Psychological Trauma: Theory, Research, Practice, and Policy 2011, Vol. 3, No.

1, 84 93

2010 American Psychological Association 1942-9681/10/$12.00 DOI: 10.1037/a0020096

A Comparison of Trauma-Focused and Present-Focused Group Therapy for Survivors of Childhood Sexual Abuse: A Randomized Controlled Trial
Catherine C. Classen
University of Toronto

Oxana Gronskaya Palesh

University of Rochester

Courtenay E. Cavanaugh
Johns Hopkins University

Cheryl Koopman
Stanford University School of Medicine

Jennifer W. Kaupp
University of California, Santa Cruz

Helena C. Kraemer
Stanford University School of Medicine

Rashi Aggarwal
New Jersey Medical School

David Spiegel
Stanford University School of Medicine

This randomized controlled trial compared trauma-focused group psychotherapy (TFGT) with presentfocused group psychotherapy (PFGT) and a waitlist condition for 166 survivors of childhood sexual abuse who were at risk for HIV infection. Primary outcomes included risk for HIV infection (based on sexual revictimization, drug and alcohol use, and risky sex) and posttraumatic stress disorder (PTSD) symptoms. It was hypothesized that TFGT would be superior to the PFGT and waitlist conditions and that receiving either treatment (combining both TFGT and PFGT) would be superior to no treatment (waitlist condition). Intention-to-treat analyses for HIV risk found that all conditions reduced risk; however, there was no effect for condition on HIV risk. Intention-to-treat analyses for PTSD symptoms found a reduction for all conditions. There was no advantage for either TFGT or PFGT in reducing PTSD symptoms; however, there was an effect for treatment compared with the waitlist condition. On secondary outcomes, there was a greater reduction in anger for TFGT compared with PFGT, and when comparing treatment with the waitlist condition, there was a greater reduction in hyperarousal, reexperiencing, anger, and impaired self-reference for the treatment condition. Adequate dose analyses generally confirmed the intention-to-treat findings and additionally found that treatment led to reductions in depression, dissociation, and sexual concerns. Keywords: randomized controlled trial, HIV, addiction, PTSD, childhood sexual abuse

Child sexual abuse (CSA) is associated with numerous adverse consequences, including risk for HIV infection. CSA has been linked to sexual revictimization (Arriola, Louden, Doldren, & Fortenberry, 2005; Classen, Palesh, & Aggarwal, 2005), risky sex (Arriola et al., 2005; Senn, Carey, & Vanable, 2008; Testa,

VanZile-Tamsen, & Livingston, 2005), and addiction to drugs or alcohol (Molnar, Buka, & Kessler, 2001), all of which are associated with risk for HIV infection (Huba et al., 2003; Morrill, Kasten, Urato, & Larson, 2001; Rees, Saitz, Horton, & Samet, 2001; Tucker, Wenzel, Elliott, Marshall, & Williamson, 2004;

This article was published Online First September 20, 2010. Catherine C. Classen, Department of Psychiatry, University of Toronto; Oxana Gronskaya Palesh, Department of Radiation Oncology, University of Rochester; Courtenay E. Cavanaugh, Department of Mental Health, Johns Hopkins University; Cheryl Koopman, Helena C. Kraemer, and David Spiegel, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine; Jennifer W. Kaupp, Department of Psychology, University of California, Santa Cruz; and Rashi Aggarwal, Department of Psychiatry, New Jersey Medical School. This study was funded by Grant MH60556 from the National Institute of Mental Health, David Spiegel, Principal Investigator. Portions of this study were previously presented at the annual meetings of the American Psychiatric Association in May 2003, the American Psychological Association in August 2003, the International Society for Traumatic 84

Stress Studies in November 2004 and 2007, and the International Society for the Study of Dissociation in November 2004. This study was conducted in the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine. We wish to acknowledge the contributions of Helen Marlo, Lori Peterson, Ruth Nevo, Renee Schneider, Meg Marnell, Louise Gaston, the many research assistants and interviewers involved in this project, the therapists and supervisors, as well as Stephanie Brown and Mary Koss for their consultation. A sincere debt of gratitude is owed to all the women who participated in this research. Correspondence concerning this article should be addressed to Catherine C. Classen, Womens College Hospital, 76 Grenville Street, 9th Floor, Toronto, ON, Canada, M5S 1B2. E-mail: catherine.classen@ wchospital.ca

GROUP THERAPY FOR SURVIVORS OF CHILDHOOD SEXUAL ABUSE

85

Zierler et al., 1991). Numerous psychological consequences include posttraumatic stress disorder (PTSD) (Rodriguez, VandeKemp, & Foy, 1998), depression (Weiss, Longhurst, & Mazure, 1999), anxiety (Heath, Bean, & Feinauer, 1996), affect dysregulation (Shipman, Zeman, Penza, & Champion, 2000), identity confusion (Roche, Runtz, & Hunter, 1999), and interpersonal problems (DiLillo, Tremblay, & Peterson, 2000). Group psychotherapy is a widely used treatment for CSA survivors (Herman & Schatzow, 1984; Kessler, White, & Nelson, 2003), but there are relatively few randomized controlled trials (RCTs) that examine efficacy (Alexander, Neimeyer, Follette, Moore, & Harter, 1989; Lau & Kristensen, 2007; Sikkema et al., 2004, 2007; Spiegel, Classen, Thurston, & Butler, 2004; Stalker & Fry, 1999; Wyatt et al., 2004; Zlotnick et al., 1997). The existing body of RCTs suggests that group psychotherapy is effective in reducing depression, PTSD symptoms, dissociation, affect dysregulation, psychological distress, and possibly sexual revictimization. It may also improve interpersonal skills, global functioning, and quality of life. Although research indicates a higher prevalence of HIV risk behaviors among CSA survivors, only two of these RCTs targeted survivors who engage in these behaviors (Sikkema et al., 2007; Wyatt et al., 2004), and those studies focused specifically on CSA survivors who were HIV-positive. They found group psychotherapy was effective in reducing intrusion and avoidance symptoms (Sikkema et al., 2007), reducing sex risk behaviors (Wyatt et al., 2004), and improving medication adherence (Wyatt et al., 2004). To our knowledge, there is no study that has investigated interventions for HIV-negative CSA survivors at risk for HIV infection. We have evidence that group therapy is effective with CSA survivors, but we do not know why these treatments work. In other words, what are the active ingredients? Thus, along with targeting at-risk CSA survivors, research is needed to determine the essential components of a group intervention for CSA survivors. Working with memories of trauma or exposure is one component that is common across many of these RCT treatments. However, there is little research that has addressed whether memory work in a group therapy context is beneficial for CSA survivors. One group treatment RCT examined the efficacy of traumafocused group therapy (TFGT) compared with a present-focused group therapy (PFGT) and did not find evidence that TFGT is more effective in treating PTSD symptomatology (Schnurr et al., 2003). The researchers used a cognitive behavioral therapy approach that included exposure and cognitive restructuring, with each participant having two to three sessions scheduled to devote to their trauma. This study was with war veterans and did not address risky behaviors. Whether a trauma-focused group treatment is more effective in reducing PTSD symptoms and risky behaviors among CSA survivors is an unanswered question. This RCT compared TFGT with PFGT in reducing HIV risk and PTSD symptoms in a sample of CSA survivors. Women who met criteria for substance abuse/dependence, experienced sexual revictimization, or who had risky sex, each within the previous year, were considered at risk for HIV infection. We hypothesized that the TFGT condition would show a greater reduction of HIV risk factors and total PTSD symptoms compared with the PFGT condition. Furthermore, we hypothesized that treatment (TFGT and PFGT combined) would result in a greater reduction in HIV risk and total PTSD symptoms compared with the waitlist condition.

