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ADOLESCENT AND FEMALE SEXUALITY

Group psychotherapy in women with a history of sexual abuse: what

did they find helpful?

Aslıhan Sayın, Selc�uk Candansayar and Leyla Welkin

Aims and objectives. To define the effects of group psychotherapy in women with a history of sexual abuse, to find possible

predictors for dropout and treatment outcome rates and to find which therapeutic factors of group psychotherapy are per-

ceived by group members to be most helpful.

Background. Sexual abuse of women is a global concern and causes many psychiatric and psychological sequelae. Group

psychotherapy is one of the preferred treatment modalities.

Design. Prospective cohort study.

Methods. Forty-seven women with a history of childhood and/or adulthood sexual abuse were recruited for weekly 12-session

group psychotherapy. Subjects were given the Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, the Cli-

nician Administered Post-traumatic Stress Disorder Scale, the Dissociative Experiences Scale, the Childhood Trauma Ques-

tionnaire and the Group Therapeutic Factors Questionnaire. Re-evaluations were made after the 6th and 12th session and

also at a six-month follow-up session.

Results. Group psychotherapy significantly reduced participants’ levels of depression (screening/12th session mean scores,

22�45/11�10), anxiety (15�45/4�32) and symptoms of post-traumatic stress disorder (42�27/9�32), and this decline became statistically significant at the 6th session and tended to persist at the six-month follow-up. Higher levels of dissociative

symptoms at baseline were associated with less response to treatment, but higher levels of attendance at group sessions.

Group members rated existential factors (41�40 � 12�39), cohesiveness (37�42 � 8�32) and universalism (37�56 � 7�11) as the most helpful therapeutic factors.

Conclusion. Group psychotherapy was significantly effective in reducing levels of depression, anxiety and posttraumatic

stress disorder symptoms in this sample of women. Dissociation had a significant effect on both treatment outcome and

treatment adherence. For this sample of women, group psychotherapy was most helpful for reducing feelings of stigma, iso-

lation and shame.

Relevance to clinical practice. Group psychotherapy can be used as a preferred treatment method for women from different

cultural backgrounds with a history of sexual abuse.

Key words: dissociation, group psychotherapy, post-traumatic stress disorder, sexual abuse, therapeutic factors, women

Accepted for publication: 31 October 2012

Introduction

Sexual abuse is a universal problem, and victims are most

often women. A meta-analysis/ of prevalence of child sexual

abuse in adults using 65 articles from 22 countries reported

that 7�9% of men and 19�7% of women had experienced sexual abuse prior to the age of 18 (Pereda et al. 2009). In

a random sample of the general population in USA, sexual

assault during adulthood was reported by 22% of women

and 3�8% of men, and risk factors for adult sexual assault

Authors: Aslıhan Sayın, MD, Associate Professor, Psychiatry Dep-

artment, Gazi University Hospital, Ankara; Selc�uk Candansayar, MD, Professor, Psychiatry Department, Gazi University Hospital,

Ankara; Leyla Welkin, PhD, Independent Scholar, Pomegranate

Connection Program, Ankara, Turkey

Correspondence: Aslıhan Sayın, Associate Professor, Psychiatry

Department, Gazi University Hospital, Bes�evler, Ankara 06500, Turkey. Telephone: +90 532 5840438.

E-mail: [email protected]

include younger age, being female, having been divorced,

sexual abuse in childhood and physical assault during

adulthood (Elliott et al. 2004). In Turkey, sexual abuse,

especially intrafamilial sexual abuse, continues to be vastly

under-reported to authorities due to social taboos (Agirtan

et al. 2009). The few published studies report a sexual

abuse prevalence of 11–37% in the adolescent population

(Aras et al. 1996, Alikasifoglu et al. 2006).

Childhood sexual abuse has been associated with long-

term psychiatric problems in adult life, including dissocia-

tive and post-traumatic stress disorders, depression, anxiety,

phobia, substance abuse, eating disorders, suicidal ideation

and behaviours, self-harm behaviours, problems in interper-

sonal and intimate relationships, impaired self-esteem, and

impaired identity formation (for a review, see Heim et al.

