Chronic Avoidance Helps Explain
the Relationship Between Severity
of Childhood Sexual Abuse
and Psychological Distress in Adulthood
M. Zachary Rosenthal
Mandra L. Rasmussen Hall
Kathleen M. Palm
Sonja V. Batten
Victoria M. Follette
M. Zachary Rosenthal is Assistant Clinical Professor, Department of Psychiatry
and Behavioral Sciences, Duke University Medical Center, and is Associate Director,
Duke Cognitive Behavioral Research and Treatment Program. His research focuses on
the role of emotion regulation in psychopathology. Mandra L. Rasmussen Hall is Doctoral Candidate, Clinical Psychology, University of Nevada, Reno. Her recent interests
are in the area of interpersonal violence and emotion regulation. Kathleen M. Palm,
PhD, is Postdoctoral Research Fellow, Brown Medical School and Butler Hospital. Dr.
Palm’s research interests include treatment development and psychotherapy outcome
research in the areas of Post-Traumatic Stress Disorder and substance use disorders.
Sonja V. Batten is Coordinator, Trauma Recovery Programs, VA Maryland Health
Care System and Assistant Professor of Psychiatry, University of Maryland School of
Medicine. She completed specialized training in traumatic stress at the National Center
for Post-Traumatic Stress Disorder and the National Crime Victims Research and
Treatment Center. Her research interests include emotional functioning and avoidance
in individuals with Post-Traumatic Stress Disorder, as well as treatment development
for comorbid PTSD and substance use. Victoria M. Follette is Chair, Department of
Psychology, UNR. Her research focuses on trauma, substance abuse, and couples issues.
She is interested in the link of experiential avoidance to a number of adverse outcomes.
She uses a contextual behavioral approach to the treatment of trauma and is interested in
psychotherapy outcome.
Address correspondence to: M. Zachary Rosenthal, PhD, Department of Psychiatry
and Behavioral Sciences, Duke University Medical Center, 2213 Elba Street, Box
3026 Durham, NC 27710.
Submitted for publication 7/8/04; revised 11/16/04; accepted 11/26/04.
Journal of Child Sexual Abuse, Vol. 14(4) 2005
Available online at http://www.haworthpress.com/web/JCSA
© 2005 by The Haworth Press, Inc. All rights reserved.
doi:10.1300/J070v14n04_02
25
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JOURNAL OF CHILD SEXUAL ABUSE
ABSTRACT. Recent studies have found that chronic avoidance of unpleasant internal experiences (e.g., thoughts, emotions, memories) is a
maladaptive means of affect regulation often adopted by women with a
history of sexual victimization in childhood. The primary aim of this study
was to replicate and extend previous findings suggesting that higher levels
of experiential avoidance may account for the relationship between childhood sexual abuse (CSA) and psychological distress in adulthood. It was
hypothesized that, in a sample of undergraduate females (n = 151), the relationship between severity of CSA (e.g., frequency, nature of victimization)
and trauma-related psychological distress would be mediated by avoidance.
Results supported this hypothesis. Findings are consistent with previous studies, and further suggest that the general tendency to avoid or escape from unpleasant internal experiences may be a specific factor that exacerbates
psychological distress among women with a history of sexual victimization in
childhood. [Article copies available for a fee from The Haworth Document Delivery
Service: 1-800-HAWORTH. E-mail address: <docdelivery@haworthpress.com>
Website: <http://www.HaworthPress.com> © 2005 by The Haworth Press, Inc. All
rights reserved.]
KEYWORDS. Childhood sexual abuse, psychological distress, emotion regulation, avoidance, coping
Sexual victimization during childhood is associated with a wide range of
adverse outcomes, including psychological distress, depression, anxiety,
substance abuse, suicidal behavior, and borderline personality disorder (for
reviews, see Browne & Finkelhor, 1986; Polusny & Follette, 1995). However, the relationship between childhood sexual abuse (CSA) and negative
outcomes in adulthood is correlational and complex. Recently, researchers
have begun to examine mediational models hypothesized to help account
for this relationship, in order to understand how psychopathology develops
following CSA.
The tendency to deliberately avoid or escape from unpleasant internal experiences (e.g., thoughts, feelings, sensations), or experiential
avoidance, has been reported in preliminary studies with undergraduate
females to mediate the relationship between sexual victimization before
the age of 18 and psychological functioning in adulthood (Marx &
Sloan, 2002; Polusny, Rosenthal, Aban, & Follette, 2004). Similarly,
avoidant coping has been shown to mediate the relationship between a
history of sexual abuse and symptoms of traumatic stress in a large sam-
Rosenthal et al.