Method Design
Participants were recruited through advertisements in newspapers and community centers, public service announcements, and fliers in the San Francisco Bay Area. A total of 448 women were assessed for eligibility, and 166 met eligibility criteria and agreed to participate. Eligibility was reviewed and confirmed by the project director (CCC). All participants gave informed consent approved by the Stanford University School of Medicine Institutional Review Board. The protocol was compliant with the Health Insurance Portability and Accountability Act. See Figure 1 for a breakdown of the flow of participants through the study. Inclusion criteria were female, 18 years of age or older, English speaking, at least one explicit memory of CSA involving genital or anal contact, at least one CSA event between ages 4 and 17, perpetrator at least 5 years older, and ability to talk about the abuse in group therapy. In addition, they had to meet at least one of the following criteria within the previous year: (a) been sexually victimized (defined as meeting behavioral definitions for having experienced sexual coercion, attempted rape or rape, or having otherwise engaged in unwanted sex), (b) engaged in risky sex (defined as having unprotected sex with an unsafe partner, which is a partner of less than 12 months whose HIV status is unknown or who is known to have other sexual partners or to use intravenous drugs), or (c) met Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSMIV) criteria for substance abuse or dependence as determined by the Structured Clinical Interview for DSMIV Axis I Disorders (First, Spitzer, Gibbon, & Williams, 1995). Participants were excluded if they had a psychotic or cognitive disorder, reported ritual abuse, were currently receiving psychotherapy, were actively suicidal within the previous month (indicating that they had thoughts of killing themselves in the past month and were at high risk for doing so), or were judged inappropriate for group therapy (e.g., behaviorally or verbally threatening, hostile, or intoxicated at the screening or baseline assessment). Following completion of the baseline assessment, cohorts of 24 participants were randomly assigned to one of three conditions: TFGT, PFGT, or a waitlist condition, resulting in eight women per group. Altogether, there were seven cohorts. Randomization was performed by the project director by pulling numbers from a hat. Participants were paid $25 for baseline and posttreatment assessments and $50 for the 6-month follow-up. Participants were invited to complete an additional set of questionnaires at baseline and the 6-month follow-up; 148 women agreed and were paid $50 for each assessment. Recruitment was from March 2000 to July 2002. Follow-up assessments occurred between September 2001 and February 2004; 141 women (85%) provided follow-up data. Research assistants conducting follow-up assessments were blind to condition.

Participants
Demographic variables are described in Table 1. There were no statistically significant differences between groups on any demographic variables. Of the 166 eligible participants, 148 women provided information on their abuse, including age of first abuse

86

CLASSEN ET AL.

Assessed for Eligibility (n = 448) Excluded (n=282) Did not meet inclusion criteria (n=133) Did not complete baseline assessment (n=128) Was a health risk (n=3) Uncomfortable in groups (n=7) Not interested (n=3) Stopped the screening interview (3) Planned to move away (n=2) Unknown reason (n=3)

Randomized (n = 166)

Allocated to trauma-focused intervention (n=55) Received allocated intervention (n=39) Did not receive allocated intervention (n=16) Could not make group times (n=2) No correct contact information (n=1) Unknown reason (n=13)

Allocated to present-focused intervention (n=56) Received allocated intervention (n=47) Did not receive allocated intervention (n=9) No correct contact information (n=2) Unknown reason (n=7)

Allocated to waitlist condition (n=55)

Lost to follow-up (n=7) No correct contact information (n=1) Could not make group times (n=2) Unknown reason (n=4)

Lost to follow-up (n=9) Unknown reason (n=9)

Lost to follow-up (n=9) No correct contact information (n=1) Unknown reason (n=8)

Analyzed (n=55)

Analyzed (n=56)

Analyzed (n=55)

Figure 1. Flow diagram of participants.

experience (M 6.65 years, SD 3.05), duration of abuse (M 7.71 years, SD 6.58 years), and number of years since it ended (M 20.55 years, SD 10.64). There were no differences between the groups on abuse characteristics, except for age of onset, with abuse beginning at a younger age for those in the waitlist condition (5.77 years) compared with TFGT (7.37 years; p .05). There were no differences between groups on HIV risk factors at baseline.

Treatment
Treatment was provided by 22 experienced therapists, including eight psychologists, two psychiatrists, and 10 masters-level clinicians. All therapists had prior experience in working with trauma survivors and group therapy. Two female therapists led each group. Fifteen therapists led only one group, four led more than one group of the same type, and two led both types of groups. Therapists read the treatment manual, attended a day-long workshop, and each cotherapist team received 1 hr of supervision every week by an expert group therapist. All sessions were videotaped. Videotapes were randomly selected and observed by an expert clinician to monitor treatment compliance and provide feedback. TFGT and PFGT were manualized group interventions (Classen, Butler, & Spiegel, 2001) of 24 weekly sessions, each session lasting 90 min. The waitlist condition participants were offered TFGT after completing the 6-month follow-up assessment. The interventions were not highly structured, but guidelines were provided in the manual regarding the nature of the work expected at the beginning, middle, and final sessions. The manual provides information regarding goals of treatment, general guidelines, specific guidelines for TFGT and PFGT, common themes, and common group problems. The manual is available on request.

TFGT involves the activation and exploration of trauma memories at a pace that is tolerable to the survivor to gain a better understanding of the impact of trauma on sense of self, interpersonal functioning, and affective experience. The aim is to restructure cognitive and emotional understanding of these events so that it no longer impairs current experience or functioning. In PFGT, the focus is on examining current functioning (especially HIV risk behaviors), illuminating in the here-and-now maladaptive expectations and behaviors that emerge in the group process, and learning more adaptive ways of interacting with others as well as better affect-regulation strategies. The aim of PFGT is to identify and modify maladaptive patterns of relating and restructuring views of self and others. Initial sessions. Initial sessions for both treatment conditions focused on establishing trust and safety in the group, identifying treatment goals, orienting members to the treatment approach, and building a therapeutic alliance. During the second or third session, psychoeducation was provided regarding sexual revictimization, risky sex, and addiction to drugs and alcohol as HIV risk factors. TFGT differed from PFGT during the initial phase, with TFGT participants being encouraged to begin discussing traumatic experiences, whereas PFGT participants were redirected to the hereand-now. Middle sessions. Middle sessions began around the 3rd or 4th week. In TFGT, the focus was on helping participants discuss their traumatic histories in a supportive and caring environment. Therapists were instructed to listen for opportunities to provide psychoeducation about the impact of trauma, to link current experiences to their traumatic past, to facilitate participants in sharing and examining their memories of abuse as it pertained to the discussion at hand, and to help them identify and explore the thoughts and feelings that arose as they were doing this work.