2010). Although these psychiatric problems are universal

among sexual abuse victims from all over the world,

women’s coping styles and the treatment for these problems

by mental health providers vary greatly between different

countries and cultures. For example, both legal and tradi-

tional approaches to sexual abuse victims in Turkey may

consider the marriage of an abuser and the victim as a

‘solution’. In some Middle Eastern countries and most com-

monly among Muslim groups like Turkey, family honour is

closely tied to the sexuality of its female members. Accord-

ing to these traditional values, young women are expected

to be virgins when they marry to assure their purity and

moral propriety. In this traditional system, women are not

primarily considered as individuals, and one of their most

important roles is to embody the family’s good reputation

and honour (Arin 2001, Sever & Yurdakul 2001). These

beliefs can be so strong that some families are prepared to

sacrifice the lives of female members in order to restore

family honour. After a rape, society perceives the violated

woman not as a victim who needs protection, but as some-

one whose impurity has debased the family honour. Her

relatives may opt to undo the shame of this violation by

taking her life. But murder is not the only possible remedy.

An alternative to murdering her is to arrange a marriage

for her, preferably with the person who violated her honour

through rape. This procedure of imposing a ‘reparative’

marriage on a violated woman is believed to remedy her

perceived offence against her family. Based on this set of

beliefs, the practice was until very recently legally sanc-

tioned by the Turkish state and was considered to ‘protect

the girl from social stigma’. After such a forced marriage,

the criminal investigation was dropped, although a rapist

could still face criminal charges if he divorced his wife

within five years ‘without a legitimate reason’ (Fledner

2000). Despite changes in the laws, some courts continue

to follow these principles. These local/cultural approaches

may encourage more abuses of victims and may also have

an influence on mental health approaches.

Given that sexual abuse of women is common and has

lifelong psychological effects, efforts have been made to

find effective treatment methods for these women. Group

psychotherapy has been one of the most widely studied

approaches (for reviews see Taylor & Harvey 2010, Trask

et al. 2011). There are many reasons why a group setting

may be a better way of healing sexual trauma. Treatment

groups create a safe and structured environment where each

woman can experience being heard and believed in a sup-

portive community of her peers. Group members may

choose themes that they consider relevant, often including

dealing with anger, self-esteem, sexuality, family-of-origin

issues, assertiveness, relationships, spirituality, perpetrators

and confrontation (Westbury & Tuttly 1999). A group for-

mat lessens the feelings of stigma, isolation and shame that

frequently follow sexual victimisation (Feiring et al. 1996,

Talbot 1996). In addition, a group setting provides partici-

pants with greater opportunities to observe and learn from

one another, especially for the acquisition of new skills.

In this study, we report the results of a group psychother-

apy experience conducted with Turkish women with a his-

tory of sexual abuse. We had two aims before conducting

this work. The first aim was to treat the psychiatric symp-

toms and psychological difficulties of survivors of sexual

trauma using group psychotherapy and also to find possible

predictors for dropout and treatment outcome rates. Sec-

ond, we aimed to find which therapeutic factors of group

psychotherapy would most help the group members. In

addition to these aims, our exploratory goal in this study

was to observe similarities and differences with regard to

responses to sexual trauma-related issues and the group

therapy setting between Turkish women and women from

other countries reported in the literature, because culture

may have an important impact on ways of responding to

and coping with trauma (Bryant-Davis et al. 2009).

Methods

Subjects

Group members (n = 47) were selected from among women

with history of a sexual abuse who applied for psychiatric

outpatient or inpatient treatment at the Psychiatry Depart-

ment of Gazi University Hospital or were staying at one of

the domestic violence shelter houses in Ankara and/or were

private practice patients of two of the authors. Some partic-

ipants learned of the groups by word of mouth. All of the

A Sayın et al.

women were interviewed before inclusion in this study by

one of the authors (A.S.). During this screening interview,

detailed oral information about the purpose and process of

this study was given, and a written informed consent form

was signed by all participants. Then, information about

their socio-demographic characteristics, previous psychiatric

treatment and sexual abuse history was obtained through a

semi-structured interview. The exclusion criteria included

being younger than 16 years of age, having a psychotic dis-

order, active alcohol or substance dependence, mental retar-

dation, severe suicidal thoughts and not signing the written

informed consent form.