27
ple of Belgian adolescents (Bal, Van Oost, De Bourdeaudhuij, & Crombez, 2003). Despite these studies, the inter-relationships among severity
of CSA (e.g., frequency, nature of victimization), avoidance, and psychological distress have yet to be examined. The two main purposes of this
study are to: (a) replicate findings from previous studies indicating that
chronic avoidance is associated with a self-reported history of CSA, and
(b) extend previous studies by examining a mediational model that specifically tests the extent to which avoidance accounts for the relationship
between severity of CSA and trauma-related psychological distress.
SEXUAL VICTIMIZATION IN CHILDHOOD
Epidemiological studies suggest that approximately 15% to 32% of
women in the United States report a history of CSA (e.g., Vogeltanz,
Wilsnack, Harris, Wilsnack, Wonderlich, & Kristjanson, 1999). Over
the past 20 years, researchers have documented the link between CSA
and psychological maladjustment. However, a handful of studies, including an influential meta-analysis, have found that the relationship
between CSA and adverse outcomes may be modest (Rind, Tromovitch, & Bauserman, 1998), and may be explained, in part, by other
variables such as one’s family environment (Nash, Hulsey, Sexton,
Harralson, & Lambert, 1993) or use of maladaptive coping strategies
(e.g., Merrill, Guimond, Thomsen, & Milner, 2003; Runtz & Schallow,
1997).
Many studies examining the impact of CSA on psychopathology
have compared those with to those without a history of CSA. Fewer
studies have examined the relationship between the severity of CSA and
negative outcomes. This is noteworthy, as definitions of CSA vary
across studies, with different criteria for the nature of the abusive experiences (e.g., non-contact experiences or sexual contact) used. Although
there currently is no standard measure of CSA severity, some researchers have created indices of severity based on reported characteristics of
one’s CSA history. For example, Zanarini and colleagues (2002) developed a system for calculating the estimated severity of CSA. Abuse specific information was collected (e.g., relationship to the perpetrator,
whether force was used, the nature of the abuse, the frequency of the
abusive incidents, etc.) and rated, such that more severe abuse received
a higher score (e.g., force = 1, no force = 0). Severity of abuse was calculated by summing the total score of all severity domains. For the pur-
28
JOURNAL OF CHILD SEXUAL ABUSE
pose of the present study, the Zanarini et al. (2002) severity index was
adopted as a useful way of integrating abuse-specific severity factors
into a composite variable.
Avoidance
Defined as “the phenomenon that occurs when a person is unwilling
to remain in contact with particular private experiences (e.g., bodily
sensations, emotions, thoughts, memories, behavioral predispositions)
and takes steps to alter the form or frequency of these events and the
contexts that occasion them” (Hayes, Wilson, Gifford, Follette, &
Strosahl, 1996, p. 1154), chronic experiential avoidance is one way to
conceptualize the range of maladaptive behaviors observed in some survivors of sexual trauma (Polusny & Follette, 1995). Greater use of
avoidance has been associated with psychopathology, including anxiety
(Craske & Hazlett-Stevens, 2002), depressive symptoms (Polusny et
al., 2004), severity of posttraumatic stress disorder (PTSD) symptomatology (Boeschen, Koss, Figueredo, & Coan, 2001), substance abuse
(Stasiewicz & Maisto, 1993), greater psychological distress (Marx &
Sloan, 2002), and poorer clinical outcomes (e.g., Hayes et al., 1996;
Roemer, Litz, Orsillo, & Wagner, 2001).
In Polusny and Follette’s (1995) model of the long-term correlates of
CSA, experiential avoidance is hypothesized to mediate the influence of
sexual abuse experiences on later psychological adjustment. Sexual
abuse survivors may engage in behavioral strategies (e.g., worrying,
dissociating, consuming alcohol, binge-purge eating, or self-harming
behaviors) that function to reduce or avoid unpleasant emotions or
thoughts associated with sexual abuse experiences. Although such
avoidance behaviors may provide some initial reduction in distress, attempts to avoid or eliminate aversive experiences can become excessive
and result in social isolation, depression, psychological distress, substance abuse problems, or other forms of psychopathology (Hayes et al.,
1996; Polusny & Follette, 1995).
Recent evidence also suggests the possibility that constructs similar to
experiential avoidance may be causally related to psychological distress.
In a series of recent studies, Lynch, Cheavens, Rosenthal, and Morse (in
press), have reported that greater inhibition of emotional experience via
thought suppression mediates the relationship between (a) negative affect and psychological distress in both undergraduate and clinical samples (Lynch, Robins, Mendelson, & Krause, 2001), (b) childhood maltreatment and adult psychological distress in a non-clinical sample
Rosenthal et al.
29
(Krause, Mendelson, & Lynch, 2003; Rosenthal, Polusny, & Follette, in
press), (c) negative affectivity/reactivity and features of borderline personality disorder in an undergraduate sample (Cheavens et al., in press),
and (d) negative affect intensity/reactivity and higher levels of suicidal
ideation and hopelessness in a sample of depressed older adults (Lynch et
al., in press).
