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Barker-ColloOF JOURNAL et INTERPERSONAL al. / COGNITIVE-BEHAVIORAL VIOLENCE / April MODEL 2000 The goal of this study was to evaluate Joseph, Williams, and Yule’s cognitive-behavioral model of response to traumatic stress when applied to a sample of 122 female sexual abuse survivors. Participants completed surveys that measured each variable presented in Joseph, Williams, and Yule’s model (i.e., event stimuli, personality, appraisals, coping, crisis support, event cognitions, and emotional states). Path analysis showed that although Joseph, Williams, and Yule’s model did not fit the data, a modified version based on the sexual abuse literature fit the data well. Modifications to the model included the removal of the variable coping and the addition of paths from event characteristics to crisis support and from personality to event characteristics.

A Cognitive-Behavioral Model of Post-Traumatic Stress for Sexually Abused Females SUZANNE L. BARKER-COLLO University of Auckland

WILLIAM T. MELNYK Lakehead University

LESLIE MCDONALD-MISZCZAK Western Washington University

As the study of sexual abuse has gained the interest of researchers, attempts to explain individual variation in response to abuse have become increasingly complex. A notable feature of recent research in the area of sexual abuse is the increasing complexity of research designs and statistical techniques being used. As noted by Alexander (1992), the future of the field is likely to depend on “more complex models, hypotheses, and research designs” (p. 166). A number of sexual-abuse-specific models have been proposed to explain individual variation in response to sexual abuse using variables that are specific to sexual abuse (e.g., Draucker, 1995; Wyatt, Newcomb, & Notgrass, 1991). Unfortunately, the variables contained in these models do not lend themselves to modification through clinical interventions and are therefore

Authors’ Note: Sincere gratitude is expressed to each of the practitioners who assisted us in obtaining participants for this study and to those women who gave their time in completing the surveys. This research was supported by Doctoral Scholarship No. 752-97-1897 awarded by the Social Sciences and Humanities Research Council of Canada. JOURNAL OF INTERPERSONAL VIOLENCE, Vol. 15 No. 4, April 2000 375-392 © 2000 Sage Publications, Inc.

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limited in clinical utility (e.g., frequency of sexual abuse incidents and maximum rapes per incident). Whereas models specific to sexual abuse have been limited in utility, Joseph, Williams, and Yule’s (1995) integrative cognitive-behavioral model of response to traumatic stress (see Figure 1) might be used to successfully examine individual variation in response to the trauma of sexual abuse. The model includes variables that may be reliably measured and modified through clinical intervention (e.g., coping and appraisals). As a model of reactions to trauma that is not specific to a particular type of trauma, Joseph et al.’s (1995) model allows reactions to sexual abuse to be placed within the broader context of stress and coping. Components of the model include three moderator variables (event stimuli, personality, and crisis support), two mediators variables (event appraisals and coping), and two outcome or symptom variables (event cognitions and emotional states). Joseph et al.’s (1995) model of response to traumatic stress proposes a complex pattern of interrelationships between model variables. The starting point of this model is the experiencing of a traumatic event that presents the individual with event stimuli. Event stimuli may be defined as the characteristics of an event such as duration, frequency, and type of sexual abuse. According to the diagnostic criteria proposed by the American Psychiatric Association (APA) (APA, 1994), salient characteristics of a traumatic event include not only the overt characteristics of the event but also the degree of actual or threatened death or serious injury and threat to physical integrity. Investigation of the relationship between specific aspects of sexual abuse and symptom outcome indicate that sexual abuse that is more forceful and frequent, more physically harmful or threatening, and that involves multiple perpetrators results in greater symptomatology (Ellis, Atekeson, & Calhoun, 1981; Kilpatrick et al., 1989; Meichenbaum, 1994; Neuman, Gallers, & Foy, 1989). As described by Horowitz (1986), due to their salience, the stimuli presented in traumatic events must be processed in discrete portions. Processing of event stimuli as event cognitions is generally thought to take the form of intrusive thoughts, emotions, and behaviors (e.g., intrusive thoughts, flashbacks, and nightmares) (Herman, 1992; Joseph et al., 1995). These event cognitions parallel the intrusive phenomena identified as a symptom of posttraumatic stress disorder (PTSD) (APA, 1994). There is evidence that these intrusive phenomena are common and may represent a normal response to traumatic events (Blank, 1993). In relating event cognitions to other variables in the model, Joseph et al. (1995) stated that these “traumatic cognitions, images, sounds, smells, and tactile experiences will idiosyncratically reflect the individual’s prior experiences” (p. 517). Event cognitions are therefore said to be moderated by

