Therapy for Childhood Sexual Abuse Survivors using Attachment and Family Systems Theory Orientations

Abstract

The aim of this paper is to understand the effects of childhood sexual abuse on a survivor’s later life. For understanding and treating the emotional distress and interpersonal problems resulting from childhood sexual abuse, attachment theory provides a valuable framework. When this framework is combined with family systems theory, it can help therapists understand the family context where sexual abuse occurs and how this affects health and functioning throughout the lifespan. Case examples of female adult sexual abuse survivors are also explored, with insight from the intersection of systems and attachment theories.

The sexual abuse of children has been gaining attention as a serious problem over the last several decades. Childhood sexual abuse (CSA) is any sexual contact with a child through the use of force, threat, or deceit to secure the child’s participation, or any sexual contact with a child who is incapable of consenting by virtue of age (particularly pre-pubescent children), disability, or power differential (Finkelhor, 1990). Research indicates that with a broad definition of sexual abuse like “any sexual involvement,” prevalence rates are as high as 50 percent; a narrow definition of sexual abuse like “forced genital activity,” yields prevalence rates of about 5% (Haugaard, 2000). Although children of both genders are vulnerable to CSA, girls are considered higher risk. A retrospective cohort study byDube et al. (2005) of 17,337 adults found that 16% of males and 25% of females experienced CSA, but its long-term impact on multiple health and social indicators was similarly deleterious for both genders.

There is undeniable evidence that CSA is associated with a substantial increased risk of psychopathology, especially post-traumatic stress disorder (PTSD), depression, and substance abuse (Molnar, Buka & Kessler, 2001; Putnam, 2003). The extent of damage to well-being and functioning differs substantially among CSA survivors. Consequences range from mild emotional or behavioral problems, such as low self-esteem and poor school performance, to severe mental illness (Browne & Finkelhor, 1986). Interpersonal problems are some of the most common issues among people who were sexually abused as children (DiLillo, 2001). Particularly when the parent perpetrates the sexual abuse, it harms a child’s lifelong ability to establish trusting, intimate relationships (Stevenson, 1999). Sexually abused children also have more sexual and marital difficulties as adults (Dube et. al., 2005; Levenkron & Levenkron, 2007).

For understanding and treating the emotional distress and interpersonal problems resulting from CSA, attachment theory provides a valuable framework, as it gives an underlying perspective for the development of psychopathology, affect dysregulation, and relationship difficulties. According to Alexander (1992), a holistic understanding of CSA must include a child’s family relationships because not only are specific family features noteworthy predictors for escalated risk of CSA, but the long-term effects of CSA are predicted by family variables above and beyond the main effects of the sexual abuse. When an attachment framework is combined with family systems theory, it can help therapists understand both the dyadic interaction and the family context where sexual abuse occurred and how it affects health and functioning throughout the lifespan. Therapists can use this attachment and systems perspective to help clients in their healing journeys. Therefore, the aim of this paper is to understand the effects of CSA on a survivor’s later life with an attachment and systems theory conceptualization. Case examples of female adult sexual abuse survivors are also explored.

Attachment Theory

According to attachment theory, the early affectional bond between caregiver and infant is crucial for healthy development (Bowlby, 1973). Infants hold an “attachment behavioral system” which functions to elicit comfort from and maintain proximity to the caregiver, leading to a consistent sense of security (Bowlby, 1973). A secure base can be identified as a caregiver to whom the child turns whenever protection is needed (Mikulincer & Shaver, 2007). Through the secure base, a child aims to maintain a balance between exploration and proximity-seeking behaviors. Through repeated interaction, infants learn what to expect and adjust their behavior accordingly. According to Bowlby (1973), individuals’ experiences with their caregivers are internalized through internal working models, leading to whether the self is seen as worthy of love and support and whether others are seen as trustworthy and available in later life. These internal working models help the child interpret and predict experiences in adult relationships.

There are four categories of infant attachment style, including one secure category and three categories of insecure attachment. Insecure attachment styles are avoidant, resistant-ambivalent, and disorganized-disoriented (Mikulincer & Shaver, 2007). Among children who have experienced abuse or neglect, insecure attachments are commonly found (Alexander, 1992), and secure attachment in infancy is associated with greater competence and functioning later in childhood (Mikulincer & Shaver, 2007). Attachment is relevant throughout the lifespan, with Alexander (1992) arguing that the prior familial attachment experiences of CSA survivors help to explain some of the variability in psychological and interpersonal symptomatology. For example, Shapiro and Levendosky (2009) found secure attachment mediated psychological distress in adolescent survivors of CSA.