Research examining the coping strategies of survivors of sexual abuse
provides further support for the impact of avoidance on long-term functioning. Findings indicate that avoidant coping, such as emotional suppression, denial, detachment, self-blame, and self-isolation, may result in
more impaired functioning than coping involving disclosure and support-seeking behavior (for a review, see Spaccarelli, 1994). More specifically, recent studies offer support for avoidance as an important factor in
the relationship between interpersonal trauma and psychological distress.
Batten, Follette, and Aban (2001), found that college women who reported a history of CSA scored significantly higher on measures of experiential avoidance and reported greater high-risk sexual behavior than
women without a history of CSA. A study examining experiential avoidance in adult rape survivors found that cognitive avoidance or “blocking”
of rape-related thoughts had small but detrimental effects on post-traumatic stress disorder symptoms (Boeschen, Koss, Figueredo, & Coan,
2001). Another study found that undergraduate women who reported
CSA only or both CSA and adult sexual assault showed significantly
greater use of “escapism” as a coping strategy than women who reported
no trauma (Proulx, Koverola, Fedorowicz, & Kral, 1995).
Two studies testing mediational models of sexual victimization, experiential avoidance, and psychological distress in undergraduate
women have recently been reported. In one study, experiential avoidance fully mediated the relationship between a history of CSA and a
measure of global psychological distress (Marx & Sloan, 2002). In the
other study, Polusny et al. (2004), reported that experiential avoidance
partially mediated the relationship between adolescent sexual assault
(attempted or completed sexual assault between the ages of 14 and 18)
and both psychological distress and depressive symptoms. Overall,
there appears to be emerging evidence that the chronic use of avoidance
as a means of regulating unpleasant cognitions and emotion may play an
important role in the maintenance of psychological distress. However,
to date, no studies have examined whether avoidance accounts for the
relationship between greater severity of CSA and greater trauma-related psychological distress.
30
JOURNAL OF CHILD SEXUAL ABUSE
Current Study
In line with theoretical predictions (Polusny & Follette, 1995) and
previous findings (Marx & Sloan, 2002; Polusny et al., 2004), the current study utilized a sample of undergraduate women (n = 151) to investigate the extent to which the self-reported severity of sexually abusive
experiences during childhood is associated with higher avoidance and
trauma-related psychological distress. Specifically, we hypothesized
that greater self-reported use of avoidance would be a regulation strategy associated with greater psychological distress, and that avoidance
would mediate the relationship between psychological distress and the
severity of CSA.
METHOD
Participants
Participants were 153 female undergraduate students enrolled in psychology courses at a medium-sized western university. All participants
were recruited through undergraduate psychology courses and were eligible to participate if they were female, at least 18 years old, and primarily English speaking. Females were specifically recruited in order to
replicate previous studies examining the role of avoidance among
women with a history of CSA. Two participants were identified as outliers (z > 3.29) on the dependent measure, and were excluded from data
analyses. Thus, the final sample included 151 undergraduate females.
Participation was voluntary and all participants received extra credit as
compensation. The mean age of participants was 21.0 years (SD = 6.1;
range = 18-57), and the majority of participants were Caucasian
(81.5%) and unmarried (93.3%).
Measures
Demographics. Standard demographic variables were assessed, including age, ethnicity, and marital status.
Sexual Victimization. Sexually abusive experiences during childhood were assessed using behaviorally specific, self-report items derived from the Wyatt Sexual History Questionnaire (WSHQ; Wyatt,
1988; Wyatt, Lawrence, Vodounon, & Mickey, 1992). Items ranged
from fondling to completed vaginal, oral, or anal intercourse, and par-
Rosenthal et al.
31
ticipants responded to the items dichotomously (yes = 1 or no = 0). CSA
was defined as endorsement of at least one form of sexual contact, ranging from fondling to completed vaginal, oral, or anal intercourse, that
occurred prior to age 14 by someone at least five years older than the
participant, or of any age if the contact was not desired or involved coercion (Wyatt et al., 1992). Other items assessed abuse-specific factors
associated with severity of abuse. The specific severity domains are
presented in Table 1, along with the severity of CSA index outlined by
Zanarini et al. (2002). The combination of these factors was used in order to comprehensively include a range of CSA characteristics as an index of severity.
