You are on page 1of 16

Clinical

Case Studies
http://ccs.sagepub.com/

Therapists as Trauma Survivors: A Case Study Detailing Cognitive Processing
Therapy for Rape Victims With a Psychology Graduate Student
Laura C. Wilson and Russell T. Jones
Clinical Case Studies 2010 9: 442
DOI: 10.1177/1534650110386106
The online version of this article can be found at:
http://ccs.sagepub.com/content/9/6/442

Published by:
http://www.sagepublications.com

Additional services and information for Clinical Case Studies can be found at:
Email Alerts: http://ccs.sagepub.com/cgi/alerts
Subscriptions: http://ccs.sagepub.com/subscriptions
Reprints: http://www.sagepub.com/journalsReprints.nav
Permissions: http://www.sagepub.com/journalsPermissions.nav
Citations: http://ccs.sagepub.com/content/9/6/442.refs.html

>> Version of Record - Nov 12, 2010
What is This?

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

cognitive processing therapy 1 Theoretical and Research Basis On the basis of U. coupled with the inherently stressful nature of therapeutic work.nav DOI: 10. Department of Justice report. Blacksburg. the alarmingly high rate of victimization implies that many therapists may be trauma survivors themselves. rape. avoidance of trauma-related stimuli). Because counselors and other mental health professionals are not immune to victimization.com Laura C.” It was revealed that Mary had been sexually assaulted 4 years before presenting for therapy and was diagnosed with depression and posttraumatic stress disorder.. The secondary aim of the current study is to discuss Mary’s progress through 12 sessions of manualized cognitive processing therapy for rape victims as further support for its efficacy. it is likely that she was experiencing a form of vicarious traumatization that further complicated her own difficulties. referred to as Mary. sagepub.VA 24061 Email: lawilso3@vt. there were 198. & Turner.Virginia Tech.edu Downloaded from ccs. Wilson1 and Russell T. have the potential to lead to substantial 1 Virginia Tech. However. trauma. Because of the timing of the symptom onset and the nature of her symptomatology. 109 Williams Hall. 2000). 2004).sagepub. empirical research suggests that sexual victimization is grossly underreported and is even more common than statistics portray (Fisher. Wilson. Blacksburg Corresponding Author: Laura C.g. The psychological consequences of a therapist’s own victimization history (e.sagepub.com/journalsPermissions.com by Andreea Nicoleta Nicolae on October 12. Keywords vicarious traumatization. who presented with complaints of “mild symptoms of depression and a lack of motivation. Cullen.1177/1534650110386106 http://ccs. 2011 .S. The primary purpose of the current article is to draw attention to the importance of self-care for mental health professionals and to provide recommendations for the promotion of wellbeing in professionals working with trauma survivors. Jones1 Abstract This case study describes the treatment of a female psychology graduate student.Therapists as Trauma Survivors: A Case Study Detailing Cognitive Processing Therapy for Rape Victims With a Psychology Graduate Student Clinical Case Studies 9(6) 442­–456 © The Author(s) 2010 Reprints and permission: http://www.850 sexual assaults reported to the police in the United States in 2003 (Catalano. PTSD.

1993) to address PTSD and depression symptoms following sexual assault. substance abuse. recall the details of the event. have been and continue to be confronted with assisting clients affected by the Virginia Tech shootings.. 2009).. For example. Resick and Schnicke (1992.. The challenge of CPT is to assist the victimized individual with achieving a healthy balance between recognition that the event occurred and not allowing the sexual assault to skew their opinion of themselves. 2007). Text Revision.6% met full criteria for PTSD at posttreatment. Therapists as Trauma Survivors Mental health professionals are vulnerable to the same traumatic experiences their clients often face. depression and reexperiencing the trauma) at intake. and the world.g. Knight. others. In regard to treatment efficacy.g. Phelps. although a substantial number of rape survivors evidenced posttrauma symptoms (e. The number of individuals who met criterion for depression also decreased from 60% at pretreatment to 11% at the 6-month follow-up. which are adapted for the specific challenges that sexual victimization survivors tend to face (e.. and interpersonal problems (Walsh. and allow themselves to experience their emotional reaction. American Psychiatric Association [APA]. Thus. 2009). & van der Kolk. Lloyd. and possible psychopathology (e. the majority of CPT completers evidenced marked improvements in functioning (e. Creamer. To do so.g.e.sagepub. For example.3%.. rape) into the client’s preexisting cognitive schemas. avoidance. and intrusions). Furthermore. many clinicians in Blacksburg. Virginia. therapists often help individuals deal with stressful experiences that they themselves have previously or are currently dealing with. feeling more hopeful about the future) and a reduction in symptomatology (e. DSM-IV-TR. only 11. this case study will outline recommendations for graduate student trainees who have experienced trauma. Therefore. Although 96% of the female participants met Diagnostic and Statistical Manual of Mental Disorder (4th ed. The treatment.. one study found the occurrence rate of PTSD in rape survivors to be 33. Sexual assault has been linked to a plethora of adverse outcomes. 1993) found that all of their groupand individual-therapy participants improved on the obtained measures of symptomatology (e.. Blaustein. 2000) criterion for PTSD at pretreatment. low self-esteem. trust and safety concerns). depression.com by Andreea Nicoleta Nicolae on October 12.and exposurebased techniques..443 Wilson and Jones work-related stress. depression. Schauben and Frazier (1995) found that 70% of female psychologists and Downloaded from ccs. The high prevalence of psychopathology in rape survivors attests to the importance of understanding the coping process following trauma to inform the therapeutic process and to assist mental health professionals in recognizing the potential impact of their own victimization. Spinazzola. conducted in both individual and group formats. re-experiencing the trauma and depression)..g. & Forbers. it is the purpose of the current case study to encourage mental health professionals to acknowledge their own traumatic experiences and indicators of psychological distress as well as follow their own advice by exercising appropriate coping strategies and seeking help when necessary. 2011 . when they themselves have also been affected. The overall aim of the therapy is to facilitate the incorporation of the traumatic event (i. including posttraumatic stress disorder (PTSD). with sexual assault as the type of trauma most likely to result in PTSD (Bronner et al.g. it is the therapist’s responsibility to guide their clients so they acknowledge that the rape occurred. expands on previous therapies by combining cognitive. In addition. For example. Cognitive Processing Therapy (CPT) Following Sexual Assault CPT for Rape Victims was initially developed by Resick and Schnicke (1992. burnout.g. depression.