Family Systems Theory

Systems theory is based on the assumption that all parts of the system are connected to each other, and a true understanding is not possible if considering the parts in isolation. Systems theory focuses on the interactions that occur among members of the system, and the entire family is the unit of analysis (Bertalanffy, 1968). Problems are viewed the result of what occurs in the interactions between people. In that, all behaviors of members within a system affect the environment, and in return, the environment affects all members of a system. Therefore, all behavior must be considered within the context of the larger system (Davidson, 1983). Furthermore, systems theorists believe that all actions have communicative aspects and the command, or manner of communication, is emphasized, rather than the content, or what it is said (Bateson, 1972). Change can occur at two levels and through feedback loops within the system. The first level refers to the small changes in behavior among family members, or “first order change.” The second level refers to changes within the system, or “second order change.”

Sexual abuse in a family, or incest, is a betrayal of relational ties and family roles. It damages a survivor’s capacity to trust and comfortably interact with others (Haugaard, 2000). Family therapists have been working with incest survivors since the late 1960s, beginning with a focus on family structures and interactional styles. Early family therapists argued for the conception of incest as a “family affair” and that all family members should be blamed for CSA; they hoped that by framing incest in such a way, they would spread the blame to adults (Kirschner, Kirschner, & Rappaport, 1993) and relieve children of some of the stigmatizing burden. Unfortunately, the family affair model later moved toward disproportionately blaming mothers. As a reaction to mother-blaming interventions and as a result of the women’s rights movement, the focus of interventions shifted to individual help for the victim or perpetrator. Recent trends in family therapy involve viewing incest not only as a result of the breakdown of normal family life, but in conjunction with individual dynamics at play in the family system.

Interpersonal and psychological sequelae resulting from childhood sexual abuse

In order to help adult survivors, therapists must understand the lifelong effects of CSA, particularly by their family members. Past research shows that sexual abuse victims experience chronic emotional and interpersonal effects of abuse under three main themes: betrayal, powerlessness, and stigmatization (Finkelhor, 1990). In the next section, we will discuss these three themes with case examples from group therapy sessions.

Theme of betrayal

The feeling of betrayal can be described as children’s recognition that a caretaker on whom they depend can cause them harm and violate the role of protector. During or after the sexual abuse, children realize that a trusted person has misdirected them through lies or misrepresented moral standards to satisfy their own sexual gratification (Finkelhor, 1990).

Social support is a critical factor in the recovery of sexual abuse survivors (Tyler, 2002), and it can buffer the development of PTSD, especially when it enhances self-esteem (Hyman, Gold & Cott, 2003).Mason et al. (2009) examined the relationship between social support and the risk of sexual assault re-victimization. Re-victimized survivors received less emotional support and more blame than survivors who were not re-victimized, highlighting the importance of social support to recovery and the role of social support as a protective factor against future assaults. Studies have found the support an abused child receives from family mediates the long-term effects of CSA (e.g. Lynskey & Fergusson, 1997). The crucial role of family support for the recovery of CSA survivors illustrates the real-world application of systems theory, as the entire family unit is connected and affects all aspects of the child's recovery.

The negative reactions of the abused child’s family can exacerbate the feelings of betrayal, especially when other family members were unable or unwilling to protect the child from the abuse or changed their attitude toward the child after abuse disclosure. In other words, feelings of betrayal are affected by the level of support in families’ responses toward the child and the abusive events (Finkelhor, 1990). This illustrates the importance of understanding CSA with the family system as the unit of analysis and how each family member can contribute to the mental health of the victim. Additionally, attachment plays a role in recovery: results from a study on CSA in female undergraduate students suggest that attachment security in peer and parent relationships protects against the negative effects of CSA (Aspelmeier, Elliott & Smith, 2007).

Ashley is 60 years old. She is the middle child of 3 sisters. Ashley reported that when she was growing up, her father abused her. She was also abused by her sister in the way that she was setting up situations for Ashley to get raped or beaten. Ashley has great feelings of betrayal toward her father, mother, and sister. Her mother confessed to Ashley that she caught her husband when he was sexually molesting her oldest daughter. Ashley is angry that her mother didn’t stop the abuse, and she didn’t protect her and her sister. Ultimately, Ashley is angry that her mother was dependent on her father, and she didn’t even consider separating from him.