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Figure 1: Joseph, Williams, and Yule’s (1995) Integrative Cognitive-Behavioral Path Model of Post-Traumatic Stress Disorder.

personality variables. A variety of personality variables have been posited as modifiers of intrusive symptomatology following sexual abuse. Although Joseph et al.’s (1995) model includes the variable personality as a single construct, one aspect of personality, neuroticism, is of particular interest in the study of response to trauma due to its impact on response to stress. Neuroticism has been defined as the predisposition to experience negative affective states and behavioral manifestations of emotional instability (McCrae & Costa, 1989). Bolger (1990) and Costa and McCrae (1992) identified neuroticism as an index of vulnerability to stressful events where persons who score high on scales of neuroticism cope more poorly with stress than others. Indeed, the presence of high levels of neuroticism has been linked to increased emotional distress and reduced effectiveness of problem-solving abilities following sexual abuse (Follette, Naugh, & Follette, 1997). Event cognitions are also said to be influenced by appraisals. Appraisals are defined by Joseph et al. (1995) as thoughts about the causation of traumatic events and the information depicted in event cognitions. Research indicates that appraisals of events involving internal causal attributions (i.e., self-blame) are associated with increased depressive, anxious, and intrusive symptomatology up to 2 years following trauma (Delahanty et al., 1997; Joseph, Brewin, Yule, & Williams, 1991, 1993). In studies of attributions of blame following sexual abuse, Wyatt et al. (1991) found that 65% (n = 55) of female abuse survivors made internal attributions about the abuse event and that this style of attribution was significantly related to negative symptom

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outcomes. Joseph et al.’s (1995) model indicates that although appraisals influence event cognitions, they are in turn influenced by personality. In the model, the occurrence of event cognitions and appraisals that follow exposure to event stimuli are proposed to elicit strong emotional states that are themselves subject to further cognitive appraisals. Emotional states commonly identified as the long-term correlates of sexual abuse include depression, sadness, guilt, anxiety, and dissociation (Briere & Runtz, 1989; Finkelhor, 1990). Event cognitions, appraisals, and emotional states are proposed to activate attempts at coping. Although the mechanisms through which coping strategies operate have not been clearly defined, few would deny their importance in reducing anxiety and subjective distress following exposure to traumatic events (Folkman & Lazarus, 1988). Investigators typically differentiate between problem-focused coping and emotion-focused coping (Folkman & Lazarus, 1988; Moos, 1993). A number of investigations have found that greater reliance on emotion-focused coping strategies results in more severe symptomatology following trauma (Cohen & Roth, 1987; Nezu & Carnevale, 1987; Z. Solomon, Mikulincer, & Flum, 1988). One important element of coping identified by Joseph et al. (1995) is crisis support. Crisis support has been defined by Joseph et al. (1995) as involving both the availability of others and their reactions to disclosures of trauma. The evidence suggests that, in general, individuals who receive higher levels of crisis support experience better psychological outcome (Joseph, Andrews, Williams, & Yule, 1992). Joseph et al.’s (1995) model indicates that crisis support is thought to influence appraisals, coping, and emotional states. Despite empirical support for and apparent clinical utility of variables included in Joseph et al.’s (1995) model, although discrete portions of the model have been empirically investigated (Joseph et al., 1991, 1993, 1996), no attempt has been made to empirically evaluate the model as a whole. In addition, those evaluations that have taken place have been limited to only one sample (i.e., survivors of the Herald of Free Enterprise disaster). The goal of this investigation was to evaluate Joseph et al.’s (1995) integrative cognitive-behavioral model of response to trauma using data collected from a sample of female sexual abuse survivors. For the purposes of this study, sexual abuse has been defined as sexual contact ranging from petting and kissing to sexual intercourse and involving varying degrees of coercion, threat, and force (Koss & Orso, 1982). In testing Joseph et al.’s (1995) model, two modifications based on the literature regarding sexual abuse were hypothesized. The first modification stems from Joseph et al.’s (1995) discussion of crisis support. In their discussion, the authors noted general agreement in the literature (Jones & Barlow,

