Module 8 Mindfulness Intervention Research Assignment Part 2

T h e D e v e l o p m e n t o f a B r i e f A c c e p t a n c e a n d M i n d f u l n e s s - B a s e d P r o g r a m A i m e d a t R e d u c i n g S e x u a l R e v i c t i m i z a t i o n A m o n g C o l l e g e W o m e n W i t h a H i s t o r y o f C h i l d h o o d S e x u a l A b u s e

�

Justin M. Hill,1 Peter M. Vernig,2 Jonathan K. Lee,2 Cynthia Brown,2

and Susan M. Orsillo2

1 Boston VA Healthcare System 2 Suffolk University

Women with a history of childhood sexual assault (CSA) are more likely to be revictimized; however, most

existing programs aimed at reducing sexual victimization do not expressly address the issue of

revictimization. The present study examined the efficacy of a brief mindfulness-based program in reducing

rates of sexual assault and revictimization in college women over the course of an academic semester.

Although the results were not statistically significant, a large-magnitude effect was noted, whereby

women with a history of CSA who participated in the program were less likely to be sexually assaulted

and raped at 2-month follow-up. & 2011 Wiley Periodicals, Inc. J Clin Psychol 67:969–980, 2011.

A recent U.S. census found that 9.6 million women between the ages of 15 and 54 reported

experiencing childhood sexual assault (CSA) or abuse that occurred before 18 years of age

(Molnar, Buka, & Kessler, 2001). Approximately 27% of female college students report having

been the victim of CSA (Arata, 2002; Mayall & Gold, 1995), which is relatively consistent with

rates derived from other populations (e.g., community, inpatient). Regardless of specific

population, women who experience CSA are at increased risk for a wide range of psychological

difficulties including substance abuse (e.g., Wilsnack, Vogeltanz, Klassen, & Harris, 1997),

high-risk sexual behavior (e.g., Thompson, Potter, Sanderson, & Maibach, 1997), personality

disorders (e.g., Linehan, 1993), depressive symptoms (e.g., Jackson, Calhoun, Amick,

Maddever, & Habif, 1990), suicidal ideation and attempts (e.g., Jackson et al.), and

posttraumatic symptoms (Saunders, Villeponteaux, Lipovsky, Kilpatrick, & Veronen, 1992).

Childhood sexual assault is also associated with a significantly increased risk of future

victimization (revictimization; Gidycz, Coble, Latham, & Layman, 1993; Messman & Long,

1996; Wyatt, Guthrie, & Notgrass, 1992). Revictimization is defined in this study as having a

history of childhood sexual assault and an experience of being assaulted again in adolescence

or adulthood. Studies demonstrate that female undergraduates with a history of CSA are 1.5

to 2.5 times more likely to be assaulted as an adolescent or adult than college women without

CSA history (Arata, 2002; Gidycz et al., 1993; Mayall & Gold, 1995). Among female

undergraduate rape victims, one-half to two-thirds report having experienced CSA (Arata,

1999a; Koss & Dinero, 1989).

The extant research suggests that among college women, revictimization is associated with

increased psychological distress (Gold, Milan, Mayall, & Johnson, 1994). Revictimized college

women also receive significantly more lifetime psychiatric diagnoses compared with nonvictims

and are assigned a lifetime diagnosis of posttraumatic stress disorder (PTSD) at higher rates

than women with either a child-only or adult-only sexual assault history (Arata, 1999b).

� This article was reviewed and accepted under the editorship of Beverly E. Thorn.

This article is based on the doctoral dissertation of Justin M. Hill submitted to Suffolk University. Portions of this dataset were presented at the 2007 and 2008 annual meetings of the Association for Behavioral and Cognitive Therapies.

Correspondence concerning this article should be addressed to: Justin M. Hill, Boston VA Healthcare System, Psychology Dept, 150 S. Huntington Ave., Boston, MA 02130; e-mail: [email protected]

JOURNAL OF CLINICAL PSYCHOLOGY, Vo l . 6 7 ( 9 ) , 9 6 9 -- 9 8 0 ( 20 1 1 ) & 2011 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). D O I : 1 0 . 1 0 0 2 / j c l p . 2 0 8 1 3

Given the prevalence of sexual assault on college campuses and the significant physical and

psychological sequelae, federal mandates require that all colleges and universities offer sexual

assault prevention programming (National Association of Student Personnel Administrators,

1994). Although many programs have been successful in changing attitudes toward sexual

victimization among college students, most have been unsuccessful at preventing sexual

victimization (e.g., Blackwell, Lynn, & Vanderhoff, 2004; Breitenbecher, 2000). Moreover, the

few programs that have been successful in reducing rates of sexual assault (e.g., Breitenbecher

& Gidycz, 1998; Hanson & Gidycz, 1993) have been ineffective in preventing revictimization.