The mean age of the participants was 31�74 (minimum 20, maximum 50, standard deviation 7�32). The majority of them were single (n = 21, 44�7%), had an education level above 12 years (n = 27, 57�4%), had a job (n = 23, 48�9%), were born in a big city (n = 25, 53�2%), had lived mostly in a big city during their lives (n = 32, 68�1%) and were living with family at the time of therapy (n = 33,

70�2%). A minority 19�1% (n = 9) of the participants had never

received any kind of psychiatric or psychological treatment

before. Among those who had received treatment before,

40�4% (n = 19) had been treated with psychotropic medi- cation, 38�3% (n = 18) had been treated with both medi- cation and psychotherapy, and 1 had received only

psychotherapy. A total of 65�9% (n = 31) were still using psychotropic medicine, 17�0% (n = 8) had been hospita- lised once in their lives in a psychiatric inpatient clinic,

and 6�4% (n = 3) had been hospitalised more than once. A total of 51�1% (n = 24) had attempted suicide in the past. After the screening interview, it was concluded that

23�4% (n = 11) did not have any current psychiatric diag- nosis. The most common diagnosis was major depression

(n = 20, 42�5%), followed by borderline personality disor- der (n = 11, 23�4%) and post-traumatic stress disorder (n = 6, 12�7%). Other psychiatric diagnoses were panic disorder, eating disorders, vaginismus, social phobia,

obsessive-compulsive disorder and conduct disorder.

According to their sexual abuse history, the majority of

these women were children when their sexual trauma

occurred (n = 19, 40�4%), the most common perpetrators were first-degree family members (n = 14, 29�8%) and husbands/lovers (n = 14, 29�8%), most of these women were raped (n = 28, 80�9%), and most of them were trau- matised more than once by the same perpetrator (n = 30,

63�8%). Revictimisation had occurred for 40�4% (n = 19) of the women (‘re-victimisation’ was defined as at least

one additional incident of sexual abuse in both childhood

and adulthood, refer Wyatt et al. 1992). A total of

25�5% of them (n = 12) had never talked about their sex- ual assault to anyone before this therapy and had not

received professional help after the assault (n = 37,

78�7%).

Instruments

After obtaining the information discussed above, the Ham-

ilton Depression Rating Scale (HAM-D), Hamilton Anxiety

Rating Scale (HAM-A), Clinician Administered Post-trau-

matic Stress Disorder Scale (CAPS), Dissociative Experi-

ences Scale (DES) and Childhood Trauma Questionnaire

(CTQ-28) were administered. All of the instruments

throughout the study were administered by one of the

authors (A.S.), who has 10 years of experience in clinical

psychiatry and is familiar with the scales. Some of the

scales are self-report scales.

The Hamilton Depression Rating Scale

This is a clinician-applied scale with 17 questions,

developed by Max Hamilton (Hamilton 1960). Scores from

8–15 show mild, from 16–28 points show moderate, and

above 29 show severe depression. The Turkish form’s valid-

ity and reliability had been previously established (Akdemir

et al. 1996), with a test–retest reliability coefficient of 0�85 and Cronbach’s coefficient of 0�75.

The Hamilton Anxiety Rating Scale

This is a clinician-applied five-point Likert-type scale with

14 questions (Hamilton 1959). It includes both psychologi-

cal and bodily symptoms of anxiety. The Turkish form’s

validity and reliability had been previously established

(Yazıcı et al. 1998), with a test–retest coefficient of 0�72 and Cronbach’s coefficient of 0�94.

