Virginia Burk, M.S., Geoffrey Gordon, M.S. and Steven Gold, Ph.D.

1. The Relationship Between Sexual Compulsivity, Dissociation, and the Number of Sexual Abuse Perpetrators and Relevance to Contextual Therapy Virginia Burk, M.S., Geoffrey Gordon, M.S. and Steven Gold, Ph.D.

2. The Connections • Dissociation is connected to childhood sexual abuse (Briere & Runtz, 1987; McNally et al. 2006). • Revictimization is connected to higher levels of dissociation (Martin, Cromer, DePrince, & Freyd, 2013). • Clinical observations has seen a connection between sexual compulsivity and dissociation (Gold & Seifer, 2002).

3. Gold and Seifer (2002) • Observed that clients that engaged in SAC would be unaware of many characteristics of the behavior. • Noticed that during SAC, there would be sexual numbing, difficulty remembering parts of the SAC, feeling dazed, and feeling like they were not in control during the behavior.

4. Sexual Adjustment and CSA • A history of CSA has been found to be associated with problems with sexual adjustment adult life (Marson, 2013; Testa, VanZile-Tamsen, Livingston, 2005). • CSA survivors are more likely to have difficulty engaging in sex, will avoid sexual activity and cues, will have decreased sexual desire, and have more intimacy problems (Meston & Lorenz, 2012, DiLillo, 2001; Van Berlo & Ensinck, 2000, Gilmartin, 1994).

5. Sexual Adjustment and CSA • CSA has been linked with more permissive attitudes about sex and more lifetime sexual partners (Testa, VanZile-Tamsen, Livingston, 2005); higher rates of prostitution (Wilson & Widom, 2008) early pregnancy (Trinkett, Noll, & Putnam, 2011) sexual risk taking behaviors (Brown, Lourie, Zlotnick, & Cohn, 2000) early coitus (Trinkett, Noll, & Putnam, 2011); and sexual compulsivity (Gold & Heffner, 1998).

6. Revictimization • People who are victimized have an increased risk for future victimization (Klest, 2012; Matlow & DePrince, 2012; Villodas et al., 2012). • CSA survivors have been found to be 2-3x more likely to be sexually abused again in adolescence or adulthood (Noll & Grych, 2011). • The higher the number of sexual abuse perpetrators, the higher the rate of long-term difficulties in psychological functioning (Gold, 2010).

7. The Study • A study was performed to discern the relationship between sexual compulsivity, sexual abuse perpetrators, and dissociation. • An additional aim of the study is to identify which areas of sexual compulsivity correlate most highly with dissociation and the number of abuse perpetrators.

8. Hypotheses • The higher the number of sexual abuse perpetrators, the higher the endorsement of sexually compulsive behavior. • The higher the rate of dissociation, the higher the endorsement of sexually compulsive behavior. • Questions on the sexual compulsivity questionnaire relating to dissociation will be correlated with a higher number of abuse perpetrators. • Questions on the sexual compulsivity questionnaire relating to powerlessness will correlate highly with dissociation.

9. The Archive • Data were originally collected during the initial intake assessment of clients admitted to a university-based outpatient therapy program specializing in the treatment of individuals with a history of trauma. All study participants reported a history of CSA. • In order to be included in the study, the participants must have completed a measure of sexual compulsivity and either a structured clinical interview for childhood sexual abuse, or a scale of dissociation.

10. The Demographics • (n=81), 24.2% identified as male, 75.8% identified as female. • Non-Hispanic white or Caucasian (31.3%), Hispanic (6%), black or African American (3.8%), and multi-racial, (2.4%), or other (2.4%). Elected not to answer (28.9%). • Ages ranged from 17 to 61, with an average of 38.7 years old. • Number of perpetrators: Average=3, Range=1 to 20.