GROUP THERAPY FOR SURVIVORS OF CHILDHOOD SEXUAL ABUSE

87

Table 1 Frequencies and Percentage of Sample for Demographic Information in High-Risk Women (N 166)
Demographics Mean (SD) age (years) Educational background, n (%) High school degree or less Some college or bachelors degree Graduate school or graduate degree Employment status, n (%) Not employed Part time (30 hr/week) Full time (30 hr/week) Total household income, n (%) $20,000 $20,000$39,999 $40,000$59,999 $60,000 Dont know/refuse to answer Racial background, n (%) Black Asian American Mexican American Other Hispanic/Latino Native American White/European American Other Relationship status, n (%) Never married Married/living together Separated/divorced/widowed Other HIV risk factors, n (%) Meets DSMIV criteria for abuse or dependence (any substance) Revictimized Engages in unsafe sex TFGT (n 55) 36.40 (10.96) 9 (16.4) 39 (70.9) 7 (12.7) 10 (18.5) 15 (27.8) 27 (50.0) 12 (21.8) 16 (29.1) 10 (18.2) 15 (27.3) 2 (3.6) 6 (11.1) 3 (5.6) 0 (0) 5 (9.3) 0 (0) 36 (66.7) 4 (7.4) 17 (31.5) 19 (35.2) 16 (29.6) 2 (3.7) 31 (56.4) 48 (87.3) 36 (65.5) PFGT (n 56) 36.37 (9.74) 8 (14.3)a 37 (66.1) 11 (19.6) 14 (25.0) 9 (16.1) 33 (58.9) 9 (16.1) 18 (32.1) 16 (28.6) 11 (19.6) 2 (3.6) 3 (5.4) 5 (8.9) 3 (5.4) 5 (8.9) 3 (5.4) 33 (58.9) 4 (7.1) 20 (35.7) 17 (30.4) 14 (25.0) 5 (8.9) 33 (58.9) 49 (87.5) 41 (73.2) Waitlist (n 55) 35.72 (10.10) 7 (12.7) 38 (69.1) 10 (18.2) 8.23 17 (30.9) 14 (25.5) 23 (41.8) 16.51 21 (8.2) 10 (18.2) 8 (14.5) 12 (21.9) 4 (7.3) 13.28 4 (7.3) 1 (11.1) 5 (9.1) 3 (5.5) 1 (1.8) 35 (63.6) 6 (10.9) 3.00 23 (41.8) 17 (30.9) 12 (21.8) 3 (5.7) 23 (41.8) 52 (94.5) 30 (54.5) 3.77 2.05 4.26 F or 2 0.08 1.22

Note. TFGT trauma-focused group therapy; PFGT present-focused group therapy; DSMIV Diagnostic and Statistical Manual of Mental Disorders (4th ed.). a Percentages do not add to 100% because of missing data.

Examination of memories was to be at a pace that participants could tolerate without becoming either hyper- or hypoaroused. By drawing connections between their traumatic childhood and recent victimization, risky sexual behavior, ongoing substance use, and other abuse-related problems, therapists aimed to help participants gain control over current behaviors, interpersonal problems, and symptoms. Although TFGT focused on exploration of trauma memories, attention was given to here-and-now group processes where appropriate. In PFGT, participants were encouraged to attend to their immediate experiences in the group, particularly in relation to interactions with the leader and with each other, and to link this to behavior outside the group. The therapists encouraged group members to explore their maladaptive patterns of behavior, negative self-image, and assumptions and beliefs that distort incoming information. The goals were to increase their awareness and tolerance of internal affective and cognitive states, to recognize triggers for trauma-related symptoms and relational problems, to identify patterns of relating that make them prone to sexual victimization, to recognize when they are engaging in risky sexual behavior, and to understand the circumstances that trigger substance abuse. Final sessions. In the final treatment phase, the focus for both interventions was on consolidating what had been learned and

working through issues raised by termination. During this approximately 4-week phase, participants were encouraged to identify the progress they made, including reviewing their goals and planning for the future. Case management. All participants received case management from a licensed clinical psychologist who was blind to treatment condition. The aim was to provide supportive services in order to mitigate dropouts and ensure the participants well-being. This included crisis management if necessary. The case manager was not to provide psychotherapy or establish a psychotherapeutic relationship with any participants. She conducted an initial assessment with each participant, which surveyed participants current life situation; stressors and supports; previous treatment; reasons for participating; and reactions, hopes, fears, concerns, and expectations toward the study. Following this initial assessment, participants were contacted about once a month for a brief check-in.

Measures
All measures were given at baseline, posttreatment (i.e., following the completion of the TFGT and PFGT groups), and 6 months posttreatment, except for the Posttraumatic Growth Inventory, which was given at baseline and 6 months posttreatment.

88

CLASSEN ET AL.