The Clinician Administered Post-traumatic Stress

Disorder Scale

This is a 17-item scale for the assessment of current and

lifetime PTSD symptoms (Blake et al. 1995). The 17

symptoms cluster into three subscales: CAPS-R for re-

experiencing, CAPS-A for avoidance/numbing and CAPS-H

for hyperarousal. A subject is considered ‘positive’ for life-

time symptoms if he/she endorses the symptoms within a

certain amount of time after the traumatic event. A sub-

ject is considered ‘positive’ for current symptoms if he/she

still has these symptoms. The Turkish version of CAPS

has a Cronbach’s alpha of 0�91 for the whole scale, 0�78 for re-experiencing symptoms, 0�78 for avoidance/numbing symptoms and 0�82 for hyperarousal symptoms (Aker et al. 1999).

Adolescent and female sexuality Group psychotherapy of sexual abuse

The Dissociative Experiences Scale

This is a 28-question self-report scale. For each question,

participants are asked to rate a sentence related to dissocia-

tive symptoms on a scale between 0–100 (Bernstein & Put-

man 1986). The Turkish version has a Cronbach’s alpha of

0�97 and a test–retest correlation of 0�77, and the cut-off point for a Turkish population is 30 (Yargıc� et al. 1995). This scale was used only at screening in this study, because

it evaluates dissociative symptoms experienced within a

lifetime.

The Childhood Trauma Questionnaire

This is a five-point Likert-type self-report questionnaire

developed by Bernstein et al. (1994). It evaluates childhood

trauma history according to five dimensions: physical

neglect, physical abuse, emotional neglect, emotional abuse

and sexual abuse. The Turkish version has a Cronbach’s

alpha of 0�96 (Aslan & Alparslan 1999).

The Group Therapeutic Factors Questionnaire

For this study, Yalom’s 60-item therapeutic factor question-

naire was used (Yalom 1975). The questionnaire contains

60 items, 5 describing each of the 12 factors (a brief

description of each therapeutic factor can be found in Table

3). Patients are asked to consider each of the 12 items (pre-

sented on five separate pages) and rank each item from the

least helpful (1) to the most helpful (12). This questionnaire

had previously been translated into Turkish (transl Tang€or

& Karac�am 1999). The HAM-D, HAM-A and CAPS were given four times

during the study: at entry (baseline), after the sixth session,

after the final (12th) session and at a follow-up session

(six months after the therapy ended). The DES and CTQ-

28 were given at entry. The Group Therapeutic Factors

Questionnaire was given after the final therapy session.

Group psychotherapy method

An eclectic method of group psychotherapy was applied

that had been developed by one of the authors (L.W.)

and used by her for 20 years. This method uses a combi-

nation of well-validated psychotherapy methods (such as

cognitive behavioural therapy, interpersonal therapy, nar-

rative therapy, psychoeducation, expressive techniques) for

trauma-focused therapies (for a review, see Taylor &

Harvey 2010). It includes 12 90-minute sessions, and each

session has an agenda. Some of the topics from the first

three sessions include group rules, safety issues and effects

of sexual trauma on psychological and interpersonal

well-being. A psychotherapeutic approach for common

psychiatric and psychological responses to trauma was

applied, and some relaxation techniques were introduced.

In sessions 4–7, participants were asked to tell their sex-

ual abuse stories, in an order determined by themselves.

In sessions 8–10, some common themes raised in the

members’ stories were discussed more deeply in the

group. Examples of some of these themes include issues

about self-respect, self-esteem, sexuality, relationships with

men, with family, anger, etc. The 11th and 12th sessions

were closure sessions during which members summarised

their group process, gave feedback to each other and

talked about their future plans. An additional follow-up

session was provided six months after finishing the 12th

session. All of the sessions were conducted by all of the

authors (one therapist and two co-therapists), who have

10–20 years of group psychotherapy experience as thera-

pists and co-therapists.

Statistical analysis

All data were statistically analysed using the SPSS, version

15.0 package (SPSS Inc., Chicago, IL, USA) programme.

For statistical analysis of the differences between the mean

scores of the HAM-A, HAM-D and CAPS during the entire

group process and on follow-up, the general linear model

for repeated measures, chi–square test, and Friedman’s and

Wilcoxon’s analysis with Bonferroni correction were used.

