Cognitive Processing Therapy for Rape Victims by Resick and
Shnicke
Contents
Rape and its aftermath
1. Introduction
Rape is much underreported, 8 % reporting crime and 13%
going to a rape crisis centre. A random survey of 930 women showed 44% had been
raped, or had suffered an attempted rape. On a random phone survey it showed
20% of women had been raped.
Symptoms and Recovery Patterns
Rape symptoms are varied but mostly commonly look like PTSD
symptoms.
4 Criteria for PTSD
1.
Criterion A: the stressor criterion, i.e. having
something traumatic happen, which involved feelings of extreme fear and
helplessness
2.
Criterion B: re-experiencing phenomena,
flashbacks, nightmares which reoccur with and without stimulus to remind of the
event.
3.
Criterion C: Avoidance behaviours, avoidance of
memories, numbing affect and withdrawal from activity
4.
Criterion D: Physiological over reactivity,
problems falling asleep, hyper vigilance, startled responses.
In the first 4 weeks following a rape, 94% of victims meet
the criteria for PTSD.
It has been shown that the greatest amount of recovery
happens in the first 3 months post crime.
The other major disorder that occurs with PTSD is
depression, with 50% of a small sample size having the criteria of a major
depressive disorder.
A major depressive disorder is 1 and or 2 plus four of the
remaining for at least a two week period
1.
Depressed mood most of the day
2.
Loss of interest
in all activities
3.
Significant weight loss or gain
4.
Insomnia or hypersomnia
5.
Psychomotor retardation
6.
Fatigue or loss of energy
7.
Feelings of worthlessness
8.
Diminished cognitive faculties
9.
Suicidal ideation
Depression generally happens in the mild to severe form for
1 to 2 weeks post crime, but not thereafter. However there was an increase in
the susceptibility to depression post crime.
People who don’t recover quickly from rape have a high
propensity to attempt suicide .
Other symptoms that come post crime are:
1.
Self-esteem issues
2.
Fear
3.
Interpersonal difficulties
4.
Sexual dysfunction
Summary
Rape is highly underreported. 20% of women have been raped,
40% have either been raped or had an attempted rape. The symptoms of rape are very close to PTSD i.e.:
1.
Having an event that causes high levels of fear
and helplessness
2.
Flashbacks, nightmares and repeated fearful
memories of the event
3.
Avoidance behaviour, suppressed memories,
suppressed affects, decreased activities
4.
Physiological over activity, insomnia,
hypersomnia, hyper vigilance, easily startled
With PTSD most improvement in symptoms happens within the
first 3 months.
Also alongside PTSD is a major depressive incident, which
generally happens within the first week to two weeks. A Major depressive disorder is either feeling
depressed all of the day or a loss of interest in everything, plus 4 of the
following for a two week period: inexplicable weight issues, loss of energy,
insomnia\hypersomnia, feelings of worthlessness, suicidal ideation, diminished
cognitive faculties, diminished motor skills.
2. Information Processing Theory and relevant treatments
There’s a sense of two life’s with rape victims the life
before rape and the life after, and they are two different worlds. The former
life is gone and the latter life is radically different. The second life can see need to be in control
all the time, to fear intimacy, to not trust any man and to never relax and
loosen control.
Information Processing Theory
IPT is that we receive vast amounts of information every day
and to process we need schemas, which are collections of ways of seeing,
encoding, comprehending (rules, beliefs and assumptions) and recalling. These
schemas allow a vast amount of information to be processed quickly.
The difficulty with PTSD disorders are that the schema and
related schemas for the event can’t process the information as it is radically
different. A standard view of rape by
people that haven’t been raped is that it happens to attractive women by
strangers in isolated places. Another standard view is that bad things only
really happen to bad people, which is also known as the just world theory.
When the traumatic event contradicts existing schemas then
one of two things happens, assimilation or accommodation. Assimilation is the process of adjusting the
event to fit the existing schemas, accommodation is the process of adjusting
the schemas to fit the event.
With accommodation this can still lead to perpetuation of
symptoms when you see over accommodation, such as I can’t trust any man.
When information can be processed then you can see it
returning via flashbacks, and nightmares. This can be maintained by cognitive
avoidance, which prevents processing of the information. Again this cognitive avoidance maintains the
strong affective responses of shame, fear and disgust. It’s almost as if when
an event happens is schema congruent then it picks up all its affects from the
schema structure. When something is schema incongruent then it has strong
affects with it, it needs to be held up and looked at as it doesn’t fit in
anywhere, and like an unfiled item, needs to have some affective post it notes
put on it to remember it, as memory is stronger with strong affect.
With over accommodation then you can either get restriction
of life, through need for control, or you can get a restriction of life through
depression which comes out of the feeling of helplessness of being able to stop
a trauma happening again.
The traumatic event can also be like a magnet to other
similar bad things that have happened, for instance a belief that bad things
keep happening to me. So prior learning and beliefs then provides a pivotal
role in how the rape is processed.
There are five major areas of functioning or schemata that
are disturbed by victimisation, which are areas that are then applicable both
to the self and others
1.
Trust
2.
Safety
3.
Power
4.