Primary outcome measures. Total HIV risk was calculated on the basis of the Sexual Experiences Survey, the Drug and Alcohol Use Interview, and the Sexual Risk Behavior Assessment Schedule described below. A total HIV risk score was calculated by taking the mean slope of each individuals risk factor. Thus, total HIV risk scores are based on only those risky behaviors that a given participant experienced or engaged in. The Posttraumatic Stress Disorder ChecklistSpecific (PCLS; Weathers & Ford, 1996) was used to assess PTSD symptoms, with total severity of PTSD symptoms being the primary outcome. This self-report measure consists of 17 items based on the DSMIV BD criteria for PTSD and inquires about symptoms in the past month. The PCLS has good validity and reliability (Weathers & Ford, 1996). The subscales of Avoidance, Hyperarousal, and Reexperiencing were analyzed as secondary outcomes. Secondary outcome measures. The Sexual Experiences Survey (SES; Koss & Gidycz, 1985; Koss & Oros, 1982) is a 13-item scale that assesses sexual victimization experiences of sexual coercion, attempted rape, and rape. The scale was modified from a yesno format by asking participants to indicate the number of times they had each experience within the previous 6 months. Because some women did not feel that the SES captured their experience, we asked the following additional questions: Did you ever have sex with someone when you didnt want to? If yes, they were asked to indicate the number of times they felt they couldnt say no, felt pressured, felt an obligation to have sex, thought it would hurt their relationship if they didnt have sex, did it in exchange for something else, had sex because they were intoxicated, or had sex for some other reason. Thus, the sexual revictimization score was based on the total number of experiences endorsed on the SES and these additional questions. The Drug and Alcohol Use Interview (Koopman, Rosario, & Rotheram-Borus, 1994; Rotheram-Borus, Koopman, & Bradley, 1988) is a structured interview that assessed amount of substance use in the past 3 months including alcohol, stimulants/ amphetamines, marijuana/hashish, inhalants, cocaine/crack, hallucinogens, heroin, ecstasy, sedatives/tranquilizers, and analgesics, as well as needle use. Substance use scores were single scores based on all substances to which the participant was addicted. The Sexual Risk Behavior Assessment Schedule (MeyerBahlburg, Ehrhardt, Exner, & Gruen, 1988) is a structured interview that assesses sexual activity and was modified to assess sexual activity within the previous 6 months. A risky sex score was based on self-report of the frequency of unprotected vaginal sexual encounters or otherwise unsafe vaginal sex (such as using condoms more than once) with an unsafe partner within the previous 6 months. A partner was considered unsafe if the HIV status of a partner of less than 12 months duration was unknown or if the partner had multiple partners. The number of unsafe partners was analyzed as a secondary outcome. It was defined as the number of partners in the previous 6 months who were either HIV-positive, whose HIV status was unknown, or who had multiple partners or used intravenous drugs. The Inventory of Interpersonal Problems32 (Horowitz, Rosenberg, Baer, Ureno, & Villasenor, 1988; Leonard, Alden, Wiggins, & Pincus, 2000) is a 32-item self-report measure that assesses interpersonal difficulties. This measure has been demonstrated to have excellent reliability and validity.

The Trauma Symptom Inventory (Briere, 1995) assesses a range of symptoms associated with trauma such as depression, anger/ irritability, dissociation, sexual concerns, dysfunctional sexual behavior, impaired self-reference, and tension-reduction behavior. Respondents are asked to indicate how much each item describes their experience in the past 6 months. This measure has been shown to have good reliability and validity. The Posttraumatic Growth Inventory (Tedeschi & Calhoun, 1996) is a 21-item scale that assesses positive outcomes as a result of trauma. It has sound reliability and validity.

Treatment Fidelity
Treatment fidelity was assessed via a brief postsession questionnaire completed by each group member at the end of every session. They were asked about the amount of time one or more group members discussed the problems they have in their lives today, the here-and-now, and their childhood experiences (i.e., either the sexual abuse and/or other childhood experiences). The latter question was intended to capture discussions of their CSA experiences as well as the context of the abuse. These items were rated on a scale of 17, with 1 meaning not at all and 7 meaning all the time. Other questions inquired about the number of times the group leaders asked group members about their childhood experiences, linked what happened to them as a child to how they are today, or asked about what was happening among them or the group leaders. In addition to the participant ratings, one randomly selected session (from Sessions 9 15) for each group was rated on this postsession questionnaire by two objective raters who were kept blind to condition. There were three raters, with two rating each session. Any discrepancies in ratings were resolved through consensus.

Data Analysis
Analysis was intention-to-treat (ITT), with all participants analyzed in their randomly assigned group. The primary and secondary outcome measures were compared using analysis of variance (ANOVA). Adequate dose (AD) analyses were conducted using the same analytic strategy, with an AD defined as attending at least 18 (75%) of the sessions. Because participants were required to have only one HIV risk factor, the number of participants meeting each risk factor varied. To maximize the ability to detect the impact of treatment on the relevant HIV risk factors, as well as to maximize our ability to detect treatment differences, we calculated a single risk factor score for each participant on the basis of their unique risk factors to give a total HIV risk score for each participant at each assessment point. A mean slope of change over time on the total HIV risk scores was calculated for each participant. The total HIV risk slopes and the PTSD severity slopes were considered the primary outcome variables. Nonnormal distributions were observed for all HIV risk factors. Consequently, all analyses of HIV risk factors were based on log-transformed data. In the treatment condition, participants who are in the same therapy group are not independent in their response. Moreover, the within-group covariance structure would not be the same for all therapy groups. With correlated repeated measures for each participant, as well as possible cluster correlations between partici-

GROUP THERAPY FOR SURVIVORS OF CHILDHOOD SEXUAL ABUSE

89

pants who are in the same therapy group, analysis using hierarchical linear models proved intractable. Consequently, data were analyzed at the group level rather than at the individual level, a conservative procedure (Murray, 1998). There were seven cohorts and three conditions, providing 21 observations for the ANOVA. All primary outcome variables (risky sex, substance use, revictimization, and PTSD symptoms) and secondary outcomes were assessed at baseline, posttreatment, and at 6 months posttreatment. Response slopes were created for each group participant who had at least two assessments, and the slopes within each group were averaged. For those who had fewer than two assessments, a zero slope was imputed. Effect sizes are at the individual level and were calculated taking the effect of being in a group into account using the following formula: ES individual ES group / n, where n is the average number of participants in the groups. Effect sizes for group were calculated using Cohens d at the group level. When comparing TFGT with PFGT, a positive effect size indicates that TFGT performed better than PFGT. Similarly, when comparing treatment (TFGT and PFGT combined) with the waitlist condition, a positive effect size indicates a benefit from treatment. To test whether there were significant changes over time within each condition, we conducted one-sample t tests comparing the slopes against a flat slope (which indicates no change) for each variable. Treatment fidelity was assessed by examining participants ratings on the postsession questionnaires as well as ratings by the

objective observers. Participants rated each session, and a mean score for each question on the postsession questionnaire over the 24 sessions was calculated. To test the validity of the participant ratings, we calculated a Spearman rank order correlation between the mean participant ratings and the objective ratings for the randomly selected sessions.

Results Attendance
TFGT and PFGT conditions were compared on group therapy attendance. Sixteen participants (29%) randomized to TFGT did not attend any therapy sessions compared with eight participants (14%) in the PFGT condition (2 3.59, p .06). Of the 39 participants who attended TFGT sessions, 31 (77%) attended at least 75% of them; of the remaining 48 (86%) participants in PFGT, 30 (61%) attended at least 75% of sessions (2 3.36, p .06).

Effects of Treatment
ITT mean slopes, standard deviations, and effect sizes for primary and secondary outcomes are listed in Table 2. Table 2 also indicates whether there were significant changes over time for any outcomes within condition. For primary outcomes, 25 women did not have follow-up data and were given flat slopes. AD mean slopes, standard deviations, and effect sizes for the primary and secondary outcome variables are found in Table 3.