The Mann–Whitney U-test, chi–square test, and Pearson’s

correlation and linear regression analyses were used to

find the variables that had a significant effect on the thera-

peutic factors, treatment efficacy and dropout rates. A

p-value < 0�05 was considered statistically significant.

Results

Treatment adherence

A total of five groups were completed, each consisting of

8–10 members. There were no statistically significant

differences between these five cohorts with regard to socio-

demographic variables, sexual trauma history, scores from

whole scales, and dropout and efficacy rates. Among the

47 women who applied for this study, 32 (68�1%) finished the whole group process. Seven (14�9%) never attended group after being screened, and these subjects were

excluded from further statistical analysis. The remaining

eight (17�0%) subjects will be referred as ‘dropouts’, because these women attended at least one session but did

not finish the whole process. To determine the predictors

A Sayın et al.

for these dropouts, chi-square and linear regression analy-

ses were conducted, and we found that being younger than

33 years of age (median) [odds ratio (OR) = �0�459; 95% confidence interval (CI) �0�571 to �0�140, p = 0�002] and a DES score lower than 30 (no dissociation)

(OR = �0�405; 95% CI �0�547 to �0�101, p = 0�006) predicted a higher dropout rate (Table 1).

Treatment response

The results for the remaining 32 subjects’ mean scores on

the scales given throughout the study, as well as a com-

parison of their scores at the baseline (screening), after

the 6th and the 12th sessions and at the six-month fol-

low-up are shown in Table 2. These analyses were made

Table 1 Regression analysis for treatment adherence

Attendance n (%)

v² p OR Sig (reg)

95% confidence interval

Finished Dropped out Lower bound Upper bound

Age

� 33 years 15 (65�2) 8 (34�8) 7�391 0�007 �0�459 0�002 �0�571 �0�140 >33 years 17 (100) 0

DES

� 27 18 (72) 7 (28) 4�778 0�036 �0�405 0�006 �0�547 �0�101 >27 14 (100) 0

DES, Dissociative Experiences Scale.

Table 2 Mean scores of Hamilton Depression Rating scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A), Clinician Administered

Post-traumatic Stress Disorder Scale-Total (CAPS-T) (subtitles re-experiencing symptoms CAPS-R, avoidance symptoms CAPS-A, hypera-

rousal symptoms CAPS-H), Dissociative Experiences Scale (DES) and Childhood Trauma Questionnaire (CTQ-28) at screening (1), after 6th

session (2), after 12th session (3) and six-month follow-up (4)

Scale Mean SD v² p* Z p†

HAM-D1 22�45 11�1 48�363 0 HAM-D1/2 �4�889 0 HAM-D2 14�64 9�89 HAM-D2/3 �4�725 0 HAM-D3 8�55 8�13 HAM-D3/4 �2�445 0�002 HAM-D4 5�55 4�95 HAM-A1 15�45 8�9 41�533 0 HAM-A1/2 �4�62 0 HAM-A2 9�82 9�17 HAM-A2/3 �4�173 0 HAM-A3 5�09 6�61 HAM-A3/4 �0�683 0�082 HAM-A4 4�32 2�44 CAPS-T1 42�27 19�68 42�823 0 CAPS-T1/2 �4�42 0 CAPS-T2 26�64 25�95 CAPS-T2/3 �3�503 0 CAPS-T3 13�77 24�21 CAPS-T3/4 �0�669 0�167 CAPS-T4 9�32 11�84 CAPS-R1 10 9�25 6�596 0�086 CAPS-R1/2 �1�255 0�069 CAPS-R2 9�55 11�32 CAPS-R2/3 �1�725 0�028 CAPS-R3 6�36 10�48 CAPS-R3/4 �1�074 0�094 CAPS-R4 3�95 7 CAPS-A1 20�55 10�25 40�026 0 CAPS-A1/2 �4�341 0 CAPS-A2 10�18 11�57 CAPS-A2/3 �3�481 0 CAPS-A3 3�82 10�63 CAPS-A3/4 �1�153 0�083 CAPS-A4 0�91 2�52 CAPS-H1 11�73 9�42 17�112 0�001 CAPS-H1/2 �3�23 0 CAPS-H2 6�91 8�22 CAPS-H2/3 �3�126 0 CAPS-H3 3�59 6�26 CAPS-H3/4 �0�306 0�253 CAPS-H4 4�45 7�75

*Friedman’s test. †Wilcoxon’s test with Bonferroni correction.