Esteem
5.
Intimacy
Cognitive and behavioural treatments for rape victims
Information Processing
In Information Processing terms then a fear can be reduced
by activating the fear and the providing information that allows it to have a
new memory formed in an existing schemata.
Stress Inoculation
Training
Gears towards fear management through stress reduction,
coping cards, stopping techniques
Assertion training
Boosts self-esteem and counter conditions fear
Supportive therapy
Group counselling with other victims.
Prolonged
exposure\flooding
Here the aim is to reduce fear through an exposure technique.
All 5 types of therapy focus on breaking the relation
between stimuli and response. So the fear cue produces avoidance, but in all
therapies the point is that the feared stimuli doesn’t represent a danger.
Of all 5 types then SIT was more effective in the short run
for removing symptoms of PTSD while over time PE was more effective at reducing
symptoms. The theory being that SIT skills stopped being used after therapy
stopped where PE makes changes in the fear schema, through habituation to fear.
However nothing was more effective that waiting list control
at removing fear, anxiety and depression.
Overview of Cognitive Processing Therapy
The production of CPT was as the result of previous
treatments being weak. The aim of CPT is to stop the client assimilating the
event but rather changing their schemata to accommodate the event without
overaccomodating. The therapists goal is to help the client accept that the
event happened, experience the emotions of the event and to accommodate this
event into their existing beliefs.
Cognitive Therapy from Beck thinks that PTSD is a problem as
it activates previous dysfunctional beliefs.
CPT thinks that the problem is that the new information is
radically different from prior schema and can’t be processed. Most of CPT is
about finding stuck points and modifying them.
Avoidance is a major aspect of PTSD and if successful
results in a complete numbing affect. There is cognitive and affective
avoidance, indeed the cognitions are avoided as they bring up strong affects.
So exposure is part of CPT approach, and this is an emotional and cognitive
exposure. The technique is to expose, then to use this exposure to identify
faulty cognitions or conflicting beliefs or areas of incomplete processing.
CPT Sessions’ detail
1.
IP is introduced and rape reactions explained
2.
Client is asked to write down what the rape
event means to her
3.
Client is taught four basic feelings and how
they relate to cognitions for example person walks down the street and someone
doesn’t say hi to them. Use ABC analysis to link emotions and cognitions
4.
Client writes down the rape event in as much
detail as is possible and read it. This serves as an exposure technique
5.
Therapist examines transcript for stuck points.
Stuck points will require extra time and interventions and also information
about normal responses from other victims of rape
6.
Work through all the maladaptive assumptions
that are shown from the transcript
7.
Spend a session each on trust, intimacy, safety,
power and control and self-esteem. Hand-outs include lists of questions, faulty
thinking patterns, challenging belief worksheets
8.
Last session is to rewrite how the rape event is
for her.
Summary
Previous treatments of rape\PTSD could remove symptoms but
didn’t really shift the fear, self-esteem and depression issues around the
event.
CPT sees that the problem with rape is that an event has
conflicted with previous schemata and therefore hasn’t been processed properly
and this is why you get the symptoms of recollection and the physical
symptomatology. Avoidance then is a large part of how the trauma of rape
continues as the event which challenges so many ways of thinking needs to be
avoided or otherwise the schemas need to be changed.
What CPT seeks to do is to get the client to accept that the
rape has happened, to feel the feelings around it, and to accommodate this
event into their existing schemata’s
without over accommodating
Exposure then is part of CPT and the way that it is done is
through getting the client to write a detail description of what happened and
what it meant to them. Then to do this repeatedly and to watch how it changes
and also the affective response to it. On the basis of the knowledge that comes
up from this transcript then what the therapist looks to do is to look for a stuck
points. A stuck point is something that is in conflict, something that is
partially processed or not processed at all, as it is horrible, or awful or too
painful to accept. To process these stuck points then firstly they need to be
experienced affectively, secondly they need to be examined to see if there are
any dysfunctional beliefs coming out of there, and thirdly they need to be
incorporated back into existing schema.
The end of CPT therapy sees the client writing the event of
their rape and what it means to them.
3. Diagnosis and Assessment
Screening
When a woman calls in they may be reluctant to say what has
happened to them. In this case a
straightforward question such as have you been victimised helps. The next question to find out is when did this
happen and whether the client has any suicidal thoughts. It is useful to know
whether or not this was an incest rape as there are special groups for these
people as it can take more time than with a standard rape victim. The next question to ask is what precipitated
the call, and to come to therapy. This
can indicate a crisis to deal with or not.
Tell the client that avoidance of feelings and thoughts is
one of the symptoms of PTSD/rape and they might well experience and increase of
feelings and thoughts prior to coming to the first session and a desire to not
come to the first session, but this is all part of the symptoms and strongly
urge that they do come to the first session. Rape victims have very high DNA
rates unless this is discussed and normalised.
If someone phones in within a week of the rape, then ask if
they have spoken to the police, if its reported later it will be harder to
prove, and to understand this is an urgent, crisis situation that needs to be
handled, so are there any suicidal thoughts, what support can you get before
you come in for our session. It’s possible if someone doesn’t want to report
the rape, then they think either it wasn’t or they are to blame, and they might
be assimilating the event. Victims need
to be treated for physical damage, and to ensure they have no STDs, so they
should have a test immediately and 6 months later and should practice safe sex
until then.
