Interpersonal problems in the context of early chronic interpersonal trauma

(1990) noted that “individual differences in styles of interpersonal interaction are the

fundamental phenomena that attachment theory is designed to explain” (p. 169). Moreover, she postulated that it is interpersonal mechanisms through which internal working models of the self and the other are expressed and maintained. It therefore appears likely that

individuals who were assaulted at an early stage of development and who did not have the opportunity to establish secure attachment with a caregiver will face immediate and long- term difficulties in the interpersonal domain. The term ‘interpersonal problems’ describes various behavioral and emotional difficulties encountered by individuals in interactions with other people. The interpersonal areas that are supposed to be affected by experiences of abuse include a wide array of the survivor’s “relationships with particular individuals in their lives (e.g., spouses and partners, friends, children, and other family members), as well as the many dimensions upon which those relationships might be impacted . . . (e.g., communication, trust, intimacy, etc.)” (DiLillo, 2001, p. 561). The following section introduces several theoretical assumptions as to why and how early chronic interpersonal trauma may lead to interpersonal problems. Subsequently, empirical evidence regarding the connection between early chronic interpersonal trauma and disturbances in the interpersonal domain will be reviewed.

1.6.1 Hypotheses about interpersonal problems in adulthood following childhood abuse

Attachment theory is one of several theoretical frameworks that have been applied to explain the link between childhood abuse and impaired adult interpersonal functioning. Bartholomew (1990), for example, argued that interpersonal problems are related to the attachment patterns individuals have established in the course of their development. Other approaches include

theoretical concepts by Finkelhor and Browne (1985), Briere (1992b) and Polusny and

Follette (1995). Finkelhor and Browne (1985) propose four concurrent traumagenic dynamics which set in when a child is exposed to sexual abuse and which lead to the distinctive effects of this type of trauma. These four dynamics include traumatic sexualization, betrayal,

powerlessness and stigmatization. According to Briere (1992b), continuous sexual abuse in childhood leads to interpersonal problems in three steps. The first step comprises immediate reactions to the abuse, involving posttraumatic stress, cognitive distortions and disturbances in psychological development. In the second step, accommodation processes to the ongoing abuse and coping behaviors (e.g., avoidance, passivity, sexualization) set in with the aim to reduce pain and to increase the feeling of safety. The third step includes long-term

consequences of abuse which reflect the impact of the immediate reactions to the abuse as well as their subsequent impact on the individual’s psychological development. The ongoing presence of these long-term effects in adulthood is presumed to interfere with daily

interpersonal functioning and to prevent the adult from gaining support from interpersonal relationships (Briere 1992b). Polusny and Follette (1995) developed a model that explains the connection between childhood sexual abuse and its long-term effects on the basis of

inadequate coping strategies that are rooted in emotional avoidance. Examples for such coping strategies include dissociation, self-mutilation, substance abuse, casual sexual relationships, and avoidance of intimate relationships. Even though these behaviors may provide initial relief to the survivor’s distress, on the long run they are likely to be followed by negative reactions such as feelings of social isolation, sexual dysfunction and

revictimization.

Interpersonal problems are considered to be a complex sequel of early and repeated trauma (van der Kolk et al., 2005), which is why they constitute one of the DESNOS subcategories (see section 1.4.2).

1.6.2 Evidence for interpersonal problems following early-onset interpersonal trauma

General problems in the interpersonal domain. Many adult survivors of childhood abuse report difficulties in establishing and maintaining social relationships. Levitt and Cloitre (2005) reported that interpersonal problems are the most frequently cited reason for seeking treatment among women with histories of childhood abuse. These disturbances include a

poorer understanding of social causality (Callahan et al., 2003; Kernhof et al., 2008), low self-esteem as well as being shy, uneasy, and self-conscious or misunderstood in