One exception to this finding is a study conducted by Marx, Calhoun, Wilson, and Meyerson

(2001). Although they found no significant differences between an intervention specifically

aimed at preventing sexual revictimization and control groups in overall rates of

revictimization at 2-month follow-up, the program seemed to reduce the incidence of rape.

Among those who reported being victimized during the follow-up interval, significantly more

(30% vs 12%) women in the control group reported having been raped compared with the

intervention group.

It has been argued that one of the shortcomings of existing sexual assault prevention

programs is the absence of a guiding theoretical model (Bachar & Koss, 2001; Morrison,

Hardison, Mathew, & O’Neil, 2004; Yeater & O’Donohue, 1999). Messman-Moore and Long

(2003) argue that an all-encompassing, theoretical framework is needed to guide future

empirical studies of revictimization and, ultimately, the development of effective risk-

reduction programs. They encourage researchers to focus less on the specific behavioral

patterns and symptoms that may be associated with revictimization and more on a single

mechanism that may underlie and account for the diverse risk factors.

Polusny and Follette (1995) developed a theoretical model to account for revictimization

that has begun to accumulate some significant empirical support and may have implications

for risk reduction programming. The model is based on a more general theory of

psychopathology that suggests that many problematic behaviors and symptoms of

psychopathology are driven by experiential avoidance (Hayes, Wilson, Gifford, Follette, &

Strosahl, 1996). Experiential avoidance is defined by Polusny and Follette as an ‘‘unwillingness

to experience unpleasant internal events such as thoughts, memories, and affective states

associated with an abuse history, and subsequent attempts to reduce, numb, or alleviate these

negatively self-evaluated internal experiences’’ (p. 158). Follette (1994) proposed that women

with a history of CSA may be unwilling to experience unpleasant internal events related to

their abuse, and, thus, they might engage in a variety of behavioral strategies aimed at

temporarily avoiding or alleviating these abuse-related internal experiences. In support of this

model, Gibson and Leitenberg (2001) found that sexually assaulted women with a history of

CSA used more disengagement methods of coping with adult victimization than women

without such a history, and Marx and Sloan (2002) reported that experiential avoidance

mediated the relationship between CSA and psychological distress.

Unfortunately, many of the behavioral strategies used by CSA survivors to cope with their

internal experiences may actually increase their risk for revictimization. For example, drug

and alcohol use, commonly conceptualized as forms of emotional or experiential avoidance

(e.g., Briere & Runtz, 1993; Polusny & Follette, 1995), have been shown to increase a woman’s

risk of being sexually assaulted (e.g., Gidycz, Hanson, & Layman, 1995). Increased sexual

activity has also been theorized to modulate abuse-related emotional pain (Briere, 1996; Briere

& Runtz); however, frequency of sexual activity has been shown to be a predictor of sexual

revictimization (Fergusson, Horwood, & Lynskey, 1997; Himelein, 1995). An avoidant coping

style may also contribute to the diminished risk recognition found among some women with a

history of sexual assault (e.g., Wilson, Calhoun, & Bernat, 1999). If experiential avoidance is a

predominant coping strategy for CSA survivors and represents a risk factor for future

revictimization, then it follows that a program aimed at reducing experiential avoidance and

cultivating acceptance of internal experiences should reduce future rates of revictimization.

