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
Severe effects of CSA
More likely if
Abused by father or stepfather
Abuse accompanied by violence
or Penetrative sexual acts
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
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
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
0 1 2 3 4 >5 0 1 2 3 4 >5
ACE score and the
Risk of being a Victim of Domestic Violence
0 1 2 3 4 >5 0 1 2 3 4 >5
ACE score and the
Risk of Perpetrating Domestic Violence
0 1 2 3 4 >5 0 1 2 3 4 >5
The attachment perspective on
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’
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
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.
interaction results in a
child who can put himself
in the mind of another and
This sense of Security
protects him or her from
the effects of trauma.
Laying down the Templates for
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
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.
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
Empathic understanding from an outsider (teacher
or relative) can compensate for effects of childhood
abuse and protect against re-enactment and trauma.
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
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
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
2. Attachment and dissociation
Children in fear of their care-giver’s hatred and
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
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.
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
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
Social network in community and in mental
health services ie levels of family support, social
support and involvement of Community Mental
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
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
Self medication: drug or alcohol abuse.
Opiate abuse in terms of cutting or other forms of
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:
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:
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
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
>>>The development of mentalisation.
Importance of therapist’s right
Traumatisation involves the right hemisphere
(feelings, memories, attachment).
Inevitability of re-enactment of abuse in
Importance of reparation during the
therapeutic process: saying sorry!
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.