Avoidance. The Acceptance and Action Questionnaire (AAQ;
Bond & Bunce, 2003; Hayes et al., in press) is a 16-item self-report instrument designed to measure psychological acceptance, emotional
willingness, and the tendency to engage in emotional avoidance. Each
TABLE 1. Domains of Self-reported Sexual Victimization Experiences During
Childhood
Points
N
%
Age of Abuse
Early Childhood (0-9)
Late Childhood (10-13)
Both
1 pt
2 pts
3 pts
29
14
7
19.2
9.3
4.6
Frequency
Once
Several times yearly or less
Monthly or Daily
1 pt
2 pts
3 pts
19
23
8
12.6
15.2
5.3
Duration
1 Month or less
>1 Month, < 1 year
1 Year or more
1 pt
2 pts
3 pts
22
9
18
14.6
6.0
11.9
Relationship to perpetrator
Stranger
Know abuser
Caretaker
1 pt
2 pts
3 pts
8
38
4
5.3
25.2
2.6
Nature of victimization
Observation without contact
Fondling
Penetration (Oral/Anal/Vaginal)
1 pt
2 pts
3 pts
14
27
8
9.3
17.9
5.3
Force used
Yes
1 pt
13
8.6
Life threatened
Yes
1 pt
2
1.3
32
JOURNAL OF CHILD SEXUAL ABUSE
item is rated on a seven-point Likert scale (1 = never true to 7 = always
true), and higher scores indicate greater acceptance (as opposed to
avoidance). Sample items include “I try hard to avoid feeling depressed
or anxious” (reverse scored) and “I rarely worry about getting my anxieties, worries, and feelings under control.” Preliminary data support the
reliability and validity of the 16-item AAQ, and higher scores on the
AAQ have been associated with greater psychopathology and distress
(Hayes et al., in press). Recent analysis of the 16-item AAQ indicates an
internal consistency reliability coefficient of .71 (Bond & Bunce, 2003)
and a two-factor structure: (a) willingness to experience internal events
and (b) ability to take action, even in the face of unwanted internal
events.
The Impact of Event Scale (IES; Horowitz, Wilner, & Alvarez, 1979)
is a 15-item self-report measure of traumatic stress symptoms. Each
item is rated on a four-point Likert scale (1 = not at all to 4 = often). The
IES has two stable factors (Intrusion and Avoidance) that form separate
subscales (Sundin & Horowitz, 2002). The IES Avoidance Subscale
(IES-A) was used in this study as a measure of avoidant reactions and
behaviors (e.g., thought suppression and behavioral inhibition). Sample
items include, “I tried not to think about it” and “I stayed away from reminders of it.” The IES has good internal consistency and test-retest reliability, as well as discriminant and convergent validity (Horowitz et
al., 1979; Sundin & Horowitz, 2002).
Psychological distress. The Trauma Symptom Inventory (TSI; Briere,
Elliot, Harris, & Cotman, 1995) is a 104-item self-report instrument designed to assess symptoms related to traumatic stress. Participants responded to each item of the TSI without having to make reference to a
specific traumatic event. The TSI has nine subscales measuring various
aspects of trauma-related symptoms, and higher scores on each subscale
indicate higher levels of symptomatology. The mean internal consistency
alpha for the TSI has been reported as .87 (Briere et al., 1995). The total
TSI score was used as the global measure of psychological distress in this
study.
Procedure
Upon arriving at the laboratory, each participant was greeted by a research assistant and given time to read and sign a consent form. The research assistant answered questions, and then described the study in a
scripted manner. Each participant was told that the study was designed
to identify ways in which women cope with stressful life experiences.
Rosenthal et al.
33
RESULTS
The first step in the data analytic plan was to examine the distribution
of the data to evaluate the influence of potential outliers, skewness, and
kurtosis. All variables were normally distributed. Because the avoidance
measures (AAQ and IES-A) are scaled differently, a z-score composite
variable was computed for the avoidance variable used in all analyses.
Next, bivariate correlations and independent samples t-tests were conducted in order to examine the inter-relationships among variables and
determine whether participants with a history of CSA reported higher
levels of avoidance and psychological distress than participants who denied a history of CSA.
The multiple regression strategy outlined by Baron and Kenny
(1986) and Holmbeck (1997) was used to test avoidance as a mediator
in the relationship between severity of CSA and psychological distress.
According to Baron and Kenny, four statistical criteria must be met to
establish a variable as a mediator, and these four conditions can be
tested using a series of regression analyses (Holmbeck, 1997). First,
there must be a significant relationship between the predictor variable
(severity of CSA) and the mediator (avoidance). Second, a significant
relationship must be established between the predictor and the dependent variable (psychological distress). Third, the mediator must be significantly related to the dependent variable. Fourth, the relationship
between the predictor and the dependent variable must be significantly
reduced when the mediator is added to the regression equation. Sobel’s
(1982) formula was used to test whether the association between severity of CSA and psychological distress was significantly reduced after
adding avoidance to the regression equation. In order to reduce the
probability of committing a Type I error, a Bonferroni-correction procedure was used whereby .05 was divided by the number of tests. Thus,
the alpha level was set at .008.