It is best to get support as soon after the crime as
possible so talking about it, getting support, normalising it as soon after the
event as possible is the most effective approach.
Initial Interview
Need to find out:
1.
About the event
2.
Reactions to the event
3.
Social support available
4.
History of traumatic events
For the therapist to not be phased by the information, to be calm, matter of fact and supportive, provides potentially corrective information to the fact that this trauma can be surmounted, sometimes a high level of affective reaction indicates to the client that something truly dreadful has happened that its possible they won’t get over. Reactions of shock, blame and fear are indicators that the event is too big for this to be handled.
Assessment
If the client scores low on intrusion but high on avoidance
it may mean they are not processing the event, high on intrusion low on
avoidance means it is being processed, if they’re high on avoidance and low on
intrusion it might mean that they are using a coping style that is more
resistant to therapy.
Assessment mechanisms
1.
Structured initial interview
a.
Demographics, sexual assault information, social
support, history of victimisation, psychological history and problems and
treatments post crime.
2.
PTSD symptom scale (PSS)
a.
17 point questionnaire
b.
Looks at intrusion, avoidance and arousal
3.
BDI
a.
21 point questionnaire
Summary
Okay so within the assessment then you need to find out if
there suicidal ideation, if there’s a crisis, if the incident has just
happened. With a calm and supportive manner then you will show that the trauma
is get something that can be overcome. As the first three months are critical
to getting over it then the amount that the event can be talked about,
processed, normalised by talking to other people is imperative.
Avoidance is also a major theme about PTSD and rape, this
should be explained and the CPT model and how the client should come to the
first session even though they probably don’t feel like it.
Cognitive Processing Session by Session
4. Session 1: Introduction and Education Phase
Session one is about education and building trust. Educating
the client in terms of what symptoms are commonly found post rape and the
nature of CPT, i.e. fully experience what went on and accept it, incorporate it
into your existing schemas without over accommodating or assimilating the
event. So what you need to explain are schemata’s, and what happens when you can’t
incorporate, avoidance and flash backs.
Because avoidance is a part of the symptoms then there is a special
emphasis here to both attend all sessions and to do all homework.
If an assessment hasn’t been done then one should be which
looks to:
1.
Find out what happened in summary
2.
What the reaction to this has been
3.
History of traumatic events
4.
Social support
The client needs to be informed that this is a very
structured form of therapy and have PTSD explained to them:
PTSD has three main components
1.
Recollection of the trauma
a.
Intrusive thoughts
b.
Nightmares
c.
Flashbacks
2.
Avoidant behaviours
a.
Avoid places that remind you of it
b.
Avoid thinking about it
c.
Avoid certain feelings that you relate to it
3.
Arousal
a.
Insomnia or hypersomnia
b.
Hyper vigilance
c.
Startling easily
At each stage you should ask the client what their
experience in these categories has been.
Then they need schemata explained to them, e.g. chairs, what
men are like and then rape.
When this has been done then you can see what the clients
view of rape is, or some of the constituent parts, e.g. the just world theory,
or who can be trusted etc. etc.
Then the client needs explaining what happens when an
experience doesn’t fit our existing schemata, then either we reinterpret the
event, i.e. assimilate, or we change the schemata, i.e. accommodate.
The problems come when either the event isn’t accepted which
can deaden your feelings, or there is an over accommodation of the schemata.
Therapies aim is to accept that the event happened, and then accommodate this
event into your existing beliefs in a functional manner.
You can get automatic thoughts about beliefs that you have
got from the rape, these thoughts may happen very quickly so you aren’t
entirely aware of them but they will affect your mood. Some of the thoughts
that you have about the rape and about yourself after the rape are accurate and
some of them aren’t. What we will do is to look for the ones that aren’t and
challenge them. The nature of thoughts is some are obvious and you are aware of
them, some happen very quickly and you aren’t the latter are known as automatic
thoughts. We have automatic thoughts as sometimes we’ve thought something so
often that we cease to be aware of it, sometimes because we need to act
quickly, sometimes because we don’t like what we are doing and just want to get
it over. We need to look for beliefs that are interfering with your treatment,
we call these stuck points.
Homework Session 1
What does it mean to you to be raped, what does it say about
you and about the world. What were your beliefs about rape before being raped?
Has the rape had an impact on your beliefs, consider the
following topic areas in your answer, safety, fear, intimacy, esteem and
control
5. Session 2: The Meaning of the event
You need to review last week’s homework which was the
meaning of the rape, what you thought of it before being rape, and what you
think about it now, this is done by the client reading out their assignment
The aim of this session is to identify stuck points that
have a negative effect. A stuck point is ideas in conflict, an idea that hasn’t
been incorporated into a schema, that is creating flashbacks and the like, a
dysfunctional belief. So what can happen
is that you have an idea about rape, about men, about yourself, then you are
raped, if the act of the rape challenges your previous ideas about rape, then
you might assimilate, if you have a dysfunctional idea about men, control etc.
then the rape might compound that to the extreme, so I must be in total control
or bad things will happen. Either of these produce stuck points. So as we look through the meaning of the
event then what we need to find out is what was thought about rape.