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1990; Joseph et al., 1996; S. D. Solomon, 1986) that increased availability of crisis support is predictive of external event appraisals (i.e., attribution of blame to others) and reduced PTSD symptomatology. However, some traumatic events (e.g., sexual abuse) can be stigmatizing and elicit shunning, avoidance, and blaming of the victim by crisis supports (Wortman & Lehman, 1985). Shunning, avoidance, and blaming by the support network and failure to engage the network may be particularly evident where the abuser is known to the survivor due to increased efforts to deny or hide the occurrence of the abuse (Meichenbaum, 1994). Therefore, as the extent of crisis support accessed by the survivor increases, so does the likelihood that some or all of these crisis supports may react negatively. As such, it was hypothesized that increased availability of crisis support will result in the initiation of negative event appraisals (i.e., internal attribution of blame). The second hypothesized modification arose in response to Joseph et al.’s (1995) proposal that event characteristics will have a direct effect on only one other variable, event cognitions. It has been found that some characteristics of sexual abuse scenarios influence another variable within the model, the engagement and provision of crisis support (Kilpatrick et al., 1989; Meichenbaum, 1994; Parrot & Bechofer, 1991; Wyatt et al., 1991). Specifically, engagement of crisis support has been linked to amount of force used by the perpetrator. As indicated by Wyatt et al. (1991), increasing level of force used by a perpetrator is significantly related to increasingly negative reactions of others to the victim when sexual abuse is disclosed. Thus, the addition of a path in the model from event stimuli to crisis support was hypothesized.

METHOD

Sample Data were obtained from a sample of 122 female survivors of sexual abuse from across the province of Ontario, Canada. Participants ranged in age from 15 to 57 years with a mean value of 31.4 years. Seventy-nine respondents (64.8%) were Caucasian, whereas 39 (32.0%) were of Native American ancestry. Of the remaining 5 participants, 3 were of Asian ancestry and 2 were of African ancestry. Education level ranged from grade 8 to completion of a university degree. The majority of respondents (53.2%) had completed 1 year of university. The majority of respondents were single (41.3%), whereas 36 (29%) were married, 20 (16.4%) were divorced, 8 (6.6%) were in

