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Adult Survivors of Childhood Sexual Abuse : A Discussion of Definitions, Prevalence, Incidence and Theory as it applies to CAT Practice

Tanner, C., 1994. Adult Survivors of Childhood Sexual Abuse : A Discussion of Definitions, Prevalence, Incidence and Theory as it applies to CAT Practice. Reformulation, ACAT News Spring, p.x.

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In the 5 years I have been practising as a CAT therapist in inner and outer London, at least half of my 20 CAT clients have had a history of sexual abuse. As far as I know, the number of CAT referrals who have a history of sexual abuse has not yet been monitored, but the general impression from colleagues is that the numbers are high. It may be that referrers choose CAT as an effective treatment for these clients. It may be that the high prevalence of a history of sexual abuse in our CAT clients simply reflects a high prevalence in the general population, or more specifically in the population of adults with mental health problems. Because adults who have been sexually abused as children feature so strongly in CAT caseloads, it is important to look at the effects of childhood sexual abuse, both in terms of research and of theory. Therefore I shall:

1. Examine the various operational definitions as used by researchers and clinicians.
2. Present the research that describes its incidence and prevalence.
3. Examine its long-term effects and clinical presentation.
4. Discuss various theories that attempt to explain its long-tenn effects.
5. Discuss the CAT model as a theory explaining its effects, and as a treatment, of these effects

This is a very complex subject and childhood sexual abuse has only been studied and explained for the last 15 or 20 years. The literature and research to date tends to ask more questions than it answers. However, more and more mental health professionals, researchers, and theoreticians are defining its long-term effects as a mental health problem.

Tremendous clinical and research confusion exists over the definition of childhood sexual abuse. This~ obviously has implications for studying the phenomenon and also for understanding and treating people who have experienced sexual abuse in childhood, There is a lack of consensus about explanatory or aetiological models. A wide variety of sexual behaviours, from non-contact to contact activities are subsumed under the name childhood sexual abuse. The ideological, theoretical and cultural framework of who is defining the phenomenon influences the definition (Westen). For example, studies on incidence and prevalence differ in their definition of childhood, some giving an upper age limit, some giving no age limit at all. Kinsey’s 1953 study gave puberty as the upper age limit. Finkelhor (1979) and Wyatt gave an upper age limit of 16-17 years.

Without consensus about an operational definition of childhood sexual abuse in terms of age, developmental, cultural, ideological and theoretical considerations, it is difficult to understand the nature of the problem. This difficulty is further exacerbated when looking at adult survivors of childhood sexual abuse. Just what is it that has been survived? What effect has the experience had on the individual? Is the experience of childhood sexual abuse specific to an individual, or general across the human species?

Before attempting to answer these questions, I would like to briefly consider its incidence and prevalence. Incidence means the number of new cases in a population in one year. Prevalence means the proportion of a population who have suffered sexual abuse at any time during childhood. The majority of studies carried out in the last 10 years refer to prevalence where the data derives from retrospective recall by adults of sexually abusive events in childhood. The number of true incidence studies looking at sexual abuse is very limited at the moment both in America and in England.
This means it is very difficult at present to answer the question, “How common is sexual abuse?” It is important to ask the question, however, as we can perhaps then know why some people present as adults with extreme psychological problems and some do not. By knowing the nature and scope of the problem we can also begin to systematically identify which factors lead to later problems and which factors may help prevent psychological problems in later life.