Table 2 Intent To Treat Analyses: Mean Slopes, Standard Deviations, and Effect Sizes for Primary and Secondary Outcomes
TFGT Outcome Primary Total HIV risk PTSD total severity Secondary Sexual revictimization Substance use Risky sex Number of partners Avoidance Hyperarousal Reexperiencing Interpersonal problems Depression Anger/irritability Dissociation Sexual concerns Dysfunctional sex Impaired self-reference Tension reduction Posttraumatic growth M 0.0112 0.5528 0.0143 0.0054 0.0085 0.0011 0.2331 0.1400 0.1807 0.9020 0.1806 0.2342 0.1347 0.1050 0.0441 0.2137 0.0820 5.69 SD 0.011 0.306 0.015 0.007 0.011 0.002 0.170 0.113 0.056 0.652 0.092 0.045 0.110 0.123 0.124 0.107 0.058 07.29 n 55 55 48 30 36 36 55 55 55 55 55 55 55 55 55 55 55 43 M 0.0234 0.4482 0.0245 0.0138 0.0202 0.0042 0.1477 0.1379 0.1637 0.6419 0.0529 0.0864 0.1204 0.1843 0.1224 0.1796 0.0487 12.30 PFGT SD 0.010 0.111 0.013 0.008 0.034 0.008 0.088 0.053 0.061 0.593 0.169 0.103 0.118 0.202 0.126 0.093 0.038 11.55 n 56 56 49 33 41 41 56 56 56 56 56 56 56 56 56 56 56 43 M 0.0156 0.2591 0.0137 0.0129 0.0001 0.0004 0.1763 0.0380 0.0448 0.3712 0.0151 0.0299 0.0257 0.0804 0.0636 0.0716 0.0471 6.47 Waitlist SD 0.011 0.179 0.016 0.016 0.018 0.003 0.101 0.091 0.049 0.610 0.158 0.076 0.106 0.084 0.053 0.144 0.068 9.74 n 55 55 52 23 30 30 55 55 55 55 55 55 55 55 55 55 55 43 Effect size TFGT vs. PFGT 0.41 0.16 0.28 0.52 0.20 0.22 0.22 0.01 0.10 0.15 0.33 0.66 0.04 0.17 0.22 0.12 0.24 0.28 Treatment vs. waitlist 0.06 0.44 0.14 0.26 0.31 0.35 0.04 0.41 0.84 0.23 0.32 0.62 0.33 0.18 0.07 0.36 0.11 0.11

Note. TFGT trauma-focused group therapy; PFGT present-focused group therapy; PTSD posttraumatic stress disorder. Means for posttraumatic growth are difference scores rather than slopes. Asterisks for TFGT, PFGT and waitlist conditions indicate significant pre/post differences. Asterisks for effect sizes indicate significant comparisons across conditions. p .05. p .01. p .001.

90

CLASSEN ET AL.

Table 3 Adequate Dose Analyses: Mean Slopes, Standard Deviations, and Effect Sizes for Primary and Secondary Outcomes
TFGT Outcome Primary Total HIV risk PTSD total severity Secondary Sexual revictimization Substance use Risky sex Number of partners Avoidance Hyperarousal Reexperiencing Interpersonal problems Depression Anger/irritability Dissociation Sexual concerns Dysfunctional sex Impaired self-reference Tension reduction Posttraumatic growth M 0.0085 0.7072 0.0144 0.0073 0.0080 0.0002 0.3120 0.1592 0.2368 1.2599 0.3019 0.3975 0.1766 0.2609 0.1813 0.3460 0.1731 11.69 SD 0.017 0.326 0.023 0.016 0.040 0.001 0.206 0.069 0.070 1.058 0.225 0.210 0.149 0.170 0.226 0.150 0.127 10.34 n 29 29 29 16 19 19 29 29 29 29 29 29 29 29 29 29 29 28 M 0.0294 0.7241 0.0262 0.0112 0.0240 0.0053 0.2386 0.2397 0.2449 1.2993 0.0924 0.1188 0.2033 0.3459 0.2128 0.2460 0.0942 14.63 PFGT SD 0.030 0.250 0.021 0.025 0.061 0.013 0.126 0.101 0.073 1.1247 0.275 0.163 0.261 0.260 0.241 0.231 0.071 10.25 n 28 28 28 13 24 24 28 28 28 29 28 28 28 28 28 28 28 28 M 0.0195 0.2865 0.0185 0.0334 0.0011 0.0003 0.2183 0.0333 0.0465 0.3956 0.0318 0.0181 0.0034 0.0996 0.0987 0.0760 0.0715 8.42 Waitlist SD 0.013 0.191 0.023 0.035 0.019 0.003 0.136 0.0091 0.052 0.756 0.194 0.121 0.153 0.084 0.103 0.173 0.084 9.43 n 46 46 43 19 25 25 45 45 45 45 45 45 45 45 45 45 45 42 Effect size TFGT vs. PFGT 0.42 0.03 0.26 0.12 0.18 0.30 0.21 0.46 0.06 0.02 0.41 0.73 0.06 0.19 0.07 0.26 0.40 0.14 Treatment vs. waitlist 0.01 0.89 0.04 0.55 0.22 0.25 0.18 0.89 1.58 0.42 0.49 0.75 0.51 0.62 0.28 0.54 0.32 0.24

Note. TFGT trauma-focused group therapy; PFGT present-focused group therapy; PTSD posttraumatic stress disorder. Means for posttraumatic growth are difference scores rather than slopes. Asterisks for TFGT, PFGT and waitlist conditions indicate significant pre/post differences. Asterisks for effect sizes indicate significant comparisons across conditions. p .05. p .01. p .001.

Primary Outcomes
ITT analysis of total HIV risk scores did not show an overall effect for condition, F(2, 18) 2.62, p .10, nor did the AD analysis, F(2, 18) 1.68, p .22. However, contrary to our prediction that TFGT would lead to a greater reduction in total HIV risk compared with PFGT, ITT planned comparisons showed a statistically significant advantage of PFGT over TFGT for total HIV risk, t(12) 2.26, p .05. It is interesting that all three conditions showed a significant reduction in total HIV risk scores over time. AD planned comparisons showed a trend for an advantage of PFGT over TFGT in reducing total HIV risk, t(12) 1.83, p .09. When comparing both groups combined with the waitlist condition on the primary outcomes, planned comparisons revealed no advantage of treatment for total HIV risk in either the ITT analysis, t(19) 0.37, p .72, or the AD analysis, t(19) 0.06, p .95. Given that PFGT showed an advantage over TFGT, we compared PFGT with the waitlist condition. A post hoc analysis comparing PFGT with the waitlist condition revealed no advantage of PFGT over the waitlist condition, t(12) 1.44, p .17. ITT analysis of PTSD total severity scores indicated a trend for an overall effect of condition, F(2, 18) 3.36, p .06, with the AD analysis showing an overall effect for condition, F(2, 18) 6.34, p .01. However, ITT planned comparisons of TFGT and PFGT on severity of PTSD symptoms showed no differences, t(12) 0.91, p .37, nor did AD analysis when comparing TFGT and PFGT on PTSD total severity scores, t(12) 0.12, p .91. An examination of PTSD total severity found an advantage for treatment compared with the waitlist condition in both the ITT analysis, t(19) 2.43, p .05, and the AD analysis, t(19) 3.59,

p .01. All conditions showed a significant reduction in PTSD severity over time. ITT analyses on the PTSD subscales revealed overall effects for reexperiencing, F(2, 18) 12.56, p .001, and a trend for hyperarousal, F(2, 18) 2.99, p .08, The AD analyses also revealed overall effects for reexperiencing, F(2, 18) 20.54, p .001, and hyperarousal, F(2, 18) 9.78, p .001. ITT planned comparisons revealed advantages for treatment on reexperiencing, t(19) 4.98, p .001, and hyperarousal, t(19) 2.46, p .05, as did the AD analyses, t(19) 6.40, p .001, and t(19) 4.08, p .001, respectively. Except for hyperarousal, where there was no change over time for the waitlist condition, all three conditions showed statistically significant change over time on each of the PTSD symptom categories.