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common-law relationships, 6 (4.9%) were separated, and 2 (1.6%) were widowed. The abuse experienced by the respondents began at a mean age of 8.7 years. Respondents reported having experienced more than 50 separate incidents of abuse in 30.3% of cases. Half of the sample were abused by an immediate family member. The abuser was a member of the extended family or an individual known to the victim in 49 (40.2%) cases. The remaining 12 individuals (9.8%) were abused by a stranger. Measures To ensure clarity, the names of the measure used in relation to each model variable is noted in brackets below the name of the model variable in Figure 1. Event stimuli. According to Joseph et al. (1995), event stimuli are the characteristics of the traumatic event. As previously noted, sexual abuse that involves greater force and greater frequency and is more physically harmful or threatening is thought to result in more severe symptomatology (Ellis et al., 1981; Kilpatrick et al., 1989; Meichenbaum, 1994; Neuman et al., 1989). In the present study, the Sexual Experiences Survey (SES) (Koss & Orso, 1982) was administered to assess the type and severity of sexual victimization. As stated by Koss and Gidyaz (1985), the SES is “designed to reflect various degrees of sexual aggression and victimization” (p. 422) by assessing both the type of sexual abuse (i.e., kissing, petting, intercourse, and oral or anal intercourse) and the type of coercion or force used during abuse (i.e., threats of physical force, verbal arguments, or physical force). The SES contains 13 items presented in a yes/no format (yes =1; no = 0) worded to portray female victimization and male aggression. Scores for this scale are determined by summing the total across responses, with a maximum score of 13. Koss and Orso (1982) reported internal consistencies (Cronbach’s alpha) of .74 (women) and .89 (men) with a test-retest item agreement of 93%. For this sample, mean performance on the SES was 8.22 with a standard deviation of 2.80. Cronbach’s alpha for SES items was .81. Although generally considered a measure of adult sexual victimization experiences, the format of the SES, in which participants are asked, “Have you ever: . . . ?” followed by the 13 yes-no items, does not exclude its use for adults reporting sexual victimization experienced prior to the age of consent. Data reported on the development, reliability, and validity of this measure make no reference to the age of occurrence of the experiences reported (Koss & Gidycz, 1985; Koss & Oros, 1982).

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For the purposes of the present study, 20 additional items were administered separately from the SES to obtain additional descriptive information from the sample. These items obtained information on relationship to the abuser, age at which abuse occurred, number of episodes of abuse, and maximum rapes per incident. Scores obtained on these additional items were not added to SES scores. Personality. Although the model presented by Joseph et al. (1995) contains overall personality functioning as a variable, the present investigation examined a specific subtype of personality, neuroticism, due to its role in regulating susceptibility to psychological distress and ability to cope with stressful events (Costa & McCrae, 1992). Neuroticism was assessed using the NEO Personality Inventory (NEO-PI) neuroticism scale (Costa & McCrae, 1992), which contains six subscales of eight items each. Subscales include anxiety, angry hostility, depression, self-consciousness, impulsiveness, and vulnerability. Each item is answered on a 5-point rating scale from strongly disagree to strongly agree, with higher scores indicating greater levels of neuroticism. Test-retest reliability for neuroticism is .87 (McCrae & Costa, 1983). Mean performance on neuroticism for this population was 48.41 with a standard deviation of 10.58. Internal consistency for this scale for the present sample was .74. Self-report measures on the neuroticism scale are significantly correlated with peer ratings on the same factor (r = .54, p < 0.05) (McCrae & Costa, 1989). Appraisals. According to Joseph et al. (1995), event appraisals are thoughts about the information depicted when an individual reexperiences a traumatic event (e.g., nightmares and flashbacks). Research indicates that appraisals involving internal causal attributions are associated with more depressive, anxious, and intrusive symptomatology up to 2 years following trauma (Delahanty et al., 1997; Joseph et al., 1991, 1993). To determine whether participants applied internal or external attributions, a modified version of the Attributional Style Questionnaire (ASQ) (Peterson et al., 1982) was administered. For the purposes of the present study, the wording of the ASQ was modified from its original format to ask participants to respond in reference to the most severe episode(s) of sexual abuse experienced (e.g., Was the sexual abuse episode(s) due to something about yourself or to something about the other people or circumstances involved?). Respondents rated each of six items on a 7-point Likert-type scale (1 = totally due to others or circumstances; 7 = totally due to me), with a maximum score of 42. All instructions and scoring were in accordance with Peterson et al. (1982). Inter-