The present study examined whether a brief acceptance-based and mindfulness-based

intervention (based on the theoretical model proposed by Polusny & Follette, 1995) would

reduce rates of sexual victimization among female college students with and without CSA

970 Journal of Clinical Psychology, September 2011

history. Acceptance-based and mindfulness-based behavioral interventions have been shown

to be effective in treating anxiety and mood disorders (e.g., Forman, Herbert, Moitra,

Yeomans, & Geller, 2007; Koszycki, Benger, Shlik, & Bradwejn, 2007; Ma & Teasdale, 2004;

Roemer & Orsillo, 2007; Woods, Wetterneck, & Flessner, 2006), psychotic disorders (Bach &

Hayes, 2002; Guadiano & Herbert, 2006), substance use disorders (Gifford et al., 2004; Hayes,

Wilson et al., 2004), and couples distress (Christensen, Sevier, Simpson, & Gattis, 2004;

Christensen, Atkins, Yi, Baucom, & George, 2006; Jacobson, Christensen, Prince, Cordova, &

Eldridge, 2000). Further, mindfulness-based stress reduction has been shown to positively

affect depression, PTSD, and anxiety among CSA survivors (Kimbrough, Magyari,

Langenberg, Chesney, & Berman, 2010). However, to our knowledge, this approach has

not been tested as a possible means of reducing sexual revictimization.

The goal of the current study was to develop and test the effectiveness of a brief sexual

assault prevention program, informed by the existing theoretical and empirical literature, in

reducing revictimization among college women with a history of CSA. The program used

acceptance-based and mindfulness-based strategies aimed at increasing participants’ will-

ingness to notice and allow unpleasant thoughts, feelings, and physical sensations and to

decrease attempts to avoid or suppress these internal experiences. We specifically designed the

program to be brief (2 sessions), to be both consistent with standard practice (Marx et al.,

2001; Morrison et al., 2004) and to ensure that it would be feasible and cost-effective for use

on a college campus. Further, although we were interested in the affect of the program on

sexual victimization, we purposefully designed the program to be broad and general in

content. Thus, the program was described as a workshop aimed at reducing stress and

increasing well-being and no sexual assault-specific material was included. This approach is

consistent with the application of mindfulness-based stress reduction to a broad diversity of

participants with a variety of psychological and medical conditions. Mindfulness-based

interventions have been shown to affect a number of problematic areas among college students

including stress, sleep disturbance (Caldwell, Harrison, Adams, Quin, & Greeson, 2010), and

cigarette use (Bowen & Marlatt, 2009), suggesting that targeting experiential avoidance may

affect a broad constellation of risk behaviors. It has been argued that integrating strategies

that might reduce sexual victimization into broader programs that focus generally on healthy

development may be more beneficial and cost-effective than the development and delivery of a

variety of disparate programs (Morrison et al., 2004).

Method

Participants

Participants were selected from a pool of 95 undergraduate women enrolled in psychology

courses at a private, New England university, and who were at least 18 years of age and

completed a measure assessing CSA. Childhood sexual assault was defined as sexual contact

that ranges from fondling to intercourse occurring before the age of 17 years that (a) occurred

without consent or was unwanted, (b) was perpetrated by a family member, or (c) was

perpetrated by a person more than 5 years older than the participant. To maximize

participation in this effectiveness study, we did not use random assignment. Thirty-women

(31.7%) met criteria for CSA and all were invited to participate in the program, which was

described as a mindfulness-based program designed to increase the health and well-being of

female college undergraduates. Of the 15 who agreed to participate, three women dropped out

after the first session, leaving 12 women with CSA history participating in the full program.

The remaining 20 women with CSA history were considered part of the no-program

comparison group. Independent samples t tests revealed that there were no significant

differences between women with and without CSA history who chose to participate in the

program compared with those who declined participation with regard to their reported

demographic information (age, academic year, race/ethnicity, religion, and previous

experience with yoga or mindfulness) or responses on the self-report questionnaires.

971Mindfulness and Sexual Revictimization

Although we predicted that the program would be most effective in reducing revictimiza-

tion, we also examined the affect of the program on sexual victimization among women

without a CSA history. From a practical standpoint, we felt that the program could be most

easily integrated into a college curriculum if it was offered to all women, regardless of their

sexual history, because college students may be hesitant to routinely disclose this private

information. To create a roughly comparable group, 25 women without a reported CSA

history were contacted and asked to participate in the program. Twenty-one women agreed

and four declined due to scheduling conflicts. An additional 24 women agreed to participate in

the no-intervention comparison group. Participants were primarily White (74.6%) and had a

mean age of 18.9 years (standard deviation [SD] 5 1.88). There were no significant differences

in ethnicity or religious affiliation between women with and without a history of CSA.