Introduce the relation between thoughts and feelings. To do
this first introduce feelings, i.e. the basis ones of sad, mad, glad and scared
and how more complex feelings of jealousy are combination of these basic ones, i.e.
scared and mad. Then use the example of a friend walking down the street and not
saying hello to you. Hand out ABC sheets
to show the relation between thoughts and feelings, ask your client to write
down any events that happen in their life, they maybe a situation that happens,
or a thought or an emotion. On the basis of putting one down then work out what
the other two are. These can be positive or negative events, intense or subtle
the point here is to see the relationship between situations, thoughts,
feelings and behaviours.
So this session should bring out the meaning the rape has
generated and that within this meaning will be stuck points.
6. Session 3: Identification of Thoughts and feelings
Review the ABC forms, you need to ensure that the client can
see how thoughts will affect emotions and behaviours.
The homework for this week is to give a detailed description
of the rape, writing down exactly what happened. Then read what you have
written. If possible do this at least once a day. Find a place where you’re not
going to be disturbed, where you can feel and express your emotions as you want
to.
The purpose of the homework is to expose the client to the
feared event to reduce their fear. It is also to become aware of stuck points,
it is also to allow the full experience of the event and to allow it to be
integrated into schemata, it is also to allow the full expression of feelings
and to allow them to dissipate such that the memory can be stored, so there’s a
sense of coming to terms with the event by integrating it rationally, defusing
the emotions so it can be stored.
7. Session 4: Remembering the Rape
The session begins with the client reading their account.
The therapist should help the client identify thoughts and feelings. You should
also look at what is difficult to recall, look at what happens when writing
stops. What were you feeling at the point that you stopped writing? Avoidance
of what happened is a common reaction, this can be shown by feeling numb,
disassociating, forgetting, avoiding writing the homework. When this happens,
you need to stay with the story, ask what is happening for them, label the
avoidance. If the client reads their story without emotion, then ask if it’s
being held back. Do not be afraid of
strong feelings, they are like a flood, they are powerful for a short while,
but after a while the water stops flowing and everything dries up and returns
to normal again. Physical arousal can happen and it is for this reason that
women think that it may not have been rape, that her body has betrayed her, and
she may feel great shame. However this is a physical reaction, just because
your body is aroused doesn’t mean to say that you wanted it or that you enjoyed
it. Sometimes the rapist may try to
distort the event by being affectionate afterwards, telling her to lock the
door etc. It can also be helpful to ask about what you would have preferred to
have done, which can isolate regrets about the event.
For homework then the client needs to write again about the
event and read it back to themselves as least daily. The first time they wrote
it probably sounded more like a police report, the second time add thoughts and
feelings to the story.
8. Session 5: Identification of stuck points
Get the client to read their account of the rape, get them
to talk about how the rape felt at the time, on writing and reading for the first
time and on doing it a second time, see how the emotions have changed with
time, have changed through being able to express them. In trying to understand the rape, sometimes
the fact that the assailant was known has the effect of making it seem like it
was not rape. It can also happen that stuck points can be events that happened
in the rape that remind/reinforce something traumatic that had happened
before. Quite often clients go through
if only scenarios which attempts to assimilate the event, to make it not have
happened in retrospect. Usually the reaction of the if only, is the belief that
the rape could have been prevented and then a feeling of guilt and shame. Many
clients question whether or not they are responsible for the rape, then feel
guilt and shame about it, which also means they can’t allow themselves the
feelings of pain and disgust as they feel they did it to themselves. One useful
way when clients talk about their responsibility for the rape is to ask would
they think the same if this was a robbery they suffered. Most people freeze
when they are raped, some fight, the main thought is to get out of the
situation alive with as little damage as possible. Some clients will act in a
way to survive during the rape, things they say, or do, which makes it hard for
them to accept after that they did it, which makes them wonder if it was rape.
The list of challenging questions is introduced during this
session. The LCQ is used to challenge stuck points. Stuck points are places
where there is a conflict between an old belief and the reality of the rape, or
where the reality of the rape has confirmed an old incorrect belief.
You can’t identify rapists there’s no identifying marks for
this behaviour. This is scary, anyone could be one, like anyone could be a
murderer, robber etc. People feel safer when they think they can identify them.
9. Session 6: Challenging questions
Remembering the rape some ways of behaving might be
inexplicable as you can’t remember the emotions that you felt, e.g. fear that were
the reason why you acted the way you did. Some questions can go around and
around in a person’s head as they need an answer to a question as it protects a
foundational belief. So why didn’t I stop it, needs an answer because it has an
underlying assumption I must be in control and the truth that I was powerless
to stop it is a very unpleasant truth to accept.
You should review the challenging questions and see what
impact they have made on how strongly the belief is held. Then you can
introduce thinking errors and how these can create and maintain dysfunctional
beliefs which have unpleasant emotional outcomes.
Homework, get a list of your stuck points and see what
thinking errors there are in there.