Unfortunately we do not yet know the answer to these questions. In the research carried out there is a tendency to confuse incidence with prevalence, to confuse operational definitions, and to leap to conclusions that are not substantiated by the research. Eileen Vizard (1988) describes researching sexual abuse as an iceberg effect. She suggests that it is not enough simply to ask random samples of the population whether sexual abuse happened to them. Nor, she suggests, is retrospective recall by adult patients of psychiatric and helping professionals a way of gaining a true picture of the real numbers of sexual abuse survivors. Either sexual abuse is a specific phenomenon that only affects a small portion of the population, or it is extremely widespread and many people are still keeping quiet for a variety of reasons. Discrepancies in the research figures reflect this statement. In Retrospective Quota/Societal Unit studies, prevalence ranges from 4% to 100% (sic). In Retrospective Random/Probability studies the prevalence of CSA ranges from 6%-54% and in relation to Reported Studies the incidence of new cases ranges from 0.1 per 1000 cases to 0.5 per 1000 cases (Vizard 1987). Also, these studies use different definitions of childhood sexual abuse, and employ very different methodology and theoretical models.

The figures quoted reflect American and British society. There are no international figures available on either prevalence or incidence, so whether childhood sexual abuse is a particular phenomenon of these societies or whether it is cross-cultural and global is not yet known. Whether childhood sexual abuse reflects society’s attitudes about sexuality, children, the family and women, or whether it reflects something entirely different is not known. At present it would seem that Eileen Vizard is accurate in describing this phenomenon as a iceberg where we are only seeing the tip.

Despite the lack of clarity regarding its definition, prevalence and incidence, we must ask, “What are its long-term effects? Are these effects true for everyone or for just some people?” Finkelhor (1986) states, “as evidence accumulates, it conveys a lear suggestion that sexual abuse is a serious mental health problem., consistently associated with very disturbing subsequent problems in a significant portion of its victims.” Several long-term impact studies, quoted by Finkelhor, indicate that there are identifiable degrees of Impairment in non-clinical adult victims of childhood sexual abuse, when compared to non victims. Many clinical studies of adults show that childhood sexual abuse has long-term harmful effects. Jehu states “a substantial number of women who present with mental health problems were sexually assaulted in childhood.” But how severe is the impairment for each individual? Perhaps women who present with mental health problems to a mental health setting are simply those who were more damaged by the abuse. At present the research does not isolate factors which separate those who suffer long-term impairment from those who do not. We do not yet clearly know why some people present with severe problems later in their life and some do not. Some of the apparent effects of sexual abuse might be due to premorbid conditions such as family conflict, emotional neglect or the victim’s predisposition to traumatise an upsetting event. These factors may actually conthbute to a vulnerability to abuse and exacerbate later trauma. Other effects may be due to later social reactions to disclosure and subsequent experiences.

For example, in 1987 Rhoda Oppenheimer and colleagues noted that two-thirds of a group of seventy eight female adult anorexics gave histories of sexual abuse in childhood. Other studies confirm that a significant number of psychiatric patients give histories of childhood incest (Wyatt & Peters; Mullen et al). However, this finding is not helpful for predicting effect as the prevalence of incest in the general population is similar (Markowe).

Certainly factors such as the duration and frequency of the abuse, the age of the victim, relationship to the offender, whether the victim disclosed the abuse, the parental and institutional response to the abuse or disclosure and in general what meaning the abuse had for the victim are important considerations.

How then does an adult survivor present clinically? Again there is no clear agreement in the literature, but in general at present the trauma of childhood sexual abuse is mainly subsumed under the diagnosis of Post Traumatic Stress Disorder (PTSD). Other disorders - such as eating disorders-feature the trauma of childhood sexual abuse (Oppenheimer). Westen indicates a high prevalence of childhood sexual abuse in the developmental histories of borderline personalities. Studies cited in his paper give prevalence lutes of 15% to 75%, depending on the sample and the definition of abuse.

First then we need to examine PTSD, as it is the main diagnosis for adult survivors of sexual abuse. The catalogue of symptoms for PTSD is long: dissociative responses, sleep disturbances, flashbacks, concentration difficulties, memory problems, hyperalertness, irrational guilt, and an intensification of symptoms when exposed to experiences that resemble the original trauma.