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nal consistencies for the ASQ are .75 for positive events and .71 for negative events (Peterson et al., 1982). The mean level of response to this questionnaire for this sample was 34.02 with a standard deviation of 9.26. Internal consistency for the scale in the present sample was .78. Coping. Coping was measured using the Coping Responses Inventory (CRI) adult form (Moos, 1993), a 48-item scale that measures eight different coping types/scales of six items each. In responding to this measure, participants are typically asked to identify an event and complete the inventory in reference to that event. For the purposes of the present study, participants were asked to complete the inventory in reference to the most severe episode(s) of sexual abuse they experienced. Scales include logical analysis, positive reappraisal, seeking guidance and support, problem solving, cognitive avoidance, acceptance or resignation, seeking alternative rewards, and emotional discharge. Each item is rated on a 4-point Likert-type scale that ranges from 0 (no, not at all) to 3 (yes, fairly often) and that when summed produces a maximum total score of 144. Scales are only minimally correlated with social desirability (average absolute r = .13 for the eight scales) (Moos, 1993). Scoring procedures were in accordance with Moos (1993). Internal consistency of the eight CRI scales for respondents ranged from .68 to .75. Overall mean level of performance on this inventory was 53.91 with a standard deviation of 7.31. Crisis support. Crisis support as defined by Joseph et al. (1995) was assessed following the procedures of the Crisis Support Scale (CSS) of Joseph et al. (1992). Using a 7-point Likert-type scale ranging from 1 (never) to 7 (always), the CSS assesses (a) availability of others, (b) contact with survivors, (c) confiding in others, (d) emotional support, (e) practical support, (f) negative response, and (g) satisfaction with support. Participants were asked to respond to each item in relation to the most severe episode(s) of sexual abuse they had experienced. The CSS has a maximum total score of 98, with high scores indicating high levels of crisis support. Cronbach’s alpha for the CSS for the current sample is .80. Mean level of performance on this measure for this sample was 13.77 with a standard deviation of 8.77. Event cognitions and emotional states. In the model, event cognitions are defined as “re-experiencing phenomenon or intrusive recollections of the trauma” (Joseph et al., 1995, p. 517), whereas emotional states refers to feelings such as isolation/loneliness, anxiety, sadness, fear, inferiority, and guilt, which often follow abuse. These two model variables were assessed using those items of the Traumatic Symptom Checklist-40 (TSC-40) (Elliott & Bri-

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ere, 1991) that fit with these definitions. Each of the TSC-40’s 40 items asks the respondent to rate the frequency (never = 0; often = 3) with which she has experienced a specific symptom. Participants were asked to rate each item in relation to the sexual abuse they had experienced. The Cronbach’s alpha for this sample was .90. Internal consistencies for event cognitions and emotional states for the present sample were .78 and .71, respectively. Procedure Thirty-two agencies providing counseling services to sexual abuse survivors from across Ontario, Canada, agreed to distribute survey packages among their clientele. Due to the possible psychological effects associated with participation in this study, practitioners were asked to agree to provide psychological debriefing to clients if required during or following completion of the survey package. Data was gathered over a period of 6 months (May 1996 to December 1996). Participant survey packages included a cover letter explaining the purpose, requirements, and the voluntary and confidential nature of participation; all instructions and materials relevant to the instruments used; and a stamped, self-addressed envelope. Agencies were asked to invite all consecutive new referrals to participate. A total of 146 of the 417 distributed survey packages (35.8%) were returned. This response rate is comparable to that obtained in similar examinations of response to sexual abuse that used a survey method (Coffey, Leitenberg, Henning, Turner, & Bennett, 1996). All respondents met the authors’definition of sexual abuse as indicated by their responses to survey items. Of the returned surveys, 9 were incomplete, 4 were completed by males, 2 were blank, and 2 were not legible. The remaining 126 surveys were examined for accuracy of data entry, missing values, outliers, and the assumptions of multivariate analysis. Univariate outliers are cases with extreme standardized scores (i.e., z scores) on one or more variables. Cases with standardized scores in excess of ±3.00 are considered outliers. Three of the cases in this sample had extreme standardized scores on one or more variables. These cases were excluded from further analysis. The potential for multivariate outliers, or cases with an unusual pattern of scores, was also examined. To identify multivariate outliers, mahalanobis distances are computed. Mahalanobis distance is the measure of the difference between a single case and the central value for all other cases. If a case has an unusual pattern of relationships between variables, the mahalanobis distance between that case and the central value for the remaining cases will be significant. As the mahalanobis distance for one case within this sample was significant, this case was not included in any further analyses. Once outliers were excluded, 122 cases remained in the data set.