10. Session 7: Faulty thinking patterns
Start the session reviewing the homework and looking at how
thinking errors can create problems in terms of emotions and behaviours. Also
look at how thinking errors maintain automatic thoughts.
As the thinking errors come up and instances of them are
shown from last week’s homework then you can introduce the challenging beliefs
worksheet, which
Then you should introduce the topics for the next five
sessions which will be areas that may have been affected by the rape. What you
need to do is to consider your beliefs in the following areas before and after
the rape and if the change in beliefs represents any stuck points for you, if
they do then we will do a challenging belief worksheet for them.
1.
Safety
2.
Trust
3.
Power
4.
Self Esteem
5.
Intimacy
Safety
Prior to the rape did you feel safe, or did you feel
threatened by others, or that you could protect yourself. It is likely that
these beliefs will be changed by the rape.
What the therapist needs to do is to find out if the clients prior
beliefs have been disrupted or reinforced by the rape and then to ascertain the
outcome of holding these beliefs and is it functional or not. With safety then you need to establish the
line between prudent safety and excessive avoidance behaviours. Generalised fear is not going to prevent rape
it is going to slow recovery. A certain person at a certain place and time
committed the rape, it wasn’t the place or time that did it, it was that
person. If safety is an issue then they should complete a challenging belief
work sheet, if not then they should choose another item from their stuck points
and do a worksheet on that.
11. Session 8: Safety Issues
Start with reviewing the worksheet that was done for the
last homework, see how the effect of creating alternative thoughts is, if it is
not strong enough look to work through this. Look at the low statistics of
being raped, indeed how much has the client been out without being
victimised. The rapist owned 1 hour of
your life, but they should not control the rest of your life and dictate what you
can and can’t do. There is more chance of you being involved in a car accident
but this hasn’t stopped you driving.
During this session you should introduce self-trust. Self-trust
is belief in your own judgement and perceptions and after a rape many people
begin to doubt their own judgement. People feel betrayed by the person who
raped them and sometimes betrayed by the people they asked for help. How did
the rape affect your feelings of trust of yourself and others?
Again if there is a trust issue coming up in the stuck points
do a challenging beliefs form on this, otherwise continue to work on stuck
points.
Trust issues can centre on coming to see that it wasn’t your
poor judgement that got you raped.
Trusting another always involves some risk, but you can protect yourself
by developing trust slowly.
12. Session 9: Trust Issues
Many women think their rape was preventable, and if they had
only been able to see the signs then they could have prevented it. From this
point they then start to lose trust in their judgement and in others who are
now untrustworthy. Trust is seen as an either or issue, when it requires
overwhelming evidence to have trust and one small speck to lose trust. Trust
should be shown to be on a continuum and subject specific. So I might trust
drivers to stay on the right side of the road, but I wouldn’t trust a stranger
to pick up a five pound note left on the floor. The trust that has been
breached is about sexual violence and people supporting them afterwards. This
is the area of trust that has been breached and it is an exceptional event and
doesn’t impact other forms of trust. In
some way the level of generalisation of safety and trust issues seem to reflect
that magnitude of the trauma. If the trauma can be reduced through
accommodating it into existing schema then the levels of generalisation will
reduce. Contrariwise through reducing the level of generalisation then
accommodation will increase, as it requires I can’t trust any man to I can
trust men to do many things, I can also not trust men to do many things but
trust is not a property of a relationship but it is related to a specific behavioural
context. To develop trust you need to look at the actual behaviour of people
and not rely on global judgements. There are no good indicators of who is a rapist
but to be suspicious and untrusting of everyone will mean that you will miss
out on people who are trustworthy and can provide genuine support and intimacy.
The next thing to do is to introduce power issues. Because in a rape situation the client can feel out of control and powerless some people can respond to this by trying to achieve total control of their relationships with people and sometimes their emotions as otherwise they fear they will become totally out of control. Self-power represents the beliefs about how you can solve problems, cope with difficulties and meet new challenges.
Homework is again to work on a power stuck point and if
there isn’t one there to work on other stuck points.
Learned helplessness is the belief that you cannot control
events or solve problems even if they are controllable or solvable.
13. Session 10 Power and Control Issues
No one has complete control over events or the behaviours of
other people. No one is helpless either. You always have some control over how
you react and respond to events and people.
Feelings of anger often arise after the event as there was
no possibility of it being expressed at the time. You need to validate a client’s
anger as a natural response to their power and control being taken away from them. There can be some reluctance to feel anger
due to its association with aggression and aggression is anathema to them as it
was the tool of their suffering at the hands of their rapist. Anger can also be self-directed as they hold
themselves to blame for the attack, once they can see that changes in behaviour
may not have prevented it, or indeed may have made it worse, they can loosen
their feelings of self-anger which will free it up for anger at the rapist.
Makes me think 2 chair work could be useful here, although high risk.
Now you need to introduce self-esteem. This will be this week’s
homework assignment and in addition you should practice giving and receiving
compliments during the week and to do at least one nice thing a day without any
string attached, e.g. take a bubble bath.
Self-esteem is the belief in your own worth. Being
understood, respected and taken seriously is basic to the development of self-esteem.