Bivariate Correlations and t-Tests
The bivariate correlations among the variables are presented in Table 2. Of the eight Pearson correlations, all but one were significant at
the p < .008 level. The relationship between severity of CSA and one
measure of avoidance (IES-A) approached significance (p = .009). Two
independent samples t-tests were conducted using CSA status (0 = no;
1 = yes) as a between groups variable. As hypothesized, compared to
participants with no reported history of CSA, those who reported a his-
34
JOURNAL OF CHILD SEXUAL ABUSE
TABLE 2. Pearson Correlation Coefficients Among All Variables
Measure
1
1. CSA-Sev
2. IES-A
3. AAQ
4. AVD-Z
2
3
4
5
.22
.30*
.33*
.34*
.37*
N/A
.48*
N/A
.59*
.64*
5. TSI
*p < .008
Note: CSA-Sev = Severity of childhood sexual abuse; IES-A = Impact of Events-Avoidance
Scale; AAQ = Acceptance and Action Questionnaire total score; AVD-Z = Avoidance z-score;
TSI = Trauma Symptom Inventory total score; N/A = Not Applicable. This notation is used because AAQ and IES-A are combined to form AVD-Z.
tory of CSA had higher scores on the TSI (no CSA M = 61.62, SD =
37.94; CSA M = 94.35, SD = 54.56; t (73.21) = 3.81, p < .008) and
avoidance z-score (no CSA M = ⫺0.48, SD = 1.43; CSA M = 0.67, SD =
1.67; t (144) = 4.33, p < .008).
Mediational Model
The first step of the mediational test involved examining the relationship between avoidance (the mediating variable) and severity of CSA
(the predictor variable). This model was significant, R2 = .11, F(1, 144) =
17.52, p < .008. Specifically, severity of CSA significantly predicted
avoidance (β = .33). Thus, the first criterion for mediation as defined by
Baron and Kenny (1986) was met.
The second step of the mediational test involved examining the relationship between avoidance (the mediating variable) and psychological
distress (the dependent variable). This model was significant, R2 = .41,
F(1, 144) = 101.34, p < .008. Specifically, avoidance significantly predicted psychological distress (β = .64). Thus, the second criterion for mediation was met.
The third step of the mediational test involved examining the relationship between severity of CSA (the predictor variable) and psychological
distress (the dependent variable). This model was significant, R2 = .12,
F(1, 149) = 19.41, p < .008. Specifically, severity of CSA significantly
predicted psychological distress (β = .34). Thus, the third criterion for mediation was met.
Rosenthal et al.
35
The final step, as described by Baron and Kenny (1986), is a test of
the relationship between the predictor variable and the dependent variable when the mediating variable is included in the model. The prediction in this case was that the magnitude of the relationship between the
severity of CSA and psychological distress would be reduced or no longer be significant when avoidance was included in the model.
To test this, psychological distress (the dependent variable) was regressed onto avoidance (the mediating variable) in the second step, after
entering severity of CSA (the predictor) in step one of the equation. The
results of this model were significant in step two, R2 = .44, F(2, 143) =
55.19, p < .008. As hypothesized, avoidance (β = .59, p < .008) remained significant over and above the effects of severity of CSA. Additionally, consistent with the prediction of mediation, severity of CSA
was no longer a significant predictor in step two (β = .16, ns).
To test the mediational effect of avoidance on the relationship between severity of CSA and psychological distress, a direct significance
test was conducted with a formula used to test the joint significance of
the pathways in this mediation (MacKinnon & Dwyer, 1993). This test,
which results in a z-score, was significant (z = 3.81, p < .008), indicating
that avoidance fully mediated the relationship between severity of CSA
and psychological distress.
Results of the regression analyses are shown in the path diagram in
Figure 1. The direct effect of CSA severity on psychological distress is
represented by the standardized coefficient for path C ( = .34). The indirect effect of CSA severity on psychological distress is computed by
FIGURE 1. Path Diagram of Regression Analyses (Standardized Beta Weights)
Showing Avoidance as a Mediator of the Relationship between CSA Severity
and Psychological Distress.
Avoidance
(B)
(A)
.64
.33
Psychological
Distress
CSA Severity
.34
(C)
36
JOURNAL OF CHILD SEXUAL ABUSE
multiplying the standardized coefficients of paths A and B that link
CSA severity to psychological distress through avoidance, = .33, =
.64 (.33 ⫻ .64 = .21). In sum, this study suggests that avoidance accounted for 21% of the total effect of CSA severity on psychological
distress.
DISCUSSION
There is growing interest in avoidance as a problematic means of regulating affect among individuals who present with a variety of psychiatric problems (e.g., Bach & Hayes, 2002; Cheavens et al., in press;
Roemer & Orsillo, 2002; Rosenthal, Cheavens, Lejuez, & Lynch, in
press; Rosenthal, Cheavens, Compton, Thorp, & Lynch, in press). More
specifically, some researchers describe avoidance as an important construct that helps explain how exposure to traumatic events can lead to
subsequent problems (e.g., Batten et al., 2001; Polusny & Follette,
1995; Polusny et al., 2004). In order to treat avoidance as a maladaptive
emotion regulation style in trauma survivors, a clearer understanding of
its role in the development and maintenance of problems associated
with sexual trauma is essential. To date, empirical investigation of
avoidance and its relationship to traumatic stress is limited. However,
the current study represents one of a growing number of recent studies
examining the role of avoidance in the lives of women with a history of
sexual trauma.