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RESULTS

Path analysis (LISREL 7.0) (Joreskog & Sorbom, 1988) was used to examine Joseph et al.’s (1995) integrative cognitive-behavioral model of PTSD (see Figure 1). As the present study examines cross-sectional data, it was not appropriate to examine the bidirectional effects presented in the model, which represent changes in relationships between variables that are proposed to develop over time. Examination of relationships over time would require the collection of longitudinal data. Due to the cross-sectional nature of the data, all bidirectional paths within Joseph et al.’s (1995) model were replaced with unidirectional paths to represent the first stage in the longitudinal chain of events presented by Joseph et al. (1995). When tested, it was 2 found that this model did not fit the data, χ (9) = 27.8, p < .001; Goodness of Fit Index (GFI) = 0.705. When a model does not fit the data, modification indices generated by LISREL 7.0 (Joreskog & Sorbom, 1988) can be used to guide modifications 2 to the model. Modification indices show the change in χ expected if a single parameter/path was freed (if currently constrained) or constrained (if currently free). Using Raykov’s (1994) criteria, modification indices that exceeded a value of 5 were considered. Two paths had modification indices greater than 5. One of these indices was associated with addition of a path from event characteristics to crisis support. The addition of this path was hypothesized a priori on the basis of the sexual abuse literature (Wortman & Lehman, 1985). The second modification index was associated with the addition of a path from personality to event characteristics. After freeing these 2 paths, the model fit the data, χ (7) = 11.27, p = .127. Addition of the two paths did not endanger the interpretability of the model. The second hypothesized modification to the model was a change in the sign of path from crisis support to appraisals. In presenting their model, Joseph et al. (1995) agreed with the general literature on stress and coping that increased crisis support is predictive of external appraisals of blame. However, the sexual abuse literature indicates that increased crisis support may elicit shunning, stigmatization, and blaming of the victim. This second hypothesis was also supported. Following the addition of the two paths identified by modification indices, a number of paths with nonsignificant beta weights remained in the model. To streamline the model, these nonsignificant paths were dropped. The 2 resulting streamlined model fit the data well, χ (13) = 13.41, p > .4; GFI = .970, (see Figure 2). Regression analysis indicates that this model accounts for 61.3% and 28.5% of the variance in the symptom variables emotional states and event cognitions, respectively. The amount of unique variance

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Figure 2: Modified Version of Joseph, Williams, and Yule’s (1995) Model Following Alterations Based on Modification Indices and Removal of Paths With Nonsignificant Beta Weights

associated with each path in the model is indicated by an R2 value in brackets below the beta weight of that path.

DISCUSSION

The primary goal of this study was to evaluate Joseph et al.’s (1995) model of PTSD when applied to a sample of 122 sexual abuse survivors and to evaluate two hypothesized modifications to the model. In testing Joseph et al.’s (1995) integrative cognitive-behavioral model, it was found that a modified version of the model fit the data well. In the modified model, force/extent of sexual abuse (event stimuli) was linked to greater frequency/variety of event cognitions. In the sexual abuse literature, increased force/extent of abuse has indeed been associated with poorer symptom outcomes (Meichenbaum, 1994; Wyatt et al., 1991). The model also offers evidence that in addition to characteristics of the event, factors such as personality, crisis support, and appraisals of blame are important in determining individual variations in symptom presentation following sexual abuse. Personality variables have also been hypothesized to mediate the relationship between the experience of abuse and symptomatology. For example, Joseph et al. (1995) stated that “intrusive ideation is . . . influenced by personality and/or representations of earlier experience” (p. 517). Joseph et al.