With your belief in the goodness of others then if you have stereotyped, global
beliefs about the others then these are likely to be wrong. The best approach
to others is to adopt a wait and see approach and as you get to know more about
them then you can understand more what you can expect of them, i.e. trust, and
what you think of them. Rapists can often be good manipulators fooling people
into thinking they are good and safe people to be trusted, but because a
minority of men are manipulators doesn’t mean to say they all are. People
sometimes make mistakes but take time to judge as to whether this indicates a
negative characteristic of that person, although some mistakes are so heinous
that one instance of them is unacceptable.
14. Session 11 Esteem Issues
The therapist should encourage the client to do nice things
for herself and to find out what it feels like to do it or not to do it, does
she feel guilty, does she feel like she doesn’t deserve it. Finding these
statements and beliefs can open up the stuck points that need to be challenged.
There is a sense within rape and PTSD that invalidated feelings are stuck
points as well, if feelings of anger are felt to be unjustified then they
aren’t accepted and their effect will be retained. A very common stuck point is
that clients feel there is something wrong with them for the rapist to have
targeted them, or something is damaged with them now after the rape.
Overgeneralisation by the client is frequent to the groups that the rapist
belongs to. Likewise their sensitivity to crime is increased and they use
selective attention to see crime everywhere fuelled by the nature of
journalism. Self intimacy is the ability to soothe and comfort oneself and to
be alone without feeling lonely. Again it is important to write beliefs before
and after the rape on the issues of intimacy to see how the rape has either
exaggerated existing beliefs or changed them.
Homework is to use the stuck points to find any intimacy
issues towards self or towards others, also required is to write again what the
rape means to you and how it has affected your beliefs about yourself, the
world and others. Again look at the key issues of safety, trust, self esteem,
power and control and intimacy.
15. Session 12: Intimacy Issues and the meaning of the event
People can use substances to self soothe, but substance
abuse is also about a control issue, feeling like you can’t cope by yourself
that your resources are depleted. Instead of grabbing a drink grab a worksheet
instead. There are two aspects of intimacy that may be salient, one friendship
and the other sexuality. One technique to use with sexual intimacy is if there
are sexual flashbacks during sex to hold your partner until the flashback
subsides.
16. Group versus individual treatment
Advantages of group work is the ability to process
emotionally and cognitively through other group members, this can be by
modelling or by direct intervention or possibly relationship forming from the
others. There is also something normalising about group, seeing other people
who have been raped as being normal and not damaged in anyway, so in some way it
gives you the ability to decentre to look more objectively. Also feedback from
other people who have been raped can be accepted by clients as they’d feel they
know what they are talking about as opposed to a therapist who may not have
been raped. There is also peer pressure to recover, to grow and to do the
homework, the group has a dynamic which can carry along the individual.
One difference between group and individual CPT is that
group people are not allowed to read out their rape stories as this could produce
secondary traumatisation. Rather the therapist explores the reaction of the
clients to writing it and to increase exposure then they are asked to write the
event with as much sensory detail as possible. When the therapist reads the
transcript then they can look for stuck points by seeing where the client
stops, skips over something, glosses over something
17. Practical considerations for running groups
Personality styles that can be difficult in groups are
dominant people and personality disorders. People who talk all the time can
restrict other members and will encourage avoidance. If a person is alienated
in the group through not liking people in the group, then the therapist should
attempt to bring them back into the group by directing comments to them. Creating a safe and supportive atmosphere are
vital for a successfully running group.
Non completion of homework is common in groups. One major reason
for this is that clients think that engaging with their rape will be
overwhelming or will destroy them, thus they are avoidant.
Exposure therapy should not be used with people who are
suicidal, have a borderline personalities with an inability to regulate affect
or a history of self harm as the outcome of exposure could be self harm or
suicide.
Staying on topic is important with rape and PTSD as there is
a strong need to avoid talking about what is difficult.
18. Client characteristics that may affect treatment
Rape and incest really need to be treated differently. CPT
for rape will target just that and so if some has an incest history then they
really need to be stable around this before CPT can be used. It is rare to
encounter people who have been raped multiple times, excluding marital rape who
have not been sexually abused as children. As CPT uses exposure techniques then
the client needs to be relatively stable before this is used.
Again due to exposure therapy anyone who has recently
achieved sobriety after a history of substance abuse is not likely to be a good
candidate as exposure therapy can be challenging and difficult emotions need to
be sat with,. Marital rape also deserves special consideration as there is
likely to be physical and emotional abuse as well. Marital rape can produce children which then
there can be difficult relations with. Battered women also report more problems
with self esteem, depression and fear than other rape victims so will need more
time to deal with this.
People with borderline personality disorders also need to be
screened out for CPT. The commonly seen borderline disorders seen with rape are
dependent, depressive and avoidant. Most women with borderline personalities
have a childhood history of sexual abuse.
Mixing borderline personality disorders with other healthy
people doesn’t work because
1.
Exposure therapy brings up other traumas which
overwhelms themselves and the rest of the group
2.
They can’t develop enough trust in brief,
problem focussed therapy
3.