Measures

Sexual Experiences Survey (SES). The SES (Koss & Oros, 1982) is a self-report instrument consisting of 10 yes/no items designed to assess various degrees of sexual

victimization. Two versions of this measure were administered. The first assessed history of

CSA defined as events that occurred before 17 years of age. The second (administered at

follow-up) asked respondents to indicate any sexual victimization that occurred in the

2-month period since the last assessment. The SES shows high test-retest reliability in college

samples and is significantly correlated with clinician-administered interviews (Koss & Gidyz,

1985). For the purpose of this study, sexual victimization is defined as a woman who

experiences any unwanted gesture from a man that is sexual in nature, ranging from fondling,

kissing, or petting to sexual intercourse with a man’s penis or another object.

Kentucky Inventory of Mindfulness Skills (KIMS). The KIMS (Baer, Smith, & Allen, 2004) is a 39-item questionnaire designed to measure mindfulness, which comprises the

following four subscales: observing, describing (labeling noticed phenomena), acting with

awareness (engaging in present moment activity without distraction), and accepting without

judgment. Items are rated on a 5-point Likert scale, ranging from 1 (never or very rarely true)

to 5 (almost always or always true). The reliability and convergent validity (with measures of

experiential avoidance and mindfulness) of the measure have been established (Baer et al.).

Internal consistency in the current sample was evaluated with Cronbach’s a and ranged from .76 to .88 at pretest and .84 to .93 at follow-up.

Acceptance and Action Questionnaire (AAQ). The AAQ (Hayes, Strosahl, Wilson, Bissett, Pistorello, Toarmino et al., 2004) is a self-report measure that assesses the construct of

experiential avoidance (i.e., engaging in efforts to avoid or reduce the frequency of memories,

thoughts, feelings, and bodily sensations), and psychological flexibility (i.e., the inability or

unwillingness to take action in the face of distressing experiences). The items on the AAQ are

rated on a 7-point Likert scale ranging from 1 (never true) to 7 (always true). Higher scores

correspond to high experiential avoidance, whereas lower scores reflect acceptance and action.

The AAQ has demonstrated convergent validity with measures of thought suppression. There

have been many variations of the AAQ (7, 9, 16, 18, and 32 items) that are highly correlated

(Hayes, Strosahl, Wilson, Bissett et al., 2004). This study used the 16-item AAQ. Cronbach’s

a ranged from .73 at pretest to .76 at follow-up.

Program utility and practice questionnaire. A measure was developed to assess the frequency with which participants practiced the mindfulness skills they learned from the

program and whether they planned to use the skills acquired from the program in the future.

Each item was rated on a 5-point Likert-type scale, ranging from 1 (about everyday) to 5 (never).

Procedure

All participants completed the study measures (i.e., SES, KIMS, and AAQ) during the initial

screening and groups were created as described above. Those who completed the

972 Journal of Clinical Psychology, September 2011

questionnaires received course credit regardless of whether they agreed to participate in the

program.

The intervention was conducted in two, 2-hour group sessions (spaced approximately 1

week apart) and comprised a combination of college women with and without a CSA history.

An overview of each session is presented in Table 1. One of three male master’s-level graduate

students facilitated each group of approximately five to eight women. To maximize

participation, scheduling conflicts of participants were accommodated and women did not

necessarily share the same group members or have the same facilitator in session 2 as they did

in session 1. A combination of psychoeducation and experiential exercises was used to

promote (a) awareness of internal responses to events, (b) observation of the present moment/

presence in one’s life, (c) awareness of the judgments one makes about her thoughts and

experiences, (d) the cultivation of a sense of compassion towards one’s internal experience, and

Table 1 An Overview of the Program

Session 1

Phase I (20 minutes)

� Greeting the group, introducing the facilitators

� Brief introduction of what they will be doing

� Discuss/list common college stressors

Phase II (20 minutes)

� Discuss ways of coping with stressors

� Coping strategies categorized into three domains

3 Social support, behavioral activation, internal control strategies

Phase III (30 minutes)

� Evaluating the strategy of attempting to control internal events such as thoughts, emotions, and

physiological sensations

3 Benefits/consequences to this strategy

Phase IV (30 minutes)

� Limits and costs of labeling, judging and attempting to control internal experiences will be

considered

� Finding the usefulness of ‘‘negative’’ emotions

� Acceptance/mindfulness as potential alternatives to internal control strategies

Phase V (20 minutes)

� Breathing exercise

� Distribute readings and self-monitoring forms

� Briefly review how the readings and self-monitoring forms may be helpful

Session 2

Phase I (20 minutes)