Other symptoms attributed to the trauma of sexual abuse include sexual dysfunction, eating disorders, substance abuse, compulsive sexuality, self-destructive behaviours, self-mutilation, socially maladaptive behaviours such as truancy, inappropriate aggression towards others, and a tendency towards isolation.

Depression is the most frequently reported symptom, and related to this is the fact that sexual abuse survivors are twice as likely to attempt suicide as those without a history of sexual abuse. These symptoms are listed by Yvonne Dolan, who has gleaned them from about 20 different studies.
The difficulty is that the above-listed symptoms also occur in people who have not been sexually abused, and PTSD is not exclusive to victims of sexual abuse.

The diagnosis of borderline personality is not included in Yvonne Dolan’s list of symptoms as a possible lasting effect of childhood sexual abuse. There is controversy over whether survivors of childhood sexual abuse present as borderline personalities. Christine Couttois states, “Many of the difficulties associated with treating borderlines might be alleviated by providing therapy which focuses on the trauma [of childhood sexual abuse].”

The argument can he summed up as follows: Should we be treating the event (trauma), the personality structure of the victim (if the trauma of sexual abuse is in fact a cause of borderline personality), the presenting symptoms, or perhaps all three? Two theoretical models - Finkethor’s Traumagenic Dynamics model, and Object Relations theory - provide possible explanations of what we axe in fact treating when we treat adult survivors of sexual abuse and why these clients present with such a range of symptoms.

Finkelhor arrived at his model of traumagenic dynamics because he argued that PTSD was not an adequate model for all the symptoms. It is only a syndrome (i.e. group of symptoms), and does not provide a theory to explain how the dynamics of sexual abuse lead to the symptoms. Central to his criticism is that the PTSD model locates almost all the trauma in the affective realm. Research on sexual abuse shows that the symptoms are located in the cognitive as well as the affective realm. Jehu, Klassen & Gazan state that “women who were sexually abused in childhood often hold distorted beliefs arising from this experience that appear to contribute to mood disturbances such as guilt, low self-esteem and sadness.” Kilpatrick and colleagues evaluated PTSD symptomatology in a sample of 126 adult women sexually abused as children and found PTSD currently present in only 10% and ever-present in only 36%. Some of these women seemed to manifest other symptoms common to sexual abuse such as depression, substance abuse, sexual problems - all without FTSD symptoms.
Pynoos and Eth explain PTSD as “an overwhelming event resulting in helplessness in the face of intolerable danger, anxiety and instinctual arousal.” Finkelhor is unhappy with this, as it only takes account of the ‘event’, not the ‘relationship’ with the abuser or the ‘situation’ in which the abuse occurred.

Finkelhor also cites Horowitz’s work based on completion tendency and how the mind tries to fit a trauma into an existing schema and integrate the event If the event is foreign to the person’s existing schema, then memories associated with the event will continue to occur until the event is integrated. This attempted integration of an event foreign to the schema will interrupt other functioning until integration is achieved. Horowitz’s work is commonly cited as an explanation of PTSD. Finkelhor criticises this model, suggesting that it does not explain the victim’s sense of worthlessness, self-blame, and anger. Perhaps this is a correct criticism if Horowitz is only suggesting that a victim is affected in the realm of memory. However, if Horowitz’s concept is expanded to include affect, cognition and behaviour then it seems to me that it still holds its usefulness as an account of the process of integration.

Finkelhor comes very close to Howoritz’s concept in his own proposed model of four traumagenic dynamics which would account for affective and cognitive distortions, the distortion of the victim’s assumptions, and the coping mechanisms which the victims develops. These mechanisms may be adaptive and well integrated to the experience of the abuse and its aftermath, but they may then become dysfunctional in coping with a world where abuse is not the norm.