In this study, the tendency to chronically avoid or escape unpleasant
internal experiences (i.e., avoidance) mediated the relationship between
severity of CSA and trauma-related psychological distress in adulthood.
Previous studies have reported the association between higher avoidance and psychological maladjustment among individuals with a history of sexual victimization (Batten et al., 2001). In addition, two
studies found that avoidance mediated the relationship between sexual
victimization and psychological distress (Marx & Sloan, 2002; Polusny
et al., 2004). These studies have important limitations. First, the interrelationships among severity of CSA, avoidance, and distress have not
been investigated. This may be due, in part, to the lack of a standard
measure of CSA severity. However, researchers recently have begun to
utilize CSA severity indices in order to more comprehensively investigate the relationship between CSA and negative outcomes (e.g., Merrill
et al., 2003; Zanarini et al., 2002). Second, previous studies testing
Rosenthal et al.
37
mediational models did not examine traumatic stress symptoms, and instead used measures of global psychological maladjustment. Although
general psychological distress is one of the correlates of CSA, it is also
important to test those symptoms and behaviors that may be more specific to the effects of sexual trauma exposure. The current study extends
upon previous research by examining avoidance as a mediator between
CSA severity and traumatic stress symptoms.
Findings from this study suggest that individuals who report a history
of sexual victimization before the age of 14 may report more trauma-related symptoms of distress when avoidance is used as a primary method
of regulating aversive cognitions and emotions. Frequent attempts to
avoid or escape unpleasant internal experiences may be a particularly
common emotion regulation strategy among individuals with a history
of CSA (Batten et al., 2001). Because of shame and guilt associated
with CSA, as well as the social stigma of such experiences, it is likely
that individuals with histories of sexual trauma would attempt to escape
from or avoid memories or associated thoughts and feelings through
various means. Further, as the severity of the CSA increases, an individual may be even more motivated to block out or not experience intense
thoughts and feelings related to the trauma. Although avoidance strategies may temporarily prevent unpleasant experiences, findings from
this study suggest that when used chronically, avoidance may be a regulation style that underlies trauma-related psychological distress.
Appropriate caution should be used in interpreting these findings.
First, the results of this study cannot be generalized well beyond a
non-clinical, mostly Caucasian, university sample of women. Additional
research is needed to replicate findings from this study using ethnically
diverse and clinical samples of women with a history of sexual victimization. Furthermore, research on the mediational role of avoidance in men
with a history of CSA is warranted in order to explore the relationship between gender, distress, and avoidance. Second, the cross-sectional design
of this study does not allow conclusions to be drawn about causality. In
order to draw more robust inferences regarding the mediational role of
avoidance, prospective studies are needed. Third, sexual victimization
was reported retrospectively in this study, and it is important to note that
this type of report could be influenced by current affective states or other
unknown variables not assessed in this study. Fourth, in addition to
avoidance, there are likely other variables that play an important mediating role in the relationship between victimization and distress. Other
types of emotion regulation strategies, for example, may also contribute
to the development and maintenance of both traumatic stress symptoms
38
JOURNAL OF CHILD SEXUAL ABUSE
and psychopathology. Future studies should more comprehensively examine regulation processes among individuals with a history of sexual
victimization.
In addition to providing empirical support for avoidance as an important link between CSA severity and symptoms of traumatic stress in
adulthood, these findings have potential implications for treatments of
traumatic stress that target the reduction of avoidance. Recently, some
trauma researchers have identified a need for augmenting exposure
therapies with acceptance-based treatment components from Dialectical Behavior Therapy (DBT; Linehan, 1993) and Acceptance and Commitment Therapy (ACT; Hayes et al., 1999) in order to address the
complicated clinical presentations of some survivors of sexual victimization (e.g., Becker & Zayfert, 2001; Cloitre, Koenen, Cohen, & Han,
2002; Orsillo & Batten, in press; Palm & Follette, 2000). Other researchers also are recognizing the value of incorporating acceptance
into the treatment of psychopathology more generally (e.g., Koerner,
Jacobson, & Christensen, 1994; Linehan, 1993; Hayes et al., 1999).
Findings from this study are consistent with previous studies and lend
further support to the clinical hypothesis that chronic avoidance of
thoughts and emotions may be an important treatment target for some
trauma survivors. Empirical support for such clinical and theoretical observations is essential in order to support the development of efficacious
and effective treatments for those with a history of CSA.
REFERENCES
Bach, P., & Hayes, S. C. (2002). The use of acceptance and commitment therapy to prevent the rehospitalization of psychotic patients: A randomized controlled trial. Journal of Consulting & Clinical Psychology, 70, 1129-1139.