� Begin with a repeat of the breathing exercise that ended the first session

� Overview of readings, self-monitoring forms, and breathing exercises that they were asked to do in

between sessions

Phase II (20 minutes)

� Discussion about the basic concept of mindfulness to refresh participants

� Exercise in accepting our internal experiences

Phase III (30 minutes)

� Discussion about willingness and personal values

� Sentence completion exercise to illustrate obstacles keeping us from our desired goals

Phase IV (30 minutes)

� ‘‘Passengers on a Bus’’ metaphor to highlight the importance of empowerment and practicing one’s

values

� Mountain Meditation exercise further emphasizing engaging in our lives that is consistent with our

values

Phase V (20 minutes)

� Summary of mindfulness in everyday life

� Handout self-monitoring forms, readings and take-home exercises

973Mindfulness and Sexual Revictimization

(e) the differentiation between internal experiences and behavior. The program did not contain

any sexual assault specific content.

Approximately 2 months (mean [M] 5 9.97 weeks) after the program was delivered,

participants completed a follow-up assessment that included the SES, KIMS, and AAQ, and

the Program Utility and Practice Questionnaire if they had participated in the program.

Although a longer follow-up period would have been preferable, to enhance feasibility, we

opted to conduct the entire study within a semester. Moreover, a 2-month follow-up was

consistent with the timeframe used in previous studies. Thirty-eight percent of sexual

prevention programs in a recent review had follow-up periods of less than 1 month and an

additional 34% followed participants from 1 to 3 months (Morrison et al., 2004). Further,

Marx and colleagues (2001) were able to detect the affect of a prevention program on

revictimization using a follow-up period of 2 months.

Seventy-one women completed follow-up assessments. Of the 32 women with CSA history,

two from the intervention group and two from the control group did not return to complete

the follow-up assessment. Within the no-CSA group, all 24 women from the no-intervention

control group completed the follow-up assessment. Two women from the intervention group

did not continue, one because of scheduling conflicts and the other could not be reached. This

left 71 women for inclusion in the treatment analyses, 29 in the intervention group (10 with

CSA, 19 without CSA) and 42 in the control group (18 with CSA, 24 without CSA). Monetary

compensation was provided for all of those who returned for follow-up assessment.

Results

Preintervention Group Differences

A series of analyses were conducted to explore preintervention differences in study variables

among participants in the different groups and conditions. Results revealed that there was no

significant main effect of group (Wilks’ L 5 .92, p 5 .08, Z2p ¼ :09), although univariate results indicated that women with a history of CSA scored significantly lower than those without such

a history on the Accept subscale of the KIMS, F(1,92) 5 8.74, p 5 .004, Z2p ¼ :09. Contrary to expectations, women with and without a history of CSA did not differ significantly in

experiential avoidance as measured by the AAQ, t(93) 5 1.36, p 5 .18, r2pb ¼ :02. There were no significant differences between those participants who were selected to receive the

intervention and those who were not on any study variables.

Sexual Victimization at Follow-up

Of the participants who completed follow-up surveys (n 5 71), 12.7% (9) reported that they

experienced sexual victimization between Time 1 and Time 2. Furthermore, 21.4% (n 5 6) of

those with CSA history reported experiencing victimization during the follow-up interval

compared with 7.0% (n 5 3) without CSA history; however, although effect size estimate

suggest that this is a moderate difference (j 5 .21), it is not statistically significant (Fisher’s exact test, p 5 .38).

A chi-square analysis revealed that there was no significant difference in reported

victimization rates between participants in the intervention group compared with those in the

control group (collapsed across CSA history; 13.8% (n 5 4) compared with 11.9% (n 5 5),

respectively, j 5 .03). With regard to rape victimization, participants from the no-intervention control group reported a higher incidence of rape (9.5%, n 5 7, vs. 0%, n 5 0), and although

this difference yielded a moderate effect size (j 5 .14), it is not statistically significant (Fisher’s exact test, p 5 .12).