Finkelhor defines a traumagenic dynamic as “an experience that alters a child’s cognitive or emotional orientations to the world and causes trauma by distorting the child’s self concept, worldview or affective capacities.” He proposes four traumagenic dynamics to account for the impact of sexual abuse: traumatic sexualization, betrayal, stigmatization, and powerlessness, lie then attempts to classify the symptoms experienced, the psychological impact, and the behaviour manifestation for each of the four traumagenic dynamics. He states that most of the effects described in the literature can be explained by one or two of the dynamics. His model conceptualises childhood sexual abuse as a situation or process rather than simply as an event, He argues that unlike other traumas that result in PTSD (such as earthquakes), sexual abuse is in fact often an extended process of traumatisation which takes place over a long period of time. Equally, the trauma may not be the abuse, but the disclosure or even the process of intervention.

Finkelhor’s model attempts to incorporate the event of the abuse, the meaning of the event for the victim in both cognitive and affective terms, and the process operating before, during and after the abuse. The clinical implications are that in treating an adult survivor one should take account of all of these.

While I agree with a number of Finkelhor’s criticisms of the PTSD model, he is perhaps missing what object relations theory can contribute to our understanding of adult survivors of sexual abuse, especially when they present with character-disordered structures, particularly borderline personalities. Finkelhor’s model accounts for the ‘what’ more fully, but perhaps not the ‘why’.

Although authors such as Dolan and Courtois criticise the diagnosis of borderline personality for adult survivors of sexual abuse, they do so on the grounds that it is a pejorative label. Courtois particularly feels that treatment should focus on the trauma, and not on the character structure of the victim. Unfortunately, this places the argument in an either/or context as though it is not possible to provide a theory and treatment model that accounts for the effects of the trauma in terms of symptoms, meaning and a way of relating to the world.

Object relations theory attempts to provide a ‘why’ for many of the symptomatic expressions of PTSD, as well as an explanation of meaning, and ways that victims might relate to the world. Therefore I would like to briefly examine the contributions that object relations theory can offer to an understanding of adult survivors of sexual abuse.

“Object relations theories emerged primarily in order to explain phenomena observed in the treatment of very disturbed patients, whose pervasive difficulty maintaining lies to people and reality seemed to reflect pathology more fundamental that maladaptive compromises among competing motive-systems” (Westen). From Klein through to Fairbairn, Kohut and Kernberg, personality has been seen as structured in the early years by object relatedness which teaches the individual how to relate to herself and to others. Where psychic developmental processes are not achieved, due to the innate structure of the infant and/or the relatedness of this innate structure to others, mainly primary caregivers, problems in self-relatedness and relation to others becomes fixed and maladaptive. Much of the theory is based on data from pathological adults and not on developmental and systematic empirical research. Character pathology and symptoms are located developmentally - the more severe the character pathology and symptoms, the earlier the developmental flaw.

Object relations theorists still seem to yield the oedipal phase to Freud in the development of neurosis, but concern themselves with the preoedipal phase for the development of character disorders. Indeed, the theory suggests that once an individual has reached the oedipal phase, character is formed and the individual has a developed personality structure. Mahler states that by age three to four years the individual has established a mature object relationship. Before this, the pre-oedipal period is characterised by narcissism, splitting, lack of self-cohesion, lack of ambivalence, lack of libidinal object constancy, fragmented representations of self and other, symbiosis, poor self-other differentiation and omnipotence; all these conditions or tendencies are transcended by the beginning or end of the oedipal phase, making neurotic functioning possible.

These views have been challenged particularly by Stern and by Peterfreund, and by developmental psychologists. They tend to see development as taking place over a much longer time span, identifying psychological growth spurts between ages seven to nine, and 13 to 16. Many of the features described as pre-oedipal by the object relations theorists are also present in latency (Westen). Thus, although object relations theory has much to contribute to the understanding of borderline personality structure, it suffers from a timetable that locates the aetiology of character disorder in the very early years of life and not in the whole realm of childhood.