Secondary Outcomes
In the secondary outcomes, there was an overall effect for anger/irritability in both ITT, F(2, 18) 19.91, p .001, and AD, F(2, 18) 11.03, p .001, analyses. Planned comparisons showed that TFGT had a significantly greater reduction in anger/ irritability compared with PFGT in both ITT, t(12) 3.52, p .01, and AD, t(12) 3.09, p .01, analyses. Only TFGT showed a significant reduction in anger over time. Anger/irritability was the only outcome where there was an advantage of TFGT over PFGT. In addition, ITT planned comparisons revealed advantages for treatment in reducing anger/irritability, t(19) 5.26, p .001, as did the AD planned comparison, t(19) 3.54, p .01. ITT analysis revealed a trend for overall effects on impaired selfreference, F(2, 18) 2.84, p .09, and the AD analysis revealed

GROUP THERAPY FOR SURVIVORS OF CHILDHOOD SEXUAL ABUSE

91

overall effects for impaired self-reference, F(2, 18) 3.70, p .05. ITT planned comparisons showed an advantage for treatment compared with the waitlist condition on impaired self-reference, t(19) 2.32, p .05, as did the AD planned comparison, t(19) 2.53, p .05. Although the overall model was not significant, ITT planned comparisons revealed a trend for treatment improving depression, t(19) 1.98, p .06. The AD analysis revealed overall effects for depression, F(2, 18) 3.65, p .05, and showed an advantage for treatment on depression, t(19) 2.12, p .05. Although the overall model was not significant, ITT planned comparisons revealed a trend for treatment reducing dissociation, t(19) 1.82, p .09. Similarly, the overall model was not significant in the AD analyses, but planned comparisons revealed a significant reduction for treatment compared with the waitlist condition on dissociation, t(19) 2.07, p .05. The AD analysis also revealed a trend for on effect for sexual concerns, F(2, 18) 3.19, p .06, with an advantage for treatment on sexual concerns, t(19) 2.37, p .05.

Treatment Fidelity
Spearman rank order correlations of participant ratings with objective ratings was .79 ( p .001) for the amount of time spent discussing their childhood experiences, .52 ( p .05) for the number of times the therapists made comments linking current life experiences with childhood experiences, .39 ( p .15) for the number of times the therapists asked about the past, and .42 ( p .12) for the amount of time spent discussing current problems. There was no association between how participants and objective observers rated the amount of time spent discussing the here-andnow (rs .08, p .78). Participant ratings of the amount of time spent discussing childhood experiences showed a mean of 4.2 for TFGT and 2.1 for PFGT, which were significantly different, t(12) 14.83, p .001. Participant ratings suggest that TFGT spent less time on current problems compared with PFGT, t(12) 2.94, p .05, with means of 4.8 and 5.6, respectively. There was a trend for a statistically significant difference in time spent discussing the here-and-now, t(12) 1.96, p .08, with a mean of 4.5 for TFGT and 5.0 for PFGT.

Nonstudy Treatment
Participants were asked whether they had engaged in any other form of psychotherapy during the course of the study. This included treatment provided by either lay or professional therapists, involving either individual, couple, or group therapy. Nonstudy treatment was received by 12 (21%) in the waitlist condition, 12 (21%) in the TFGT condition, and 11 (19%) in the PFGT condition. In all but two cases, treatment involved individual therapy by a professional therapist.

Discussion
This RCT examined the efficacy of TFGT compared with PFGT in reducing HIV risk behavior and PTSD symptomatology among female CSA survivors. Contrary to our hypotheses, we found that PFGT was more effective than TFGT in reducing overall HIV risk,

but we found no difference when comparing both treatments combined with the waitlist condition or when comparing PFGT to the waitlist condition. We found no advantage of TFGT over PFGT in reducing PTSD symptoms but a clear advantage of treatment over the waitlist condition in reducing overall severity of PTSD. On secondary outcomes, we found a greater reduction in anger for TFGT compared with PFGT in both ITT and AD analyses. ITT and AD analyses for treatment compared with the waitlist condition showed a greater reduction in hyperarousal, reexperiencing, anger, and impaired self-reference. AD analyses also found that treatment resulted in a greater reduction in depression, dissociation, and sexual concerns. Whereas these results suggest that PFGT may be more effective than TFGT in reducing overall HIV risk, there was no advantage when compared with the waitlist condition. Thus, these results do not support using either group therapy approach to reduce sexual revictimization or behaviors that put women at risk for HIV. Both group therapy conditions devoted only one session to psychoeducation about these HIV risk factors and risk reduction, although these topics were also discussed during the course of the treatment whenever it was relevant to the group discussion. It is possible that incorporating an even greater emphasis on HIV skills training into these group therapy approaches could result in a greater effect on these HIV risk factors. It is striking that all three conditions showed a reduction in HIV risk. There are a number of reasons why participants in the waitlist condition may have reduced their HIV risk. By virtue of asking about risky behaviors, the assessments themselves may have raised awareness and motivated participants to be less risky. In addition, all participants were followed by a case manager, which could plausibly serve as an intervention. The anticipation of receiving treatment may have had a positive effect, perhaps increasing hope for the future and greater self-reflection. These factors may have restricted our ability to identify differences between treatment and waitlist conditions. Finally, it is possible that the improvement across all conditions is due to regression to the mean. Although group therapy resulted in a significant reduction in PTSD severity compared with the waitlist condition, there was no advantage of either TFGT or PFGT. On the other hand, we found that TFGT reduced anger/irritability, but PFGT did not. Discussing the traumatic experiences may provide an opportunity for women to express and work through their anger. This underscores the fact that although there was only limited advantage to the condition in which trauma history was directly addressed, this study makes it clear that there was no disadvantage to such an approach. The secondary analyses comparing treatment with the waitlist condition suggests that group therapy can affect a range of problems, including identity confusion or self/other disturbances. An even broader range of benefits was found for women who received an adequate dose of treatment (attending at least 75% of the sessions), including improvements in depression, dissociation, and sexual concerns, in addition to those already mentioned. It is notable that these symptom reductions were seen in a CSA sample that did not exclude individuals with personality pathology or those addicted to drugs or alcohol; such individuals are often screened out of studies with CSA survivors. Although we did not formally assess for complex PTSD, most would likely meet criteria for it (Herman, 1992) and, we would argue, resemble the typical CSA survivor who presents in the mental health professionals