The tendency of this client type to move from
crisis to crisis detracts from the work of the rest of the group
People with avoidant personality disorder will be quiet and
not do their homework and need to be challenged to process the rape cognitively
and emotionally.
19. Therapist Considerations
Having a male co-therapist can be useful as it is helpful to
dispel the overgeneralisations about men.
Male therapists often provide counselling to the family and friends of
rape victims. Prior to working with rape
victims a therapist should examine their own beliefs about rape, especially
about culpability and just world beliefs.
It is an important point to remember that no matter how foolhardy the
behaviour, drinking with a stranger, hitchhiking no one deserves rape as a
consequence. If a therapist believes that the victim can cause, or has some
culpability to rape, then they shouldn’t work with rape victims.
Therapists can get secondary traumatisation through working
with rape victims. Therapists then can
start avoidance tactics in getting the client not to talk about their
experience.
20. Results of CPT
CPT is performing well PTSD reduces from 96% to 88%, for
depression 60% to 14%
Summary
CPT, Cognitive Processing Therapy works on the basis that
when you have traumatic events that can’t be incorporated into existing
schemata then several things can happen. Firstly the event can be assimilated, i.e.
reinterpreted to maintain the existing schemata. Secondly you can get over
accommodation where previous dysfunctional beliefs can be exaggerated, or new
dysfunctional beliefs can be introduced.
When a traumatic event happens that challenges existing
schemata, then there are some strong and negative emotions, anger, sadness,
guilt, shame, depression and the like.
As there is such a challenge cognitively to existing schemata and
emotionally due to the level of pain, then there is a strong tendency to
avoidance. Putting the event out of
mind, putting the feelings out of mind, both reduces the emotional pain and the
cognitive dissonance with the existing schemata. However to not process the event emotionally
and cognitively leads to its flaring up, its return. This can be seen in terms
of recurrence of the event in terms of
flash backs, nightmares, and a
danger based physiology which can see the startled response happening to loud
bangs, or dark places etc. Again an
inability to process the event emotionally and cognitively can lead to a
generalisation of the trauma, so that similar type places can now have the same
impact as the original trauma. The rationale behind this is because the event
hasn’t been processed it is still active, because it hasn’t been processed.
Likewise when emotionally the rape hasn’t been processed then one impact of it
can be a deadening of all emotions, to avoid emotions, because if they are
experienced in part, then there is the fear of the overwhelming emotions coming
back. Indeed this is something of a theme with traumatic experiences of fear of
being overwhelmed by cognitions that challenge the previous way of being and
emotions that threaten to overwhelm the affective realm.
The findings from studies show that firstly 24% of women
have been raped. Secondly that depression is often experienced by victims.
Thirdly that treatment is most effective within the first 3 months. Fourthly
that incest victims, people with personality disorders need more intensive treatments.
CPT’s approach to rape, is to fully experience the rape, in
terms of the feelings associated with it and what it means cognitively to the
person. So exposure therapy is used to go over the rape in some detail both
factually, as in what happened, emotionally in terms of how it felt, and what
the impact on cognitions has been. The
aim is to produce a functional accommodation of the traumatic event. Standardly
the schemata that are affected are those around self-esteem, intimacy, trust,
power and safety so these are areas to investigate, to find out what the
beliefs before the rape in these areas are, and what they are afterwards.
How the work develops is to look at the rape to establish
what are the stuck points. These are areas that haven’t been processed through
avoidance, or have been processed incorrectly and have produced dysfunctional
beliefs, they can also be cognitive conflicts that have prevented processing.
So with stuck points, these can be worked through either with exposure and
feeling the feelings, or through DTR’s where the thoughts can be held up and
processed.
The way to do this is, is through the following session
structure
Session 1 (Introduction and education)
Introduce
·
CPT theory
·
Schemata
·
Symptoms
o
Avoidance
o
Arousal
o
Recollections
·
Aim of therapy
o
Successful accommodation
·
Automatic thoughts
Find out what the clients experience of symptoms has been
Homework
What does it mean to you to be raped, what does it say about
you and about the world. What were your beliefs about rape before being raped?
Has the rape had an impact on your beliefs, consider the
following topic areas in your answer, safety, fear, intimacy, esteem and
control.
Homework rationale
What we are looking to do here, is to find how the event has
contradicted your existing beliefs and how you respond in light of this new
evidence. The impact of this change of beliefs can have an impact on how you
feel and act in the world, so what we’re going to do is to have a look and see
how accurate this change of beliefs are.
Session 1 then seeks to build relationship and trust with
the client, to educate them into the therapy that they are going to be
embarking on, and to give them an understanding of commonly held symptoms,
which should be a normaliser.
Session 2 (The meaning of the event)
Introduce stuck points
Review homework and list stuck points
Introduce
·
Four basic feelings and how they build to form
more complex emotions so joy + fear is excitement
·
The relationship between thoughts and feelings,
give the example of the person walking down the street
Teach
·
Relation between thoughts and feelings using an
ABC sheet
Homework
·
Do as many ABC sheets you can to learn the
relation between thoughts and feelings and behaviours. Do this anytime you have
a strong emotion, or behaviour start filling in the box that is most obvious
and work out the other two. If you have any thought or feelings around the
rape, it would be very useful to look at these
Session 3 (Identification of Thoughts)
Review the homework and pick up any stuck points. Ensure
that the ABC sheets are used in the right way, so that thoughts and emotions
are correctly described. Also to see how if another thought was had how a
different emotion would be created, and how if a different emotion was created
how a different behaviour would ensue. Through working through the ABC analysis
then you can also look for stuck points:
1.