Adolescent and female sexuality Group psychotherapy of sexual abuse

in two steps. First, a nonparametric analysis for

K-repeated samples (Friedman) was performed to analyse

the changes in scores from baseline to follow-up. Second,

to find exactly when a significant decrease in scores

had occurred, nonparametric analysis for 2-Related

Samples (Wilcoxon’s test with Bonferroni correction) was

performed. According to these results, the significant

decline in HAM-D (mean = 22�45 versus 14�64, p < 0�001), HAM-A (15�45/9�82, p < 0�001), CAPS-total (CAPS-T) (42�27/26�64, p < 0�001), CAPS-A (20�55/10�18, p < 0�001) and CAPS-H (11�73/6�91, p < 0�001) began during the first six sessions. This tendency to decline

continued through the follow-up session, and the statisti-

cal significance was lost between 12th session and the

six-month follow-up, except for the HAM-D (8�55/5�55, p = 0�002). CAPS-H scores increased between the 12th session and the six-month follow-up session without a

statistically significant difference. For the CAPS-R scores,

a significant decline began between the 6th and the 12th

sessions (9�55/6�36, p = 0�028), and this significance was lost between the 12th session and the six-month follow-

up session.

As shown in Table 2, the standard deviations were

high, which suggests that there were some extreme cases

that did not respond to therapy. To find predictors for

treatment outcome, we divided the subjects into two

groups with regard to treatment efficacy. For those sub-

jects whose scores from all scales decreased more than

50% between baseline and the end of therapy (12th ses-

sion), the treatment could be considered ‘efficacious’

(n = 25, 78�1%). Chi-square and linear regression analy- ses were performed to find the predictors for treatment

outcome. The only significant result was for DES scores:

for the majority of those who had a DES score of <30

(no dissociation), the treatment was efficacious (n = 17,

94�4%), while for the 42�9% (n = 6) of the women who had a DES score above 30, the treatment was not effica-

cious (OR = �0�448; 95% CI = �0�651 to �0�095, p = 0�010).

Understanding the therapeutic factors

Table 3 shows the results of the Group Therapeutic Factors

Questionnaire. Existential factors (mean � standard devia- tion, 41�40 � 12�39), universality (37�56 � 7�11) and cohe- siveness (37�24 � 8�32) were rated as the most helpful therapeutic factors in the group process, while identification

(23�56 � 7�90), interpersonal learning – input (24�64 � 8�70) and interpersonal learning – output (25�80 � 7�91) were rated as the least helpful factors.

Discussion

We were able to fulfil the three aims we had for this study.

The first aim was to help these women to heal from their

trauma-related psychiatric and psychological difficulties.

Most of these women had severe psychiatric symptoms at

screening, including depression, anxiety, post-traumatic

stress disorder and dissociation. Their symptom patterns

were similar to those previously reported for comparable

populations (for a review, see Barker-Collo & Read 2003).

As shown in Table 2, most of the group members had sig-

nificantly less depressive, anxiety and post-traumatic stress

disorder symptoms, both immediately after and six months

after this therapy. These results show that group psycho-

therapy was effective for this sample, a result that is in

accord with previous literature (for reviews see Taylor &

Harvey 2010, Trask et al. 2011). A significant decline in

symptoms began as early as the 6th session for depression

and anxiety, along with their overall symptoms of PTSD,

primarily avoidance and hyperarousal symptoms. The only

exception was the re-experiencing of symptoms of PTSD,

which showed a small decline at the 6th session evaluation,

but this decline became significant at the 12th session

evaluation. We think that the possible reason for this ‘late’

decline in re-experiencing symptoms is that from sessions

4–7, participants were asked to tell their sexual abuse sto-

ries. Telling their trauma stories in front of other members,

as well as listening to the other members’ stories, may have

caused a temporary increase in some participants’ re-experi-

encing symptoms. But as group members became ‘de-sensi-

tised’ to the telling and hearing of stories, their symptoms

begin to decline.