Sexual Revictimization at Follow-Up

The analyses conducted for sexual revictimization at follow-up included only those with a

history of CSA. A total of 21.4% of women experienced a revictimization over the 2-month

follow-up period. Although the women with CSA history who participated in the intervention

974 Journal of Clinical Psychology, September 2011

were less likely to be victimized than those with CSA history who did not receive the

intervention (10.0%, n 5 1, compared with 27.8%, n 5 5), and this difference is moderate in

size (j 5 .21), it was not found to be statistically significant (Fisher’s exact test, p 5 .28). Further, 22.0% (n 5 9) of those with CSA history who did not receive the intervention

reported at least one attempted or completed rape compared with 0% (n 5 0) in the

intervention group. Although effect size estimates suggest this is a moderate difference

(j 5 .21), it is not statistically significant (Fisher’s exact test, p 5 .15). Among women with CSA history who reported a sexual assault during the follow-up interval, 80.0% (n 5 8) in the

comparison group reported rape compared with 0% (n 5 0) in the intervention group. Again,

this difference was not statistically significant (Fisher’s exact test, p 5 .33), but the phi value

suggests a strong effect (j 5 .63).

Program Affect on Acceptance and Mindfulness. To investigate the program’s effectiveness on participants’ levels of acceptance and mindfulness, a 2 (Group:

Intervention�Control)�2 (Time: Pre-screening�2-month follow-up) repeated measures

multivariate analysis of variance (MANOVA) was performed. No significant interaction was

observed (Wilks’ L 5 .88, p 5 .12, Z2p ¼ :12). Univariate analyses revealed that participants in the intervention group scored significantly higher on the Observe subscale of the KIMS

between Time 1 and Time 2 compared with those in the control group, F(5, 65) 5 7.15, po.05, Z2p ¼ :09. No differences between those with and without CSA history emerged (see Table 2).

A 2 (Group: Intervention�Control)�2 (CSA Status: with CSA�without CSA)�2

(Time: Pre-screening�2-month follow-up) repeated measures MANOVA was performed to

investigate the program’s effectiveness at increasing the levels of acceptance and mindfulness

specifically among participants with a history of CSA. Box’s test of equality of covariance

measures indicated that there were no violations of assumptions (p 5 .37). The Time of

Measurement�CSA interaction was not significant, L 5 .92, F(5, 63) 5 1.03, p 5 .41, Z2p ¼ :08, nor was the Time of Measurement�Group interaction, L 5 .90, F(5, 63) 5 1.37, p 5 .25, Z2p ¼ :10. The Time of Measurement�Group�CSA History interaction was also not significant, L 5 .95, F(5, 63) 5 .64, p 5 .67, Z2p ¼ :05. Furthermore, univariate analyses

Table 2 Means and Standard Deviations for Study Measures for Program Participants at Pretreatment and Follow-Up

Control Intervention

CSA (n 5 18) No CSA (n 5 24) CSA (n 5 10) No CSA (n 5 19)

Measure Pre Post Pre Post Pre Post Pre Post

KIMS-OBS a

30.65 28.40 28.26 27.57 29.42 29.75 25.88 28.33

(7.97) (6.80) (5.89) (6.36) (4.70) (6.35) (6.4) (7.33)

KIMS-DES 25.28 25.22 28.08 26.58 29.00 28.30 26.21 27.42

(6.69) (8.26) (5.78) (7.25) (5.19) (6.93) (6.91) (6.27)

KIMS-ACT 27.80 26.17 29.41 27.32 29.30 27.80 29.16 28.58

(5.93) (7.05) (4.66) (6.51) (5.36) (6.34) (6.09) (5.10)

KIMS-ACC 29.28 30.61 33.32 33.00 29.90 29.20 34.16 34.16

(7.40) (8.56) (6.76) (6.65) (5.20) (7.86) (5.67) (7.37)

AAQ 64.79 67.28 63.77 62.38 64.10 65.40 61.11 59.05

(14.14) (9.52) (10.92) (13.11) (8.94) (9.69) (8.52) (12.09)

Note. Values in parentheses represent standard deviation. CSA 5 childhood sexual assault; KIMS-

OBS 5 Kentucky Inventory of Mindfulness Skills: Observe subscale; KIMS-DES 5 Kentucky Inventory

of Mindfulness Skills: Describe subscale; KIMS-ACT 5 Kentucky Inventory of Mindfulness Skills: Act

with awareness subscale; KIMS-ACC 5 Kentucky Inventory of Mindfulness Skills: Accept subscale;

AAQ 5 Acceptance and Action Questionnaire. a Significant difference at po.05 for the intervention group from pretreatment to follow-up for No CSA.