Dysfunctional thoughts
2.
Avoidant behaviour
Homework
·
Produce a detailed description of the rape.
Write what happened describing it in as much detail with all your senses and
all the feelings and thoughts that you had. Do it in a place where you have
privacy and can allow the expression of your emotions. Do this as often as you
can, you may well find that the story changes in terms of finding out more
about what happened and what it means to you.
Homework rationale
·
Describing your rape will allow you to process
it, to allow yourself to have the feelings and thoughts around it will allow
you to process it and add it to your existing schemata
Session 4 (Remembering the rape)
The client needs to read out their story, you need to be on
the lookout for any avoidant behaviour. You can see this where the client
stops, or feels nothing, or forgets. At these points stay with the story, ask
what was happening for them when they stopped, what is happening for them now
and label the avoidance. Some of the avoidance may be due to fear of emotional
overload, so explain large emotions can be like a flood, there is a rush, but
gradually the water dries up.
As the story unfolds look for stuck points. After the story,
ask:
1.
What he said to her
a.
Rapists can often try to distort the event,
which can mean the victim does to
2.
What she would have done differently
a.
This can highlight stuck points
Homework
Rewrite the rape, adding more detail, and extend it to other
rape incidents or rape related trauma such as police examinations, or attempts
to get support. Also this time write both your feelings at the time, then use
parenthesis to write your feelings now
Session 5 (Identification of stuck points)
Get the client to look at how their thoughts and emotions
have changed through expressing themselves through their descriptions of the
event. Again look for stuck points. Introduce the notion of if only, where the
client thinks they could have prevented the rape, then feel, shame, guilt and
self-loathing because of this.
Introduce the list of challenging questions. These are the
CBT thinking errors, and can help maintain and therefore challenge beliefs.
Often it can help to challenge thinking in terms of these categories as you may
find that you are holding beliefs that you shouldn’t be.
Homework:
Choose a stuck point and apply the list of challenging
questions to see what the outcome is
Session 6 (Challenging questions)
First of all you need to review the challenging questions
that were the previous weeks homework, then work through these to look for any
stuck points. With stuck points then you can highlight the thinking errors that
may be shown and see how these thinking errors can become automatic and
influence current behaviour. Some issues come up as to why I didn’t do things
differently, so it’s a case of working with the client to understand why they
behaved as they did. Some thoughts may go around and around without resolution,
such as why didn’t I stop it, there may be an underlying thought about how I
must be in control all the time
Introduce faulty thinking patterns
Homework
Look through your stuck points and see if you can see any
faulty thinking patterns at work
Session 7 (Faulty thinking patterns)
Work through last week’s homework, and look for thinking
patterns, and show how these can create negative thoughts and feelings, look
for a current example.
Now that you have identified thinking errors introduce the
challenging beliefs worksheet
Work through an instance of challenging belief from a stuck
point to show how it’s done
Introduce the fact that over the next 4 sessions you are
going to look at 4 themes that are often affected by rape: Trust, Safety, Self-esteem,
intimacy, and power. So were going to look at what your beliefs are prior to
rape and post rape, see how they have changed and see how they serve you
Homework
Read the Safety worksheet .Use the challenging beliefs worksheet
to work through the most impactful safety issue
Homework rationale
To challenge beliefs that are based on thinking errors and
causing unpleasant outcome
Session 8 (Safety issues)
Review the homework which was a challenging beliefs worksheet
on a stuck point for trust. Look through the work and see if it can be
improved.
Go through the safety worksheet
Homework
Read the safety worksheet and see what applies to you .Use
the challenging beliefs worksheet to work through the most impactful trust issue
Homework rationale
To challenge beliefs that are based on thinking errors and
causing unpleasant outcome
Session 9 (Trust issues)
Repeat the pattern for trust
Session 10 (Power and Control issues)
Repeat the pattern for control
Session 11 (Esteem issues)
Repeat the pattern for esteem
Session 12 (Intimacy Issues and the meaning of the event)
Repeat the pattern for intimacy. Do a final description of
the event to see if it has been suitably accommodated
I realise, if you are reading this that the above summary,
and possibly this paper won’t make full sense without reading the book, to know
what the worksheets are on the various aspects of power, self-esteem, intimacy,
trust and safety. Sorry for this, maybe
I will try to fill out details on these topics at another time. Again with some
of the client sessions they seem on one hand, too little and one hand too much,
I mean to fully explore issues of self-esteem could take years, and then
looking at faulty thinking patterns could be too light. I think there will need
to be a strong sense of focussing within sessions, to keep clients on topic of
rape and topic. So finished this book, this paper but this needs to be
practiced with clients to be fully fleshed out, so an initial attempt.
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