VIOLENCE by pengtt


									The Assessment and Treatment of Women
     who have been sexually abused

    An approach based on attachment
  research, psychoanalytic and systemic
            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
 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
             Women                    Men



     0   1   2   3   4   >5   0   1   2   3   4   >5
             ACE score and the
 Risk of being a Victim of Domestic Violence
 Women                                    Men


      0   1   2   3   4   >5   0   1   2   3   4 >5
               ACE score and the
     Risk of Perpetrating Domestic Violence
       Women                          Men



      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
              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.
                                          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
       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:
 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
    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.

       The ASSESSMENT is carried out
   In relation to the external system of social
   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
 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
   Apparently inexplicable behaviour.
   Somatic dissociative phenomena.
   The phenomenon of dissociation should no longer be
    ignored in our understanding of such phenomena as:

    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
 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
 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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