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(1995) also asserted that appraisals are thoughts about event cognitions that draw on personality. Specifically, it has been proposed that women with low self-esteem, low self-efficacy, or rigid role socialization may be more likely to blame themselves for the occurrence of abuse (Bandura, 1986; Walker, 1984). Both direct and indirect paths in the model replicate this proposed relationship. In the modified model, increased crisis support was linked to internal appraisals of blame, which was in turn linked to reduced negative emotional states. This finding is also supported in the sexual abuse literature. In the sexual abuse literature, it has been found that some characteristics of sexual abuse scenarios influence the engagement and provision of crisis support (Kilpatrick et al., 1989; Meichenbaum, 1994; Parrot & Bechofer, 1991; Wyatt et al., 1991). Specifically, engagement of crisis support has been linked to amount of force used by the perpetrator. As indicated by Wyatt et al. (1991), increased levels of force used by a perpetrator was significantly related to increased likelihood of negative reactions of others to disclosure of the abuse. The findings of this study support this proposed relationship between event stimuli to engagement of crisis support. As the modified model fits with the majority of relationships proposed by Joseph et al.’s (1995) integrative cognitive-behavioral model and with the general literature on response to trauma, it appears that models of response to trauma that place reactions to sexual abuse within the broader context of stress and coping are applicable to sexually abused populations. However, the findings also indicate that examination of sexual abuse within the larger trauma response literature must take into consideration the uniqueness of sexual abuse and its effects as a traumatic event. For example, although the literature on response to trauma generally agrees that greater availability of crisis support is predictive of positive event appraisals (i.e., external attribution of blame) and reduced symptomatology (Jones & Barlow, 1990; Joseph et al., 1996; S. D. Solomon, 1986), it has been proposed that increased crisis support following sexual abuse may have the opposite effect through shunning, avoidance, and blaming of the victim by members of the crisis support network (Wortman & Lehma, 1985). The findings of this study support the presence of this unique relationship. In understanding the relationships presented in the model, the literature on PTSD must also be examined. For example, Blank (1993) and Horowitz (1980, 1986) concurred that event cognitions are a normal response to trauma that allow processing of traumatic information and lessen other negative symptomatology. In the model, increased event cognitions were associated with decreased negative emotional states. This suggests that processing traumatic information at a high rate results in a lessening of other negative symptomatology, in this case, negative emotional states. Although some studies

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(Wyatt et al., 1991) associate negative emotional outcomes with selfblame, the results of the present study support the findings of Tennen and Affleck (1990) who suggested blaming others results in poorer emotional adjustment. In the model, increased event cognitions were associated with reduced negative emotional states. This raises the following question: Reduction of which aspect of symptomatology should be the focus of clinical intervention? According to Joseph et al. (1995), event cognitions are iconic representations of event stimuli. Due to their overwhelming nature, these representations are held in active memory for further conscious processing. As described by Horowitz (1986), traumatic events must be processed in small and discrete portions that allow the individual to maintain equilibrium. The processing of event stimuli as event cognitions is generally thought to take the form of intrusive thoughts and behaviors (e.g., dreams and flashbacks) (Herman, 1992; Joseph et al., 1995). High levels of event cognitions are thought to indicate that information about the traumatic event is being processed at a high rate. Negative emotional states, on the other hand, have been linked to an inability to process and cope with trauma. As increased levels of event cognitions were indeed found to be related to reduced levels of negative emotional states, the role played by event cognitions in the processing of traumatic information would seem to be upheld. This interpretation of the findings points toward the necessary role of event cognitions in coping with trauma. Despite their apparent importance to processing of traumatic information, event cognitions such as flashbacks and nightmares are extremely disturbing symptoms. Perhaps in continuing to use techniques to reduce these symptoms, clinicians should temper their use with an understanding of the role event cognitions appear to play in the processing of event-related stimuli. Limitations The main limitation of this study is its reliance on self-report measures. The use of self-report measures may result in bias due to the limiting format in which questions are answered. Although some reduction in potential bias effects were sought through ensuring confidentiality and anonymity of responses, the findings would be strengthened by using additional measures in future research. Specifically, reports by involved clinicians would provide a basis for cross-validating the responses. One related limitation is important to emphasize. The symptoms reflected in the model are not unique to individuals with a history of sexual abuse. It must therefore be emphasized that one cannot infer that someone who