Bal, S., Van Oost, P., De Bourdeaudhuij, I., & Crombez, G. (2003). Avoidant coping as
a mediator between self-reported sexual abuse and stress-related symptoms in adolescents. Child Abuse and Neglect, 27, 883-897.
Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in
social psychological research: Conceptual, strategic, and statistical considerations.
Journal of Personality & Social Psychology, 51, 1173-1182.
Batten, S. V., Follette, V. M., & Aban, I. B. (2001). Experiential avoidance and
high-risk sexual behavior in survivors of child sexual abuse. Journal of Child Sexual
Abuse, 10, 101-120.
Becker, C. B., & Zayfert, C. (2001). Integrating DBT-based techniques and concepts to
facilitate exposure treatment for PTSD. Cognitive & Behavioral Practice, 8, 107-122.
Rosenthal et al.
39
Boeschen, L. E., Koss, M. P., Figueredo, A. J., & Coan, J. A. (2001). Experiential
avoidance and posttraumatic stress disorder: A cognitive mediational model of rape
recovery. Journal of Aggression, Maltreatment & Trauma, 4, 211-245.
Bond, F. W., & Bunce, D. (2003). The role of acceptance and job control in mental
health, job satisfaction, and work performance. Journal of Applied Psychology, 88,
1057-1067.
Briere, J., Elliot, D. M., Harris, K., & Cotman, A. (1995). Trauma Symptom Inventory:
Psychometrics and association with childhood and adult victimization in clinical
samples. Journal of Interpersonal Violence, 10, 387-401.
Browne, A., & Finkelhor, D. (1986). Impact of child sexual abuse: A review of the research. Psychological Bulletin, 99, 66-77.
Cheavens, J. S., Rosenthal, M. Z., Daughters, S. D., Novak, J., Kosson, D., Lynch, T.
R., & Lejeuz, C. (in press). An analogue investigation of the relationships among
perceived parental criticism, negative affect, and borderline personality disorder
features: The role of thought suppression. Behavior Research and Therapy.
Cloitre, M., Koenen, K. C., Cohen, L. R., & Han, H. (2002). Skills training in affective
and interpersonal regulation followed by exposure: A phase-based treatment for
PTSD related to childhood abuse. Journal of Consulting & Clinical Psychology, 70,
1067-1074.
Craske, M. G., & Hazlett-Stevens, H. (2002). Facilitating symptom reduction and behavior change in GAD: The issue of control. Clinical Psychology: Science and Practice, 9, 69-75.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and Commitment
Therapy: An experiential approach to behavior change. New York: Guilford Press.
Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach
to diagnosis and treatment. Journal of Consulting & Clinical Psychology, 64, 11521168.
Hayes, S. C., Strosahl, K. D., Wilson, K. G., Bissett, R. T., Pistorello, J., Toarmino, D.
et al. (in press). Measuring experiential avoidance: A preliminary test of a working
model. The Psychological Record.
Holmbeck, G. N. (1997). Toward terminological, conceptual, and statistical clarity in the
study of mediators and moderators: Examples from the child-clinical and pediatric
psychology literatures. Journal of Consulting & Clinical Psychology, 65, 599- 610.
Horowitz, M., Wilner, N., & Alvarez, W. (1979). Impact of event scale: A measure of
subjective stress. Psychosomatic Medicine, 41, 209-218.
Koerner, K., Jacobson, N.S., & Christensen, A. (1994). Emotional acceptance in integrative behavioral couple therapy. In S.C. Hayes, N.S. Jacobson, V.M. Follette, &
M.J. Dougher (Eds.), Acceptance and change: Content and context in psychotherapy (pp.109-118). Reno, NV: Context, Press.
Krause, E. D., Mendelson, T., & Lynch, T. R. (2003). Childhood emotional invalidation and adult psychological distress: The mediating role of emotional inhibition.
Child Abuse & Neglect, 27, 199-213.
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: The Guilford Press.
40
JOURNAL OF CHILD SEXUAL ABUSE
Lynch, T. R., Cheavens, J. S., Morse, J. Q., & Rosenthal, M. Z. (in press). A model predicting suicidal ideation and hopelessness in depressed older adults: The impact of
emotion inhibition and affect intensity. Aging and Mental Health.
Lynch, T. R., Robins, C. J., Mendelson, J. Q., & Krause, E. D. (2001). A mediational
model relating affect intensity, emotion inhibition, and psychological distress. Behavior Therapy, 32, 519-536.
MacKinnon, D. P., & Dwyer, J. H. (1993). Estimating mediated effects in prevention
studies. Evaluation Review, 17, 144-158.
Marx, B. P., & Sloan, D. M. (2002). The role of emotion in the psychological functioning of adult survivors of childhood sexual abuse. Behavior Therapy, 33, 563-577.