975Mindfulness and Sexual Revictimization

revealed that the program did not significantly affect levels of acceptance and mindfulness

specifically among women with a history of CSA from Time 1 to Time 2 (see Table 2).

Program Utility and Practice

Those who reported practicing mindfulness exercises at least once during the follow-up

interval (n 5 15) were significantly less likely to be victimized compared with those who did not

(n 5 14; 0% vs. 29.0%; Fisher’s exact test, p 5 .04, j 5 .40). Ninety-three percent of participants reported that they would use the skills acquired in the program in the future.

Discussion

The victimization rates found in this study provide further evidence that sexual victimization

among college women is a significant issue. Approximately 37% of female undergraduates

who initially agreed to participate in the study reported a history of CSA and 12.7% of

participants experienced some form of sexual victimization during the follow-up period. This

rate is slightly lower than those found in previous studies (e.g., Breitenbecher & Gidycz, 1998;

Breitenbecher & Scarce, 1999; Hanson & Gidycz, 1993). The revictimization rate during the

follow-up period (regardless of participants’ assigned group) was 21.4%. Comparably, the

revictimization rates reported in previous studies were 27% to 28% (e.g., Breitenbecher &

Gidycz; Hanson & Gidycz; Marx et al., 2001). In the current study, women with CSA history

were revictimized at a rate that was approximately three times higher (although this result was

not statistically significant) than women without CSA history, adding support to the notion

that having a history of CSA is a risk factor for future sexual victimization.

Consistent with previous research (e.g., Breitenbecher & Gidycz, 1998; Breitenbecher &

Scarce, 1999; Gidycz et al., 2001), the program in the current study was not effective at

reducing overall rates of sexual assault, though it may have had some affect on rape risk.

Similar to the findings by Gidycz and colleagues, in this study, women in the control group

were more likely to experience a rape-related victimization compared with those who received

the program (9.5% vs. 0%). Although effect size estimates suggest this is a moderate

difference, it was not statistically significant.

The percentage of women in the control group who reported revictimization during the

follow-up period (27.8%) is consistent with those in previous studies (Breitenbecher & Gidycz,

1998; Hanson & Gidycz, 1993; Marx et al., 2001). In contrast, among program participants,

reported rates of revictimization in the current study (10%) were lower than the 21%–28%

rate reported in other studies (Breitenbecher & Gidycz; Hanson & Gidycz; Marx et al.). It is

important to note, however, that although reported rates of revictimization between the

intervention and control groups were estimated to be of a moderate size, they were not found

to be statistically significant. Unfortunately, the small sample size makes it difficult to interpret

this finding. However, it may suggest that an acceptance-based and mindfulness-informed

approach could have some promise.

General sexual assault prevention programs have not been successful at reducing

revictimization among women with CSA history. For example, Hanson and Gidycz (1993)

found roughly equivalent rates of revictimization (attempted/completed rape) among women

who participated in their prevention program (15%) compared with those who did not (12%).

In contrast, the current program, specifically informed by research and theory on

revictimization, had a moderate effect in reducing reported rates of revictimization

(attempted/completed rape) among women who participated in the program (0%) compared

with those who did not (22%), although this difference was not statistically significant. These

results are similar to those reported by Marx and colleagues (4% vs. 11%), who also tailored

their program to the specific needs of revictimized women. Marx also found that among those

who reported a revictimization, women who participated in the program were less likely to

report having been raped (12% vs. 30%). Similarly, in the current study, 80% of women in the

control group compared with 0% of women who participated in the program reported being

raped. Although this difference was not statistically significant, it is important to note that the

976 Journal of Clinical Psychology, September 2011

effect size was large and, at follow-up, none of the women in the intervention group reported

being revictimized by rape.

Contrary to initial hypotheses, the acceptance-based and mindfulness-based risk reduction

program did not significantly decrease experiential avoidance nor increase mindfulness. In

contrast to previous studies (e.g. Batten, Follette, & Aban, 2001; Marx & Sloan, 2002), women

with CSA history in the current study did not score significantly higher on the AAQ than

women without such a history at baseline. Based on the norms developed from undergraduate

samples comprised primarily of women (Hayes et al., 2004), the mean scores on the AAQ

reported by women in the control and intervention groups at Time 1 (M 5 approximately 64

and 62, respectively) and Time 2 (M 5 approximately 64 and 61, respectively) were slightly

lower than those of female, nonclinical norms (M 5 approximately 67). We did find that

women with CSA history were significantly less accepting of their internal experiences at

baseline as measured by the KIMS; however, the program was not effective at significantly

increasing participants’ levels of mindfulness at follow-up. Although the risk reduction

program comprised a number of clinical methods aimed at increasing mindfulness and

acceptance of internal experiences, it may be that the relatively brief intervention was not

powerful enough to produce measurable changes on these outcome variables.

