame and ‘being in control’ Shame: essential to be aware of signs of ‘toxic’ shame due to the humiliation of being made to feel one is ‘nothing’ and the need to to bring this up in treatment to reduce: Dissociation Violent acting out Premature ending of treatment. Picking up dissociation Inexplicable shifts in affect and Discontinuities in train of thought. Changes in facial appearance, speech and mannerisms. Apparently inexplicable behaviour. Somatic dissociative phenomena. The phenomenon of dissociation should no longer be ignored in our understanding of such phenomena as: TREATMENT STABILISATION and EMPOWERMENT Psycho-education in relation to traumatisation and dissociation for both patient, family or friends (and CMHT staff involved). Establishment of external secure base. Use of relaxation techniques and Safe Place to begin to achieve affect modulation in relation to arousal and fear. Dealing with dissociation Its management requires a good attachment relation in therapy and techniques to reduce its frequency and intensity. Aim when dealing with trauma is to maintain ‘one foot in the past and one in the present’. Issues of shame Grounding techniques for dissociation. Dissociation and Reflective function Use of video or tape-recording in severely dissociated patients. >>>The development of mentalisation. Importance of therapist’s right brain involvement Traumatisation involves the right hemisphere (feelings, memories, attachment). Inevitability of re-enactment of abuse in therapy. Importance of reparation during the therapeutic process: saying sorry! Therapist’s survival Safety of therapeutic setting Importance of peer or other supervision because of likelyhood of re-enactment. Secondary traumatisation is inhererent to this type of work and needs to be addressed at all levels: self care, case load, support.
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