interpersonal relationships (Callahan et al., 2003). Women sexually abused in childhood describe themselves as overly solicitous and exploitable (Kernhof et al., 2008) and as having more problems with being assertive compared to women without histories of sexual abuse (Cloitre et al., 1997). At the same time, Cloitre et al. (1997) found sexually abused women to show higher degrees of control and responsibility than non-abused women. The authors argue that these results indicate confusion about power dynamics in interpersonal relationships as for the abused individual it might not be clear when to be submissive and when to take control and responsibility over a situation. Such a constellation of problems may make these women particularly prone to conflicts in relationships and further sexual or physical assaults (Kernhof et al., 2008). Indeed, a large number of investigations indicated that survivors of early chronic interpersonal trauma are at increased risk of revictimization. This means that they are at risk of experiencing further sexual or physical assaults after the exposure to the initial traumatic event (e.g., Banyard, Williams, & Siegel, 2001; Dietrich, 2007; Messman- Moore & Long, 2000; Nishith, Mechanic, & Resick, 2000; Noll, Horowitz, Bonanno, Trickett, & Putnam, 2003; Sanders & Moore, 1999). In turn, repeated exposure to interpersonal trauma makes individuals particularly likely to develop PTSD, a greater severity of PTSD symptoms (Follette & Vijay, 2008; Nishith et al., 2000, Ozer et al., 2003) as well as other mental health problems (Banyard et al., 2001) compared to a single trauma exposure (for a review, see Classen, Palesh, & Aggarwal, 2005). On the one hand, it is contextual or environmental factors which continue to put the individual at risk of further exposure to traumatic stressors (e.g., growing up in a dysfunctional family environment) (Banyard et al., 2001). On the other hand, psychological consequences of the initial traumatic experience, such as the previously described interpersonal problems, may contribute to retraumatization (Dietrich, 2007).

Intimate partner relationships and sexual functioning. Studies involving women with histories of childhood sexual abuse suggest that their interpersonal problems are often related to intimate partner relationships and sexual functioning (e.g., Davis & Petretic-Jackson, 2000; DiLillo & Long, 1999; Rumstein-McKean & Hunsley, 2001). This notion is consistent with the view promoted by attachment theorists saying that early disruptions of interpersonal

bonds by childhood abuse are likely to be followed by insecure attachment in adulthood, particularly with regard to intimate relationships. According to the empirical evidence, survivors of childhood sexual abuse are prone to sexual dysfunction (Davis & Petretic- Jackson, 2000), lower satisfaction in intimate relationships, a lower level of trust in their partners and a poorer communication between partners (DiLillo & Long, 1999). Furthermore, they report engagement in high-risk sexual activities (e.g., increased number of sexual

relationships, lower use of contraception measures, prostitution) as well as a lack of sexual satisfaction (for a review, see DiLillo, 2001). Evidence of elevated rates of separation and divorce in samples of survivors of childhood sexual abuse serves as a further indicator of low interpersonal functioning in intimate partner relationships (Mullen, Martin, Anderson,

Romans, & Herbison, 1994).

1.6.3 Implications of the evidence

The empirical literature seems to largely agree on the conclusion that early chronic

interpersonal trauma is linked to interpersonal problems in various contexts that non-abused individuals are not affected by. However, most of these studies solely compared individuals who reported early-onset interpersonal trauma with individuals who did not report any traumatic experience. Thus, no clear conclusions can be made as to whether interpersonal problems are specific to early-onset and chronic interpersonal trauma or whether they occur in all types of interpersonal trauma. Direct comparisons of different types of interpersonal trauma with regard to both attachment insecurity and interpersonal problems are rare even though they could provide valuable information about, for example, the role of age of onset and chronicity of physical or sexual abuse in the development of interpersonal disturbances. A better understanding of this relationship could support the development of more specific interventions targeting interpersonal problems that arise as a consequence of particular forms of interpersonal trauma. For this reason, the present investigation will seek to relate both the degree of attachment insecurity as well as interpersonal problems to the type of interpersonal trauma that individuals have experienced.

Apart from the lack of consideration of different trauma types, studies on the consequences of interpersonal trauma are also affected by a number of methodological problems that limit the conclusions that these studies permit as well as the generalizability of their results. Thus,

before describing the empirical study that is part of this thesis, the most apparent of these problems and their implications will be reviewed.

1.7 Methodological problems of research on the psychological consequences of early