Drew Westen makes a very strong case for locating character disorder formation in terms of maladaptive object relations in the whole realm of childhood. In terms of childhood sexual abuse this is a particularly useful concept since the majority of childhood sexual abuse takes places during the latency years, not the pre-oedipal period. Westen states, “if object relations develop considerably after the age of 4 then life experiences that affect this development could conceivably have a significant impact on this basic dimension of personality structure”. Westen usefully discusses psychic reality and actual reality and how both realities need to be taken into account to explain the development of a borderline personality. He accepts that historical accuracy of experience and psychic experience do not correlate, but the two cannot be totally separated. He postulates that borderline personalities may treat the world and others as abusive and abused not just because of unresolved pre-oedipal development, but because this is an actual experience. Events have an impact meaning and meaning has an impact on events.

In a 1990 study of adolescent female in-patients, Westen showed that sexual abuse in particular coloured the object world. He suggests that these results indicate a causal connection between actual abuse and a particular way of experiencing social reality. Westen also identifies in this same study certain pit-oedipal risk factors combined with sexual abuse in the formation of borderline personality. In other words, children who are sexually abused may have experienced unempathic mothering, and thus premorbid conditions needs to be taken into account, as well as the event of the abuse. However, another interesting finding of his study was that duration of abuse was extremely highly correlated with a tendency to produce poorly bounded, egocentric representations, a characteristic he identifies as belonging to early childhood. Westen particularly argues that while self-esteem and object relations of self to self and self to other have their roots in the pre-oedipal period, this continues to develop throughout childhood and adolescence. Particular pathogenic events such as sexual abuse can colour the object world of the individual and affect different object-relational processes. Thus character disorders such as borderline personality may be formed by the event as much as by early childhood experience. However, he cautions that nothing is exclusive -there are pre-oedipal risk factors that may be operating as well as a severely traumatic event, The important factors to assess are the meaning of the event to the individual due to the experience itself, the child’s cognitive development at the time of the event; the individual’s experience prior to the event; and personality structure. “Different experiences that are typically pathogenic may differentially affect different object-relational processes and the same experience may affect different processes or structures at different developmental junctures.”

Perhaps Dolan and Courtois object to the diagnosis of borderline personality for good reasons, but they are throwing out the baby with the bathwater. If they understand borderline personality to develop in early years and not to be partly caused by a pathogenic event such as sexual abuse then I can understand their point of view and how they arrive at the conclusion that by treating the personality disorder one is in danger of not giving adequate attention to the event and the meaning the event has for the Individual. However, by expanding object-relations theory to include among the causes of borderline personality not just early experience, but also events and the meaning that event has for an individual, it seems possible to treat the individual in the context of both a character disorder and an actual experienced event. I would argue that in some cases borderline personality and PTSD coexist - and both need to be treated.

Westen’s perspective seems to have more merit than Finkelhor’s four traumagenic dynamics, and borderline object relations as discussed in Westen’s paper offers a more thorough explanation. Object relations theory coupled with development theory, particularly social learning, also goes some way towards explaining why some individuals experience extreme psychological symptoms in adult life after the trauma of childhood sexual abuse, while other individuals do not. For example, a child with good empathic mothering who is sexually abused, but able to make sense of the experience in an appropriate developmental manner, may be less damaged, with perhaps no lasting effects. While this seems unlikely, it does account for the discrepancies in prevalence and incidence figures reported in many surveys. Equally, appropriate responses at the time of the abuse may prevent lasting psychological effects and enable the individual to integrate the experience into existing schemas, in Horowitz’s concept.

How does CAT conceptualise the experience of childhood sexual abuse, both in terms of the Procedural Sequence Model, and in terms of treatment through reformulation, TP’s and TPP’s? Does CAT as a model take account both of the event of the abuse and of the meaning the abuse has for the individual? And finally, does CAT offer a theoretical framework to understand how TP’s and TPP’s arise through the event of childhood sexual abuse?