We found that this treatment was efficacious for 78�1% of these women. This rate is similar to the rates reported in

the literature, because a large meta-analysis of 26 studies

Table 3 Mean scores of Group Therapeutic Factors Questionnaire

Therapeutic factors Mean SD

Altruism 29�24 10�12 Cohesiveness 37�24 8�32 Universality 37�56 7�11 Interpersonal learning – input 24�64 8�70 Interpersonal learning – output 25�80 7�91 Guidance 26�00 8�15 Catharsis 30�48 7�14 Identification 23�56 7�90 Family re-enactment 34�32 11�59 Self-understanding 42�32 11�35 Hope instillation 36�40 9�61 Existential factors 41�40 12�39

A Sayın et al.

including 44 treatment conditions for psychotherapy of

PTSD reports that, of patients who completed treatment,

67% no longer meet the criteria for PTSD (Bradley et al.

2005). What is interesting is that none of the variables had

a significant effect on treatment efficacy. The only signifi-

cant result was for dissociation at baseline; the treatment

was significantly more effective for members who had a

lower score for dissociation at baseline, as compared to

those who had higher dissociation scores. This finding is in

contradiction to results from previous studies which have

shown that more severe dissociative symptoms at baseline

are associated with the same or even better outcomes for

psychological treatments for PTSD (Lynch et al. 2008,

Hagenaars et al. 2010). Dropout rates were also similar to

the rates reported in the literature (Bradley et al. 2005). A

younger age and having lower levels of dissociation at

baseline predicted a higher dropout rate. Dissociation is a

complex symptom and may have a significant negative

effect on individual’s daily life and functioning. This may

have created a higher level of motivation for treatment,

which is reflected in a lower dropout rate.

Our second aim was to find how different characteristics

of group members affected their understanding of the group

process, especially the therapeutic factors of group psycho-

therapy. In this sample, group members reported that exis-

tential factors, universality and cohesiveness were the most

helpful therapeutic factors. This finding supports the ratio-

nale for using group psychotherapy in trauma treatment,

because, as previously stated, a safe and structured group

environment helps members to feel supported, heard and

believed and lessens their feelings of stigma, isolation and

shame (Feiring et al. 1996, Talbot 1996, Westbury &

Tuttly 1999).

We have two hypotheses to explain why group members

chose these particular factors. First, we believe that the set-

ting had a significant effect upon ‘cohesiveness’. The groups

were run in the private office of one of the authors. Mem-

bers were permitted to come half an hour before the group

started. Many group members chose to do this, and they

often brought food with them, drank coffee and talked with

each other. This somewhat resembles ‘women’s day’ in

Turkish culture, social events where women come together

regularly to eat, drink and talk with each other. We believe

these ‘before-the-group’ talks encouraged the occurrence of

cohesiveness. In addition, most of the group members con-

tinued to meet regularly after the whole group process

ended. Some of them even began to organise community

education programmes. Second, we think that ‘culture’ had

an important effect on ‘universality’. The most common

perpetrators for our sample were first-degree family

members (29�8%) and husbands/lovers (29�8%). Incest is a major social taboo in Turkey, and usually, both the victims