Ashley was betrayed by her mother, father, and sister—her entire family system. Although resilient and actively involved in her healing journey, she dealt with interpersonal problems as a result of her sexual abuse as a child. However, Ashley had a long-term, close relationship with her husband, whose protectiveness allowed him to function as a loving and secure base. They were also willing to work on their relationship openly and honestly.

Experiencing betrayal is associated with externalization and internalization problems (Finkelhor, 1990). Past research has shown that depression is among the most common of internalization problems that sexual abuse survivors confront. CSA is associated with adult-onset depression in both genders, and research suggests that early stressors produce long-term dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, leading to increased vulnerability toward depression in later life (Weiss, Longhurst & Mazure, 1999).

Feelings of betrayal can manifest themselves not only through behavioral problems, but also through insecure attachment styles. For example, if a child grows up in an environment where he or she cannot depend on the caregiver for love and protection, the child may turn inward and not express emotions for fear of increased pain or retaliation, thus developing a dismissive or avoidant attachment pattern. Alternatively, in an inconsistent parenting environment where there is a lack of responsiveness to a child, this will influence the child's sense of self and make him or her feel unworthy of love. In this situation, children tend to develop extreme dependency and clinginess, characteristic of a preoccupied attachment pattern.

Some survivors of CSA develop a fixation on safety in their adult relationships. This is understandable, considering maltreatment as a child directly predicts insecure adult attachment (Riggs & Kaminski, 2010). Fearfulness, jealousy, feelings of emptiness, abandonment fears, problems with identity, emotional outbursts, and lack of boundaries are all features of Borderline Personality Disorder (BPD; American Psychiatric Association, 2000). Survivors of CSA often have many “borderline” traits and are at increased risk of being diagnosed with BPD (Ogata et al., 1990). In a sample of incest survivors, Alexander (1993) found that attachment predicted avoidance of memories of the abuse along with various personality disorders, including BPD.

Rose is 61 years old. She had been adopted after her biological family died in a car crash. She reported that her biological parents were Jewish Danish immigrants. When she was adopted, she was 6 years old. Her stepfather was the minister of a church who molested her in the basement where he worked. Rose reported having flashbacks of violence toward her. She said that her stepfather was an authoritarian who controlled everything. When Rose was a child, she understood that her parents were doing something that they weren’t supposed to do, since they were talking one way at church while behaving differently toward her at home.

Rose had many difficulties later in life as a result of her CSA and the lack of a secure base and loving caregivers. The blatant betrayal of her adoptive parents made it very difficult for her to form interpersonal relationships as an adult, and this fear of intimacy probably contributed to her status as the only support group member without a spouse. She suffered from multiple health problems and did not have the social support that would have allowed her to cope adequately with all her economic, medical, and social struggles.

Externalizing factors of betrayal include anger and hostility. Survivors often express anger towards the abuser, other family members, society, and themselves (Finkelhor, 1990). Gender differences emerge regarding the direction of anger. For example, boys who have been sexually abused tend to show more aggressive behaviors such as bullying (Jones, Finkelhor, & Halter, 2006). Alternatively, girls show more aggressive behaviors toward themselves. Female survivors of CSA are more likely to have attempted suicide (Dube et. al., 2005). Steele (1992) found that girls who had experienced CSA had higher levels of suicidal thoughts and activities. Adolescents with histories of suicidal behavior and suicidal ideation are more likely to experience attachment-related trauma (e.g. abuse or separation from a parent) than controls (Adam, Sheldon-Keller & West, 1996). Fortunately, attachment security partially protects against negative CSA outcomes (Aspelmeier, Elliott & Smith, 2007).

Theme of powerlessness

Another dynamic of CSA that has a harmful influence on survivors is the feeling of powerlessness. Powerlessness can be defined as a disturbance of a child’s body against the child’s will. When the child’s efforts to stop the abuse are thwarted, it increases the feeling of powerlessness (Finkelhor, 1990). When the abuser has an authoritarian personality, continuously commanding the child’s behavior and threatening the child with serious harm, abuse is more likely to be associated with a sense of powerlessness (Finkelhor, 1990). If an abuser is frightening and brutal, it can result in more severe, long-term damage for the victim than if he is warm, playful, and seductive (Levenkron & Levenkron, 2007). A small child who is being sexually abused does not have the power to defend himself or herself from the predator in the home. Unlike other traumatic events that are rare or isolated, living with an abuser is unremitting stress for a dependent child. A chronic state of hyperarousal and vigilance can cause dysregulation of a child's developing brain and body, as the home, a supposed safe haven, is a place of danger and degradation where the abused child is powerless to escape.