11. Abuse Demographics • 16% of the population reported physical abuse accompanied by sexual abuse • 31% reported being forced to fondle their perpetrator • 43.4% reported being fondled by their perpetrator • 12% reported being forced to masturbate their perpetrator, • 19.3% reported having their perpetrator touch them in a masturbatory manner • 9.6% reported attempted intercourse • 22.9% reported digital penetration of their vagina • 9.6% reported digital penetration of their anus • 24.1% reported being forced to perform oral sex on their perpetrator • 14.5% reported having oral sex performed on them by their perpetrator • 22.9% reported vaginal intercourse by their perpetrator • 9.6% reported anal intercourse by their perpetrator • 6% reported vaginal penetration by an object • 3.6% reported anal penetration by an object.

12. Sexual Experiences Inventory • Self report scale that measures sexual addiction and compulsivity with questions regarding sexual thoughts, feelings, and behaviors. • SEI-F and SEI-M. • There are 72 Likert scale items with five choices, a) not at all, b) once, c) 2 to 5 times, d) 6 to 10 times, and e) more than 10 times. • Two time frames: ‘ever’ and ‘within the past three months’. • This scale has been validated and is yet unpublished.

13. Number of Perpetrators • Clients are requested to voluntarily provide information about their abuse history, including the number of people who sexually abused them before the age of eighteen, via a structured clinical interview for childhood sexual abuse. • Administered by psychology trainees in a doctoral program under the supervision of a licensed psychologist.

14. Dissociative Experiences Scale • Bernstein and Putnam (1968). • 28 item self-report test used for screening of dissociative disorders. • Scored on a 0 (never) - 100 (all the time) scale, and the total score is found by calculating the mean of all 28 items. • The higher the score, the higher the frequency of dissociative symptoms, and the more likely the person is to have a dissociative disorder.

15. Results (Regressions) • The reported lifetime total number of sexual abuse perpetrators that a CSA victim reported significantly predicted scores on the ‘last three months’ SEI subscale b = .307, t(40) = 2.037, p < .048. • The DES total score significantly predicted scores on the ‘last three months’ SEI subscale b = .398, t(81) = 3.910, p < .001. • The DES total score significantly predicted scores on the ‘ever’ SEI subscale b = .398, t(81) = 3.907, p < .001.

16. Results (Correlations) • The male and female scores for the SEI subscales were combined into one data set. • The majority of the questions on both gender-specific versions of the SEI do not have significant differences on each item between males’ and females’ responses. • In order to reduce the likelihood Type I error, specific questions on the SEI pertaining to the hypotheses were picked to analyze.

17. Correlations (Dissociation) • SEI “ever” items correlated with lifetime number of sexual abuse perpetrators.

18. Correlations (Dissociation) • SEI “last three months” items correlated with lifetime number of sexual abuse perpetrators.

19. Correlations (Powerlessness) • SEI “ever” items correlated with total score on the DES.

20. Correlations (Powerlessness) • SEI “last three months” items correlated to the total score on the DES.

21. Discussion • This study provides support for Gold and Seifer (2002). • Dissociation was related to sexual compulsion in both the last three months and in the respondent’s lifetime. • Questions measuring dissociative qualities in sexual compulsion were related to the lifetime number of reported sexual abuse perpetrators.

22. Discussion Cont. • The higher the number of sexual abuse perpetrators that a survivor of CSA has before the age of eighteen, the more likely it is for that survivor to engage in current sexually compulsive behavior. • Questions measuring aspects of powerlessness on the SEI were correlated with the dissociation as well, including many high risk sexual behaviors.

23. Sexual Dissociation • Out of the 17 dissociative SEI items, 10 were significantly correlated to the number of reported sexual abuse perpetrators. • 3 items were significantly correlated in both the ‘ever’ and the ‘last three months’ subscales. • Possibilities: • Dissociation is occurring due to uncomfortable feelings toward sexuality. • Compulsive acts are occurring because of dissociation.

24. Sexual Dissociation Cont. • Out of the 21 SEI questions about powerlessness, 16 were correlated to the number of reported sexual abuse perpetrators. • 6 items were correlated with both the ‘ever’ and ‘last three months’ subscales. • Many of the items indicated the possibility of long term negative side effects. • These high consequence sexual behaviors may serve to distract the respondent from their dissociative symptomatology. • The respondents may not be experiencing (or trying not to experience) the dissociative symptoms for the periods of time that they are engaging in sexually addictive or compulsive behavior. • Alternative may be that dissociation is occurring due to sexual reminder of trauma.