Merrill, L. L., Guimond, J. M., Thomsen, C. J., & Milner, J. S. (2003). Child sexual
abuse and number of sexual partners in young women: The role of abuse severity,
coping style, and sexual functioning. Journal of Consulting & Clinical Psychology,
71, 987-996.
Nash, M. R., Hulsey, T. L., Sexton, M. C., Harralson, T. L., & Lambert, W. (1993).
Long-term sequelae of childhood sexual abuse: Perceived family environment,
psychopathology, and dissociation. Journal of Clinical & Consulting Psychology, 61,
276-283.
Orsillo, S. M., & Batten, S. V. (in press). Acceptance and commitment therapy for
posttraumatic stress disorder. Behavior Modification.
Palm, K. M., & Follette, V. M. (2000). Counseling strategies for adult survivors of
childhood sexual abuse. Current Directions in Clinical Psychology, 11, 49-60.
Polusny, M. A., & Follette, V. M. (1995). Long-term correlates of child sexual abuse:
Theory and review of the empirical literature. Applied & Preventive Psychology, 4,
143-166.
Polusny, M. A., Rosenthal, M. Z., Aban, I., & Follette, V. M. (2004). Experiential
avoidance as a mediator of the effects of adolescent sexual victimization on adult
psychological distress. Violence and Victims, 19, 1-12.
Proulx, J., Koverola, C., Fedorowicz, A., & Kral, M. (1995). Coping strategies as predictors of distress in survivors of single and multiple sexual victimization and
nonvictimized controls. Journal of Applied Social Psychology, 25, 1464-1483.
Rind, B., Tromovitch, P., & Bauserman, R. (1998). A meta-analytic examination of assumed properties of child sexual abuse using college samples. Psychological Bulletin, 124, 22-53.
Roemer, L., & Orsillo, S. M. (2002). Expanding our conceptualization of and treatment
for generalized anxiety disorder: Integrating mindfulness/acceptance-based approaches with existing cognitive-behavioral models. Clinical Psychology: Science &
Practice, 9, 54-68.
Roemer, L., Litz, B. T., Orsillo, S. M., & Wagner, A. W. (2001). A preliminary investigation of the role of strategic withholding of emotions in PTSD. Journal of Traumatic Stress, 14, 149-156.
Rosenthal, M. Z., Polusny, M. A., & Follette, V. M. (in press). Avoidance mediates the
relation between perceived criticism in the family of origin and psychological distress in adulthood. Journal of Emotional Abuse.
Rosenthal et al.
41
Rosenthal, M. Z., Cheavens, J. S., Lejuez, C. W., & Lynch, T. R. (in press). Thought
suppression mediates the relationship between negative affect and borderline personality disorder symptoms. Behaviour Research and Therapy.
Rosenthal, M. Z., Cheavens, J. S., Compton, J. S., Thorp, S. R., & Lynch, T. R. (in
press). Thought suppression and treatment outcome in late-life depression. Aging
and Mental Health.
Runtz, M. G., & Schallow, J. R. (1997). Social support and coping strategies as mediators of adult adjustment following childhood maltreatment. Child Abuse & Neglect,
21, 211-226.
Sobel, M. E. (1982). Asymptotic confidence intervals for indirect effects in structural
equation models. In S. Leinhardt (Ed.), Sociological methodology 1982 (pp. 290312). Washington, DC: American Sociological Association.
Spaccarelli, S. (1994). Stress, appraisal, and coping in child sexual abuse: A theoretical
and empirical review. Psychological Bulletin, 116, 340-362.
Stasiewicz, P. R., & Maisto, S. A. (1993). Two-factor avoidance theory: The role of
negative affect in the maintenance of substance use and substance use disorder. Behavior Therapy, 24, 337-356.
Sundin, E. C., & Horowitz, M. J. (2002). Impact of Event Scale: Psychometric properties. British Journal of Psychiatry, 180, 205-209.
Vogeltanz, N. D., Wilsnack, S. C., Harris, T. R., Wilsnack, R. W., Wonderlich, S. A., &
Kristjanson, A. F. (1999). Prevalence and risk factors for childhood sexual abuse in
women: National survey findings. Child Abuse & Neglect, 23, 579-592.
Wyatt, G. (1988). Wyatt Sexual History Questionnaire. University of California, Los Angeles.
Wyatt, G. E., Lawrence, J., Vodounon, A., & Mickey, M. R. (1992). The Wyatt Sex
History Questionnaire: A structured interview for female sexual history taking.
Journal of Child Sexual Abuse, 1, 51-68.
Zanarini, M. C., Yong, L., Frankenburg, F. R., Hennen, J., Reich, D. B., Marino, M. F.,
& Vujaniovic, A. (2002). Severity of reported childhood sexual abuse and its relationship to severity of borderline psychopathology and psychosocial impairment
among borderline inpatients. Journal of Nervous & Mental Disease, 190, 381-387.