92

CLASSEN ET AL.

office. Both TFGT and PFGT either directly or indirectly addressed the wide range of symptoms associated with complex PTSD such as PTSD symptoms, affect dysregulation, stigma, shame and guilt, distrust, low self-esteem, and interpersonal problems. Although neither group therapy approach was found to significantly reduce womens sexual revictimization, risky sex, or substance use, it is important to note that neither PFGT nor TFGT worsened these risk factors, including substance use. This is a population prone to serious drug and alcohol abuse. For symptomatic CSA survivors, substances are often used as a way to selfmedicate. It is widely believed that commencing intensive psychotherapy without first addressing addiction is likely to worsen the substance abuse problems. Psychotherapy is frequently deferred for people who are actively using drugs and alcohol, yet we asked only that participants refrain from using on group days. These findings call into question the practice of delaying psychotherapy for addicted persons until they remain clean and sober for an extended period of time. The failure of this study to provide evidence of TFGT being more effective than PFGT in reducing PTSD symptomatology raises a number of questions. Was treatment benefit derived primarily from nonspecific factors? For instance, do CSA survivors benefit simply from sharing their experience with other CSA survivors in a safe environment? Alternatively, are there different but equally effective mechanisms underlying each intervention that accounts for their benefit? A recent meta-analysis of direct comparison studies found that bona fide psychotherapies produce equivalent effects for trauma survivors with PTSD (Benish, Imel, & Wampold, 2008). Is trauma-focused work not optimal in a group intervention given the challenges of ensuring that the pacing of the memory work is appropriate for all members? Or does TFGT require adjunctive individual therapy so that survivors have more opportunities to process the material discussed in group? Is 6 months too short, particularly for a Stage II trauma group, to expect significant behavioral and psychological benefits? These questions warrant further investigation. Limitations to this study include that we did not attempt to assess participants readiness for TFGT beyond requiring that participants felt that they would be able to discuss it in a group. It is possible that not all participants in TFGT were sufficiently stabilized in their lives to benefit from this intervention. The length of treatment may have been insufficient to effect change in this highly traumatized sample. All assessments, including assessments of risk behaviors, were self-report. Asking survivors to estimate the number of times they engaged in behaviors or were victimized over the previous 6 months may have been too long a period from which to get an accurate estimate of risk. Furthermore, the sample size limited our ability to detect differences. Finally, assessment of treatment fidelity was based primarily on participant reports. The main strength of this study was that it was an RCT using a real-world sample. It could be construed as a weakness that this study does not isolate a single disorder, but this is also its strength because it is more representative of treatment-seeking CSA survivors (Seligman, 1995). A recent meta-analysis of RCTs for PTSD concluded that investigations of polysymptomatic survivors of childhood trauma are needed (Bradley, Greene, Russ, Dutra, & Westen, 2005). Other strengths were the use of a manualized approach for each intervention, using well-validated measures,

selecting experienced therapists, monitoring each of the group interventions, and providing weekly supervision to the therapists. In conclusion, this study suggests that group therapy is effective in reducing PSTD symptoms among adult CSA survivors, but no strong evidence was found for group therapy reducing HIV risk factors. Secondary analyses suggest that TFGT may be more effective in reducing anger. Group therapy also appears to reduce problems related to the experience of self, and there was some evidence that it reduced depression, dissociation, and sexual concerns. Taken together, the results suggest that TFGT and PFGT can improve the lives of these women. Future studies should clarify whether there are two different mechanisms at work in each of these interventions. To address this research question, researchers should carefully assess the readiness of CSA survivors to engage in Stage II trauma work. CSA survivors should not be randomized to TFGT unless it is clear that they are able to do this work. Additional research is needed to determine the most effective interventions for reducing sexual revictimization and HIV risk behaviors in this highly traumatized population. Future treatment outcome studies with CSA survivors should not exclude participants who manifest the more difficult signs and symptoms of complex PTSD if the treatment is to generalize to this broader population.

References
Alexander, P. C., Neimeyer, R. A., Follette, V. M., Moore, M. K., & Harter, S. (1989). A comparison of group treatment of women sexually abused as children. Journal of Consulting and Clinical Psychology, 57, 479 483. Arriola, K. R., Louden, T., Doldren, M. A., & Fortenberry, R. M. (2005). A meta-analysis of the relationship of child sexual abuse to HIV risk behavior among women. Child Abuse & Neglect, 29, 725746. Benish, S. G., Imel, Z. E., & Wampold, B. E. (2008). The relative efficacy of bona fide psychotherapies for treating post-traumatic stress disorder: A meta-analysis of direct comparisons. Clinical Psychology Review, 28, 746 758. Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2005). A multidimensional meta-analysis of psychotherapy for PTSD. The American Journal of Psychiatry, 162, 214 227. Briere, J. (1995). Trauma Symptom Inventory. Odessa, FL: Psychological Assessment Resources. Classen, C., Butler, L. D., & Spiegel, D. (2001). A treatment manual for present-focused and trauma-focused group therapies for sexual abuse survivors at risk for HIV infection. Stanford, CA: Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine. Classen, C. C., Palesh, O. G., & Aggarwal, R. (2005). Sexual revictimization: A review of the empirical literature. Trauma, Violence, & Abuse, 6, 103129. DiLillo, D., Tremblay, C., & Peterson, L. (2000). Linking childhood sexual abuse and abusive parenting: The mediating role of maternal anger. Child Abuse & Neglect, 24, 767779. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1995). Structured Clinical Interview for DSMIV Axis I DisordersPatient Edition (SCIDI/P, Version 2.0). Washington, DC: American Psychiatric Press. Heath, V., Bean, R., & Feinauer, L. (1996). Severity of childhood sexual abuse: Symptom differences between men and women. American Journal of Family Therapy, 24, 305314. Herman, J. L. (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5, 377391. Herman, J., & Schatzow, E. (1984). Time-limited group therapy for women