Continuous feelings of being trapped add to a sense of powerlessness. According to the Learned Helplessness Hypothesis developed by Abramson, Seligman, and Teasdale (1978), when a person considers outcomes in life to be uncontrollable—or if their attributions for failure are stable, global, and internal—he or she is more likely to develop depression. Much evidence has accumulated that overall, when a person lacks an internal sense of control over his or her life, that person is more prone to depression (e.g. Burger, 1984). Another major effect of powerlessness is anxiety, which is expressed through increases in fearfulness, somatic complaints, changes in sleep, and nightmares (American Psychiatric Association, 2000). These symptoms are frequently associated with post-traumatic effects of CSA, often resulting in the development of anxiety disorders, including PTSD (e.g. Molnar, Buka & Kessler, 2001).

For example, Ashley reported her feelings of helplessness and powerlessness since her father was in charge of everything, and she could not disclose her abuse to anyone. Ashley also reported that her father’s temper was giving him more power, and she felt like she had no voice. For Ashley, her feelings of powerlessness as a child led her to become preoccupied with remaining in control of situations as an adult. In order to command more power over her life, she was very committed to therapy and spent many years on developing a strong sense of self.

Prolonged and repeated trauma endured as a result of CSA can sometimes lead to “complex PTSD”, a serious syndrome resulting when the victim is held captive by the abuser through coercive control (Herman, 1992). Complex PTSD is more difficult to diagnosis and treat, leaving survivors with more severe health issues and somatic complaints, personality and identity changes, and with an increased vulnerability to future harm. Women’s increased risk of re-victimization in adulthood following CSA has been reported many times in the literature (e.g. Maker, Kemmelmeier & Peterson, 2001). However, secure attachment can lead to a willingness to confront memories of trauma (Alexander, 1993).

A predisposition toward anxiety disorders and PTSD can be tied to the attachment perspective. It is the responsibility of an attentive, caring parent not only to protect a child, but also to teach the child self-protection strategies. A parent who is abusive or neglectful does not serve as a secure base and may not teach a child the necessary coping strategies. A child who grows up in such a way will not have a functional working model of how to remain secure and sufficient, and this child may be predisposed to further victimization. Moreover, the lack of a supportive family system would make any victimization more likely to result in psychological damage.

Ashley, Rose, Roberta, and Sue, who were participating in the group therapy, all reported having continuous nightmares, intrusive thoughts, and flashbacks--traumatic reenactments--of their sexual abuse. Ashley reported that until her 40s, she had constant nightmares about the incidents of the abuse and rape. She reported that she started to change the events in her nightmares through talking to herself in her dreams and showing herself a way out of the abuse. Rose, on the other hand, reported that she had lots of nightmares until her stepfather died. Roberta's intrusive thoughts and flashbacks of her abuse consistently undermined her relationships with her children and ability to be present and engaged with them; she is still using anxiolytic medications, along with antidepressants, to feel like she is in control of her life.

The theme of stigmatization

The last dynamic related to sexual abuse is stigmatization. Stigmatization can be described as abuse-specific shame and self-blame. It is linked with negative feelings and guilt, as well as a concept of the self as bad and responsible for the abuse (Finkelhor & Browne, 1986). Such negative connotations about abusive experiences are communicated to children (Finkelhor, 1990). Over time, survivors of sexual abuse start to accept and internalize these messages as a negative self-image (Levenkron & Levenkron, 2007). These negative meanings are transmitted to children in many ways. For example, the abuser may directly blame, insult, or humiliate the child for the abuse, or the abuser may command the child to keep this activity secret.

Stigmatization also occurs when attitudes from others carry negative connotations, both in and out of the family (Finkelhor, 1990). Guilt is frequently observed among sexual abuse victims; many survivors feel guilty and blame themselves for the abuse (Levenkron & Levenkron, 2007). Another event increasing the victim’s sense of guilt occurs when the offender has to separate from the family after the disclosure (Westerlund, 1992). Feelings of responsibility for their abuse are especially common among older children (Smith & Israel, 1987). An abused child may also be prone to self-blame due to an insecure attachment, as a history of victimization could lead to negative expectations of others, a lack of self-efficacy, and a reduced capacity for coping that would diminish help-seeking behaviors (Liem & Boudewyn, 1999). When a child experiences stigmatization following sexual victimization by an adult, it is an example of misdirected blame and the failure of the family system to put responsibility on the perpetrator.