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presents with these symptoms has been sexually abused. The women in this sample self-identified their history of sexual abuse before entering the study. This study provides information on various clinical presentations and concerns that may manifest themselves in this population. The use of a clinical sample in conducting this study poses a number of limitations to the generalizability of the findings. First, all of the sexually abused women in this sample were given the opportunity to complete the survey through their contact with an organization or individual who provides mental health services to survivors of sexual abuse. Because the sample was obtained through respondents’ contact with mental health professionals, the findings cannot be generalized to those women who have been sexually abused but who have not come into contact with mental health services. Similarly, whereas all consecutive referrals to each participating agency were given the opportunity to participate in the study, only 35.8% of distributed surveys were completed. The generalizability of the results is therefore limited only to those willing to complete the survey and cannot be extended to those who did not wish to participate. In addition, due to the need to ensure that completion of the survey did not impact negatively on participants, clinicians involved in this study were asked to provide participants with debriefings as required should participants experience negative psychological effects as a result of their participation. Although there is no data available to determine whether any of the respondents required debriefing as a result of their participation, the availability of debriefing services may have impacted on willingness to complete the survey. Finally, whereas this study tested a model of response to trauma, the data collected were retrospective and cross-sectional, precluding the investigation of the bidirectional relationships proposed. Future research should examine the fit of the model or individual paths within the model when applied to changes in response to sexual abuse over time. In addition, the size of the sample was not adequate to allow cross-validation of the findings. Future research should reevaluate the findings of this study. Conclusion The challenges that sexual abuse presents to society in general and to mental health professionals in particular are enormous and complex. This study provides a better understanding of the interrelationships between psychosocial factors and symptom presentation in female survivors of sexual abuse. The modified model presented here provides a valid framework for

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understanding the impact of various factors on response to sexual abuse and for planning interventions with survivors of sexual abuse. As a model of responses to traumatic stress that is not specific to a particular type of traumatic event, the model also provides a framework for comparison of survivors of sexual abuse and survivors of other forms of trauma. If replicated, the results of this study could provide a context for understanding individual differences and commonalties in response patterns and provide direction to clinicians in how to approach these differences to better relieve negative symptomatology. The need for further examination to validate and expand on the findings of this study is warranted.

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Dr. Suzanne L. Barker-Collo obtained her doctoral degree in clinical psychology from Lakehead University. Her research interests include the evaluation of cognitive and behavioral assessment and intervention strategies including their application to cognitive rehabilitation and special populations (i.e., developmental disabilities and brain injury). She holds a lectureship in neurorehabilitation in the Department of Psychology, University of Auckland. Dr. William T. Melnyk has 33 years experience in clinical psychology as a teacher, researcher, administrator, and clinician. He has been a member of provincial, national, and international committees including the Ontario Board of Examiners in Psychology and the Association of State and Provincial Psychology Boards. He has taught in statis-

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tics and design, psychometrics, abnormal psychology, cognitive behavior modification, psychotherapy, and professional and legal issues. He has published and presented more than 35 articles and led more than 50 workshops. He runs an extensive private practice. Dr. Leslie McDonald-Miszczak obtained her doctoral degree in developmental psychology at the University of Victoria. She currently holds an associate professorship in the Department of Psychology at Western Washington University.