and their families would rather ‘keep it a secret’ instead of

talking about such abuse. Incest may even result in murders

within families. Sexual abuse by husbands/lovers is some-

times not considered illegal in Turkey. For these reasons,

women in Turkey who are sexually abused by first-degree

relatives and/or husbands usually do not share their trauma

story with anyone else. Shame and fear may be the main

emotions for women who choose to remain silent after this

kind of sexual abuse. Understanding this helps us to under-

stand why these women might choose ‘universality’ as one

of the most helpful therapeutic factors. Hearing other

women’s stories and realising that they are not the only

people who have had to face such an event may have less-

ened these women’s feelings of isolation, and this may have

helped them through their healing process. This is also

closely related to the ‘existential factors’; these women may

have learned that ‘life is not always fair’ by listening to

other women’s stories. Existential well-being, defined as

having a sense of being unique, having a purpose in life

and finding meaning in a ‘hostile and hurtful’ world, has

previously been shown to be an important factor in recov-

ery from sexually abusive experiences (Feinauer 2003, Shaw

et al. 2005). Rating existential factors as one of the most

helpful therapeutic factors in group psychotherapy suggests

that group participants were able to make meaning in their

lives that has become more significant to them than their

sexually abusive experiences. They were able to see them-

selves as having survived a difficult and destructive experi-

ence resulting from another person’s disturbance. Once

freed from self-blame, these women could believe they have

an opportunity to change their lives and could put their

traumatic experiences into the past. This finding is beauti-

fully reflected in a comment made by one of our group

members: ‘I used to carry my life on my shoulders like a

burden. Now I am ready to flow with it’.

We had a third exploratory goal in this study and that

was to observe similarities and differences with regard to

responses to sexual trauma–related issues and the group

therapy setting between Turkish women and women from

other countries reported in the literature. One of our thera-

pists (L.W.) had run groups with sexually abused women in

the USA for 20 years, so she had a chance to compare these

similarities and differences. Another paper compares obser-

vations of group patterns for sexual abuse survivors in

these two countries with significantly different cultures.

But, to summarise, we report that although groups from

these two countries were overwhelmingly similar in many

ways, differences emerged in expression and containment of

Adolescent and female sexuality Group psychotherapy of sexual abuse

effect, cohesion and relatedness, perceptions of reaction to

authority and power, and external/internal locus of control

(L. Welkin, S. Candansayar and A. Sayın, unpublished

results). Religiously and culturally determined contrasts in

perception, attitude, communication and behaviour may

have significant effects on patients’ perceptions about thera-

peutic factors (Salvendy 1999). Turkish culture is often

described as a culture of relatedness or collectivism where

interpersonal relations are of central importance, in con-

trast to a culture of separateness and individualism where

personal autonomy is more highly valued (Ka�gıtc�ıbas�ı 1994). People in more relational cultures are thought to

seek high levels of relatedness and moderate levels of

autonomy to maintain their mental health, while people in

more individualistic cultures seek high levels of autonomy

and moderate levels of relatedness (Sato 2001). Universality

and cohesiveness are, we believe, therapeutic factors that

can be closely related to ‘relatedness’. In a study conducted

with Turkish psychiatric inpatients, it was reported that

patients rated existential factors, instillation of hope and

universality as the most helpful group therapeutic factors

(Sayin et al. 2008). To our knowledge, there is no other

study about therapeutic factors in sexual abuse survivor’s

groups, but it would be interesting to compare our results

with results from more individualistic countries.

Although our results are promising, this study has some

major limitations. First, our sample is small and is not

representative of all Turkish sexual abuse victims, because it

includes only women living in the capital city of Turkey. Sec-

ond, this is not a controlled study, and we did not compare

the therapeutic effect of group psychotherapy to any other

form of treatment or a waiting list. Third, all the treatment

outcome ratings were performed by one of the therapists in

the group and that may have created a bias.

Conclusion

We believe that this study, despite its limitations, provides

further support for the effectiveness of group psychotherapy

for women from different cultural backgrounds with a his-

tory of childhood sexual abuse. Group psychotherapy was

significantly effective for reducing levels of depression, anxi-

ety and PTSD symptoms in this sample of women. Dissoci-

ation had a significant effect on both treatment outcome

and treatment adherence. Further studies conducted with

sexually abused women from different countries would

surely enrich the literature and help us to understand better

how to help victims of sexual abuse.

Relevance to clinical practice

Mental health treatment for sexually abused women should

be planned with careful consideration of both local cultural

differences and universal human fundamentals. Group psy-

chotherapy can be a preferable treatment for these women,

because it especially helps to reduce feelings of stigma,

isolation and shame.

Contributions

Study design: AS, SC, LW; data collection and analysis: AS

and manuscript preparation: AS, SC, LW.

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