Roberta is 37 years old. She is married with two sons. When she was growing up, starting at age 6, Roberta was sexually abused by her older brother. She reported that he was doing sexual things to her and threatened her not to tell their parents. At age 11, Roberta told her brother to stop, and he did. However, Roberta started feeling guilty, since “It was so easy to stop him. Why didn’t I stop him earlier?” Roberta told her parents about the abuse and some people from church at age 17. She reported that it was almost as difficult as the abuse to go through that disclosure process, and she still suffers from anxiety and depression.

Roberta still feels guilty that it was ‘easy’ for her to stop the abuse by her brother: just saying ‘no’ one time was enough, and she did not do it until she was 11 years old. She reports that she feels responsible for the abuse due to this. Additionally, through the exchange of affection, attention, privileges, and gifts for sexual behavior, a child might learn sexual behavior as a strategy to manipulate others to satisfy personal needs.

Sue is a 49 year-old sexual abuse survivor who has never been married but has partner for 11 years. She reported that when she was growing up, her father was her perpetrator. She reported that her parents spent little time together and had little communication. Sue reported that when she was growing up, she spent most of her time with her father, and he was trying to satisfy his sexual needs through her. Sue and her father had ‘long art lessons’ and her father expected her to behave like his ‘lover’. He would buy expensive gifts for her while her mother became jealous. Sue reported that she has a hard time understanding why her mother was not monitoring them while they were spending enormous amounts of time alone with each other.

The healing journey of adult sexual abuse survivors

Attachment history exerts a powerful and direct influence on relationships later in life. Adults with insecure attachment styles have dysfunctional attitudes, which relate to problems with self-esteem and predispose them to higher rates of depression over time (Roberts, Gotlib & Kassel, 1996). Some maladaptive attachment patterns that may emerge from the loss of an attachment figure are compulsive self-reliance or compulsive care-giving; adults with anxious attachments are more likely to demand love and care or to be compulsively caring yet simultaneously resentful that the caring is not reciprocated (Bowlby, 1977). One of the most important attachments is the marriage of the abuse survivor, which is more likely to experience conflict and distress due to the abused partner’s history of victimization and neglect, coupled with a faulty working model of how healthy relationships should function.

Such interpersonal difficulties often make therapy or counseling with mental health professionals indispensable for the person with a history of CSA who is looking to improve his or her mental health. However, there may be a drawback for the abuse survivor if he or she only participates in individual or group therapy to process CSA, while simultaneously neglecting the dynamics and needs of the current family system. Research indicates that participating in group therapy for married individuals who experienced CSA predicted poorer marital outcomes (Follette, Alexander & Follette, 1991). This might be because focusing on childhood abuse increases attachment-related anxiety within one’s current marriage. Effective therapists must adequately address attachment relationships preceding and following the experience of abuse, up to and including the current romantic relationship, in order to beneficially transform the internal working model. Alexander (1993) argues that interpersonal relationships are so vital to well-being that therapists should reassess whether a primary focus on childhood abuse is even necessary, as “a feeling of interpersonal security—established through the support of adults in childhood, a current supportive relationship, or the development of trust in a therapist—appears to be a prerequisite for even being willing to talk about the abuse” (p. 359).

Lingering feelings of powerlessness and betrayal can interfere with one’s ability to reveal vulnerabilities to a spouse. Therefore, therapists who are working with CSA survivors individually or within groups must serve as a secure base for the clients whose partners cannot serve as one (Alexander, 2003). Of course, the eventual aim for therapists is to help their clients use their partners as a secure base to explore their attachment needs (Cowan & Cowan, 2001).

Utilization of attachment theory helps therapists to identify the fundamental presenting problem, such as attachment insecurity, in distressed couples and families. It also helps therapists identify the development of insecurity and its manifestation in the relationship, such as through maladaptive actions and emotions, including jealousy, anxiety, and avoidance of the relationship. It also provides therapists with a framework to alleviate attachment insecurity by facilitating authentic dialogue about attachment needs among members of the system (Johnson, 2004).

Conclusion

Understanding the effects of sexual abuse is a complex task due to the large variety of factors that are influential such as age, frequency, and amount of associated aggression (Trickett & McBride-Chang, 1995). This paper provides an overview of the effects of CSA on adult survivors with insight from attachment and family systems perspectives in order to help clinicians develop more comprehensive therapy models for working with sexually abused clients.