The fact that the program seemed to be effective at increasing participants’ ability to

observe internal sensations despite its brevity suggests that observing internal sensations may

be a mindfulness skill that takes less time and effort to cultivate. Moving from an increased

awareness and observation of one’s internal experiences to a nonjudgmental, compassionate

acceptance of uncomfortable thoughts and feelings is likely a process that takes considerable

practice and support (Orsillo, Roemer, & Holowka, 2005). Therefore, a longer and more

involved program may be needed to achieve these desired effects.

This study was a preliminary effort aimed at developing and examining the potential benefit

of an acceptance-based and mindfulness-based risk reduction program. Consequently, it is

limited by a number of methodological shortcomings. The method of recruitment may have

created a sample bias, in which individuals with higher levels of experiential avoidance

refrained from volunteering to participate in the study. Further, because participants were not

randomly assigned to groups, those in the intervention group may have been more willing to

engage in acceptance and mindfulness than those in the control group.

There is significant variation in the way that CSA is defined and measured in the literature,

and the definition used in the current study, which included sexual experiences occurring

before 17 years of age, likely produced a heterogeneous sample of those with both childhood

and adolescent sexual assault histories, which could limit the generalizability of the findings to

other samples. Further, several features and contextual factors related to CSA that could

affect response to the program (e.g., chronicity of abuse, relationship with perpetrator, age at

first victimization, use of drugs or alcohol to avoid painful associated emotions, sexual activity

level) were not assessed in the current study. The reliance on self-report measures of

victimization is also less than ideal, as guilt, shame, and demand characteristics may have

influenced participant disclosure.

Another limitation is that group composition and facilitator were not held constant between

sessions 1 and 2. Thus, group process and working alliance may have varied as a function of

group members and program leaders. Additionally, it is possible that a male experimenter

leading the groups could have triggered some discomfort in the CSA survivors. However, the

fact that the program was not described as a sexual assault prevention program and sexual

assault was never mentioned during the interventions reduces the likelihood of this being a

significant factor.

One of the potential advantages of using mindfulness skills to reduce risk is that they can be

taught to a relatively large and diverse audience in a time and cost efficient manner. However,

we chose to first examine the potential benefit of this newly developed program in a smaller

sample, which may have made it difficult to detect potential group differences, and decreased

the external validity of our findings.

Another limitation to the study is the relatively short amount of time between preintervention

and follow-up (M 5 9.97 weeks). Although other studies had similar follow-up intervals

977Mindfulness and Sexual Revictimization

(e.g., Breitenbecher & Gidycz, 1998; Gidycz et al., 1993; Marx et al., 2001), there is some

evidence that incorporating additional longer term follow-up assessments allows the potential

effects of a program to be more easily detected (e.g., Gidycz et al., 1995, 2001). Given the

small sample in the present study, concerns over the affect of attrition (especially over a break

between semesters) led to the decision to conduct follow-up assessment as soon after the

intervention as possible.

Although the risk reduction program developed for the current study had only few

statistically significant effects on outcome, the effect sizes ranged from small to large. The

proportion of women with CSA history who were sexually assaulted or raped was notably lower

among those who participated in the program and compares favorably to previous studies.

Further, it is worth noting that the effect sizes appear promising, particularly for reducing

the incidence of rape among individuals with CSA history. Future research addressing the

methodological limitations noted here is important to fully examine the potential affect of

acceptance-based and mindfulness-based programs on revictimization. In addition to

increasing the frequency and depth of mindfulness training (as well as amount of practice

time between sessions), it may be useful to consider integrating components that have been

found to be relatively successful in other programs (e.g., Hanson & Gidycz, 1993; Marx et al.,

2001). Finally, it should be emphasized that programs such as the one in the current study are

designed to enhance skills with hope that the likelihood of sexual victimization will be

minimized. These skills do not control the perpetrator’s behavior and in no way divert

responsibility for the assault from the perpetrator to the victim.

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