The PSORM account of personality traces it back to the early years, during which the infant, due to attachment behaviours, actively engages in elaborating procedures to relate to the mother, the self and the environment. Thus it takes account of mental, behavioural and environmental events where the Individual develops roles to elicit reactions from the other, and a procedure to enact a particular activity or role. Ryle states “the model of the procedural sequence includes the individual’s active involvement with her surroundings, her appraisal of her involvement, her formation and pursuit of goals in this context; her anticipation of her capacity to attain these goals and the consequences of doing so, her consideration of the means available and her selection and enactment of one, her evaluation of the efficacy and results of her action and her confirmation or abandonment of the aim or the means.”

In terms of interpersonal interaction Ryle expands this to include role procedures to account for more complex and conflictual appraisals. A role procedure requires the individual to predict the response of the other Early role procedures, as in object relations, are concerned only with parts or aspects of the mother, and their development precedes the individual’s capacity to discriminate self from other. When there is empathic mothering, developmentally the individual moves on to complex self-derived and other-derived role procedures. if these are well integrated then whole-person procedures are established, which enable to individual to appropriately conduct appraisal functions via the procedural sequence model. In this model, learning a procedure always implies learning the other’s responding procedure (reciprocal role procedure) in order to successfully carry out an appraisal function.

When integration of self-self and self-other role procedures is interfered with due to abuse or deprivation, then whole-person procedures cannot develop, and the individual’s capacity to unite contrasting, polarized part-procedures carrying opposite emotional implications may be damaged. If the damage is severe the result is poorly integrated adult personality (personality disorders).

Within the procedural sequence model there are self-self and self-other reciprocal role procedures. The model is circular and can be entered into at any point, i.e. aim, meaning, choice of role, action, consequence, feedback and perception. Whole-person role procedures can be revised from appraisal, as can actions. However, when there are unrevised procedures due to neurotic function or personality disorder, intervention is required.

Target Problems are agreed, and an account is given of the individual’s development of the unrevised procedures TPP’s) which account for the persistence of the TP’s. An account is also given fur the reciprocal roles, based on early and developmental experience.

Thus in CAT we can give an account of the event, the meaning the event has for the individual, the situation of the event (duration of abuse, relationship to abuser, etc.) and the affective, cognitive and behavioural results of the event (TPP’s). We must. ensure, however, in our reformulations that we clearly and accurately describe sexual abuse as it shapes the RRR, TPP’s and TP’s. If reciprocal roles have been elicited due to a specific event, we need to describe what has changed, why roles have changed and how.

We must also be careful not to throw out PTSD in terms of Target Problems and the Target Problem Procedures underlying this diagnosis. Again, although not all adult survivors manifest PTSD, if individuals do fall within this diagnosis (perhaps in addition to borderline personality), a very accurate account of the event, and the meaning the event had for the individual, should be obtained. If maladaptive procedures are described without linking them to the event of childhood sexual abuse then if will be difficult for the individual to change or revise appraisals as she will be so overwhelmed by the symptoms. Equally, a full historical account is helpful in trying to make sense of the meaning which the childhood sexual abuse has for the individual, and to what extent the event, rather than the individual’s early development, is responsible for her reciprocal roles.

Thus both the CAT model and the object relations model linked with developmental psychology, explain and treat both outcomes of childhood sexual abuse - PTSD and borderline personality. By making sense of their procedures and reciprocal roles CAT also accounts for why some people develop severe problems and others do not.

Both models offer what Finkelhor has criticised the PTSD model for not offering - an account of the event, the relationship and the situation. Both models pay attention to the affective and the cognitive realm. The PSORM particularly takes account of the assumptions and coping mechanisms developed as a result of the abuse, its aftermath and the situation and relationships within which the abuse took place. In addition, by identifying Target Problems CAT can focus - more clearly than the object relations model - on the symptoms and the meaning of the symptoms if PTSD is present.