25. The Contextual Model (Gold, 2000)

26. Treatment Formulation • Client guided conceptualization. • Enhance adaptive living skills, remediate deficient learning. • Three components • Interpersonal • Conceptual • Practical

27. Six Priorities of Treatment

28. How it Relates • The majority of CSA survivors grew up in an ineffective family, and ineffective families tend to have low levels of expressiveness (Gold, 2000). • Affection and love are rare in low emotionally expressive families. • It is possible that CSA survivors only felt wanted and loved during sexual abuse. • This would explain why self-dissatisfaction and belief that one’s body is the only worthwhile aspect is common in significant correlations.

29. The Therapeutic Approach • Sexual compulsivity may be related to trauma, however, the trauma should not be immediately addressed. • Three stage approach to trauma; safety and stabilization should be focused on first. • Sexually compulsive behavior would be important in safety and stabilization.

30. SAC Behaviors, Dissociation, and the Contextual Model • Paramount - focus on the therapeutic relationship. • The client should conceptualize their dissociation and SAC, can use Meichenbaum-style interviewing. • Psychoeducation about the family environment can lead to less self-blame.

31. SCAN-R • SCAN-R: • Select • Cue • Analyze • Note • Revise

32. SCAN-R Cont. • Select: • Client and practitioner identify a specific incident of CSA. • Cue: • Client provides step-by-step account of the incident. • Client identifies the cues that trigger the client’s engaging in CSA.

33. SCAN-R Cont. • Analyze: • Client describes how the process evolved. • Increases awareness of the associated thoughts/feelings/behaviors that were overlooked. • Desensitizes the client to the detailed discussion of CSA.

34. SCAN-R Cont. • Note: • Client identifies a specific affect that consistently triggers CSA episodes. • Client recognizes CSA is not motivated by desire or interest, rather it is relief of distress. • Revise: • Client revises previously held assumptions about CSA. • Client concludes there are more effective, lower cost, lower risk means to an end than CSA.

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36. References Cont. Matlow, R. B., & DePrince, A. P. (2012). The influence of victimization history on PTSD symptom expression in women exposed to intimate partner violence. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. Doi:10.1037/a0027655 McNally, R.J., Perlman, C.A., Ristuccia, C.S., Clancy, S.A. (2006). Clinical characteristics of adults reporting repressed, recovered, or continuous memories of childhood sexual abuse. Journal of Consulting and Clinical Psychology, 74(2), 237-242. Meston, C. M., & Lorenz, T. A. (2012). Physiological stress responses predict sexual functioning and satisfaction differently in women who have and have not been sexually abused in childhood. Psychological Trauma: Theory, Research, Practice, and Policy, doi:http://dx.doi.org/10.1037/a0027706 Noll, J. G., & Grych, J. H. (2011). Read-react-respond: An integrative model for understanding sexual revictimization. Psychology of Violence. Advance online publication. Doi: 10.1037/a0023962 Testa, M., VanZile-Tamsen, C., and Livingston, J.A. (2005). Childhood sexual abuse, relationship satisfaction, and sexual risk taking in a community sample of women. Journal of Consulting and Clinical Psychology, 73(6), 1116-1124. Trickett, P. K., Noll, J. G., Reiffman, A., & Putnam, F. W. (2001). Variants of intrafamilial sexual abuse experience: Implications for long-term development. Journal of Development and Psychopathology, 13, 1001– 1019. Van Berlo, W., & Ensinck, B. (2000). Problems with sexuality after sexual assault. Annual Review of Sex Research, 11, 235–258. Villodas, M.T., Litrownik, A.J., Thompson, R., Roesch, S.C., & English, D.J. (2012). Changes in youth’s experiences of child maltreatment across developmental periods in the LONGSCAN consortium. Psychology of Violence, 2(4), 325-338. Wilson, H.W. & Widom, C.S. (2008). An examination of risky sexual behavior and HIV in victims of child abuse and neglect: A 30-year follow-up. Health Psychology, 27(2), 149-158.