GROUP THERAPY FOR SURVIVORS OF CHILDHOOD SEXUAL ABUSE with a history of incest. International Journal of Group Psychotherapy, 34, 605 616. Horowitz, L., Rosenberg, S., Baer, B., Ureno, G., & Villasenor, V. (1988). Inventory of Interpersonal Problems: Psychometric properties and clinical applications. Journal of Consulting and Clinical Psychology, 56, 885 892. Huba, G. J., Tenner, A., Panter, A. T., Remafedi, G., Melchior, L. A., Greenberg, B., . . . Marconi, K. (2003). Modeling HIV risk in highly vulnerable youth. Structural Equation Modeling, 10, 583 608. Kessler, M. R. H., White, M. B., & Nelson, B. S. (2003). Group treatments for women sexually abused as children: A review of the literature and recommendations for future outcome research. Child Abuse & Neglect, 27, 10451061. Koopman, C., Rosario, M., & Rotheram-Borus, M. J. (1994). Alcohol and drug use and sexual behaviors placing runaways at risk for HIV infection. Addictive Behavior, 19, 95103. Koss, M., & Gidycz, C. (1985). Sexual Experiences Survey: Reliability and validity. Journal of Consulting and Clinical Psychology, 53, 422 423. Koss, M., & Oros, C. (1982). Sexual Experiences Survey: A research instrument investigating sexual aggression and victimization. Journal of Consulting and Clinical Psychology, 50, 455 457. Lau, M., & Kristensen, E. (2007). Outcome of systemic and analytic group psychotherapy for adult women with history of intrafamilial childhood sexual abuse: A randomized controlled study. Acta Psychiatrica Scandinavica, 116, 96 104. Leonard, M. H., Alden, L. E., Wiggins, J. S., & Pincus, A. L. (2000). Inventory of Interpersonal Problems manual. San Antonio, TX: Psychological Corporation. Meyer-Bahlburg, H. F. L., Ehrhardt, A. A., Exner, T. M., & Gruen, R. S. (1988). Sexual Risk Behavior Assessment ScheduleYouth. New York: New York State Psychiatric Institute and Department of Psychiatry, College of Physicians and Surgeons, Columbia University. Molnar, B. E., Buka, S. L., & Kessler, R. C. (2001). Child sexual abuse and subsequent psychopathology: Results from the National Comorbidity Survey. American Journal of Public Health, 91, 753760. Morrill, A. C., Kasten, L., Urato, M., & Larson, M. J. (2001). Abuse, addiction, and depression as pathways to sexual risk in women and men with a history of substance abuse. Journal of Substance Abuse, 132, 169 184. Murray, D. M. (1998). Design and analysis of group-randomized trials. New York: Oxford University Press. Rees, V., Saitz, R., Horton, M. J., & Samet, J. (2001). Association of alcohol consumption with HIV sex- and drug-risk behaviors among drug users. Journal of Substance Abuse Treatment, 21, 129 134. Roche, D. N., Runtz, M. G., & Hunter, M. A. (1999). Adult attachment: A mediator between child sexual abuse and later psychological adjustment. Journal of Interpersonal Violence, 14, 184 207. Rodriguez, N., Vande-Kemp, H., & Foy, D. W. (1998). Posttraumatic stress disorder in survivors of childhood sexual and physical abuse: A critical review of the empirical research. Journal of Child Sexual Abuse, 7(2), 17 45. Rotheram-Borus, M. J., Koopman, C., & Bradley, J. S. (1988). Drug and Alcohol Use Survey for Adolescents. New York: Division of Child Psychiatry, Department of Psychiatry, College of Physicians and Surgeons, Columbia University. Schnurr, P. P., Friedman, M. J., Foy, D. W., Shea, M., Hsieh, F. Y., Lavori, P. W., . . . Bernardy, N. C. (2003). Randomized trial of trauma-focused group therapy for posttraumatic stress disorder: Results from a Department of Veterans Affairs cooperative study. Archives of General Psychiatry, 60, 481 489.

93

Seligman, M. E. P. (1995). The effectiveness of psychotherapy: The Consumer Reports study. American Psychologist, 50, 965974. Senn, T. E., Carey, M. P., & Vanable, P. A. (2008). Childhood and adolescent sexual abuse and subsequent sexual risk behavior: Evidence from controlled studies, methodological critique, and suggestions for research. Clinical Psychology Review, 28, 711735. Shipman, K., Zeman, J., Penza, S., & Champion, K. (2000). Emotion management skills in sexually maltreated and nonmaltreated girls: A developmental psychopathology perspective. Development and Psychopathology, 12, 47 62. Sikkema, K. J., Hansen, N. B., Kochman, A., Tarakeshwar, N., Neufeld, S., Meade, C. S., & Fox, A. M. (2007). Outcomes from a group intervention for coping with HIV/AIDS and childhood sexual abuse: Reductions in traumatic stress. AIDS and Behavior, 11, 49 60. Sikkema, K. J., Hansen, N. B., Tarakeshwar, N., Kochman, A., Tate, D. C., & Lee, R. S. (2004). The clinical significance of change in traumarelated symptoms following a pilot group intervention for coping with HIV-AIDS and childhood sexual trauma. AIDS and Behavior, 8, 277 291. Spiegel, D., Classen, C., Thurston, E., & Butler, L. (2004). Traumafocused versus present-focused models of group therapy for women sexually abused in childhood. Washington, DC: American Psychological Association. Stalker, C., & Fry, R. (1999). A comparison of short-term group and individual therapy for sexually abused women. The Canadian Journal of Psychiatry, 44, 168 174. Tedeschi, R. G., & Calhoun, L. G. (1996). The Posttraumatic Growth Inventory: Measuring the positive legacy of trauma. Journal of Traumatic Stress, 9, 455 471. Testa, M., VanZile-Tamsen, C., & 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, 1116 1124. Tucker, J. S., Wenzel, S. L., Elliott, M. N., Marshall, G. N., & Williamson, S. (2004). Interpersonal violence, substance use, and HIV-related behavior and cognitions: A prospective study of impoverished women in Los Angeles County. AIDS and Behavior, 8, 463 474. Weathers, F., & Ford, J. (1996). Psychometric review of PTSD Checklist (PCL-C, PCL-S, PCL-M, PCL-RP). In B. Stamm (Ed.), Measurement of stress, trauma, and adaptation (pp. 250 251). Lutherville, MD: Sidran Press. Weiss, E. L., Longhurst, J. G., & Mazure, C. M. (1999). Childhood sexual abuse as a risk factor for depression in women: Psychosocial and neurobiological correlates. The American Journal of Psychiatry, 156, 816 828. Wyatt, G. E., Longshore, D., Chin, D., Carmona, J. V., Loeb, T. B., Myers, H. F., . . . Rivkin, I. (2004). The efficacy of an integrated risk reduction intervention for HIV-positive women with child sexual abuse histories. AIDS and Behavior, 8, 453 462. Zierler, S., Feingold, L., Laufer, D., Velentgas, P., Kantrowitz-Gordon, I., & Mayer, K. (1991). Adult survivors of childhood sexual abuse and subsequent risk of HIV infection. American Journal of Public Health, 81, 572575. Zlotnick, C., Shea, T., Rosen, K., Simpson, E., Mulrenin, K., Begin, A., & Pearlstein, T. (1997). An affect-management group for women with posttraumatic stress disorder and histories of childhood sexual abuse. Journal of Traumatic Stress, 10, 425 436.

Received May 11, 2009 Revision received January 30, 2010 Accepted April 7, 2010