To summarise: Childhood sexual abuse is a very difficult subject and a very new subject Just as our clients find it difficult to make sense of the experience, so too do we as a society and as professionals. That we do not yet have an agreed definition, and that our definitions are biased by ideology, theory and culture is also difficult for clients. How can this event have meaning and be integrated for the individual if the culture cannot give it meaning and integrate the experience? Another difficulty is located within the individual who doesn’t know whether she is one of many or only a few. Is it the individual’s efforts which must overcome the trauma, or can we culturally and professionally help to acknowledge the problem? We are just beginning to understand childhood sexual abuse and what it means for individuals and for society. We do know that some people are adversely affected by it. Mental health professionals are being called upon increasingly to cope with the consequences. Therefore it is important that we attempt to understand the nature and scope of the problem both for the individual and for society.

In terms of CAT practice, I have found studying the subject in terms of definition, numbers, theory and effects extremely helpful. We are in some ways groping in the dark as much as anyone in the field. We do not know what numbers we are treating or why so many people are presenting with a history of sexual abuse. We need to monitor numbers, and consider definitions that are helpful to our clients

It is now clear to me that the event and the meaning of the event for the individual are extremely important. Both in terms of reformulation and of subsequent sessions the therapeutic task seems to be to help the client make sense of the event in the context of her own life. It is obviously difficult both for the therapist and for the client to hold onto this, but if the meaning the event has for the individual is not given adequate attention and consideration then change will, I predict, be difficult. We also need to pay attention to techniques that help to alleviate some of the very distressing symptoms of PTSD (when present), and help the client manage these symptoms as well as addressing their underlying causes.

 

References

Courtois, C. (1988). Healing the incest wound Adult survivors in therapy. W.W. Norton & Co.
Dolan, Y. (1991). Resolving Sexual Abuse. W.W. Norton & Co. Finkelhor, D. (1986). A Sourcebook on child abuse. Sage.
Horowitz MJ. (1976). Stress response syndromes. New York. Harvard University Press.
Jehu, B. (1988). Beyond Sexual Abuse Therapy with women who were childhood victims. Wiley.
Jehu, D., Klassen C. & Gazan, M. (1985-1986). Cognitive restructuring of distorted beliefs associated with childhood sexual abuse. Journal of Social Work and Human Sexuality.
Kilpatrick, 0.0., Amick-McMullan, A., Best, C., Burke, MM. & Saunders, 8.13. (1986). Impact of child sexual abuses: Recent research findings.
Markowe, ILL. (1988). The frequency of childhood sexual abuse in the U.K. Health Trends 20:1.DHSS.
Mullen, P.13. et al. (1988). Impact of sexual and physical abuse on women’s mental health. The Lancet.
Oppenheimer, R, Howells, K., Palmer, RL. & Chaloner, DA. (1985). Adverse experiences in childhood and clinical eating disorder a preliminary description. Journal of Psychiatric Research, 19.
Pynoos, RS. & Eth, S. (1985). Developmental perspective on psychic trauma in childhood. In: DR. Figley (ed), Trauma and and its Wake: The study and treatment of post traumatic stress disorder. New York: Bruner/Mazel
Ryle, A. (1991). Object relations theory and activity theory: A proposed link by way of the procedural sequence model. British Journal of Medical Psychology, 64.
Vizard, 13. (1987). The historical and cultural context of child abuse, lit P. Mahler (ed), Child abuse: the educational perspective.
Vizard, B. & Tinnier, M. (1988). Recognition and assessment of child sexual abuse. In: A. Bentovin, B. Elton, I Hildebrand, M. Tranter & 13. Vizard (eds), Child sexual abuse within the family: assessment and treatment John Wright.
Westen, D. (1990). Towards a Revised Theory of Borderline Object Relations: Contributions of Empirical Research. International Journal of Psychoanalysis 71,661.
Wyatt, GE & Peters, SD. (1986). Issues in the definition of child sexual abuse in prevalence research. Child Abuse and Neglect.

Claire Tanner

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