trust of herself and others. 2009). It has been suggested that these distressing effects may be further complicated or exaggerated by characteristics of the therapist..6%). these changes can persist for months or years (McCann & Pearlman. 2011 .1%) than law enforcement staff (15. 3 Presenting Complaints Mary presented to treatment with complaints of emotional numbness. low motivation (e. Rudolph.” Furthermore.). a lack of interest in most activities (e. Williams & Sommer. 2 Case Presentation “Mary” is an unmarried White woman in her mid-20s. Follette.com by Andreea Nicoleta Nicolae on October 12. Although McCann and Pearlman (1990) introduced the concept of vicarious traumatization. as it was used to help a future psychologist confront her own trauma history in the hopes of improving her overall level of functioning and preparing her to assist her own clients. Her previous mental health history included brief counseling for mild depression approximately 6 years ago and approximately 4 years ago following the aforementioned sexual assault. who was self-referred to the clinic for “mild symptoms of depression and a lack of motivation. 1997). such as trauma histories (McCann & Pearlman. and Downloaded from ccs.444 Clinical Case Studies 9(6) 83% of female sexual violence counselors in their sample endorsed experiencing at least one of the five types of sexual victimization (e. 1995). 1995). Vicarious traumatization is a construct used to describe the internal experiences of therapists as well as changes to their cognitive schema that occur while interacting with clients (Ben-Porat & Itzhaky.g. However. Stamm. worldview. and Milbeck (1994) found that law enforcement personnel who work with trauma survivors reported greater levels of distress than trauma mental health professionals. 1993). Pearlman and MacIan (1995) found that trauma therapists with a history of sexual victimization evidenced greater levels of PTSD-like symptomatology than trauma therapists without a trauma history. the effects of mental health professionals’ own victimization are often ignored. Previous research suggests that therapists may be at greater risk of vicarious traumatization when they have a personal history of trauma (McCann & Pearlman. n.. Mary was sexually assaulted by a male acquaintance in the presence of several friends. The current case study illustrates CPT for Rape Victims (Resick & Schnicke. 1990. Mary was pursuing a doctoral degree in counseling and lived with her longtime boyfriend. which acknowledges that therapists may experience posttrauma-like symptoms when working with trauma survivors.sagepub. Williams & Sommer. 1990. & Stamm. Polusney. This traumatic event significantly affected her interpersonal relationships immediately following the assault and continues to affect her sexual relationships.. Furthermore. anger. it has been suggested that working through their own trauma history may prepare counselors for assisting their clients through the therapeutic process and help them develop positive coping strategies for working with trauma clients (Collins & Long. For example. At the time of intake. It is the authors’ hope that the current article will draw attention to the importance of selfcare for mental health professionals. 2003. approximately 4 years before referral. 1990).d. For example.g. and spirituality as well as how one understands world events (Pearlman & Saakvitne.g. which includes acknowledging their own mental health needs and indicators of distress. This difference was attributed to the greater number of mental health staff who sought personal therapy (59. sexual intercourse and hobbies). schoolwork). attempted rape and sexual harassment). 1992. 1995) and level of experience (O’Malley Reyntjens & Rubin. and sense of control over situations. These changes may occur in areas such as identity.

Although Mary experienced depression for approximately 6 months at the beginning of her undergraduate career. Consequently. she was pursuing a doctoral degree in counseling. Mary was living with her boyfriend. 4 History Family Mary was raised by her biological parents in the northeastern United States from birth until age 3.com by Andreea Nicoleta Nicolae on October 12. As such. Furthermore. During the initial interview. however. Mary had become frustrated that despite her psychological knowledge and clinical training and experience. Mary reported that many of her friends openly questioned whether she was lying about the sexual assault because they were in disbelief that a mutual friend would commit such an act.” She indicated that her childhood was difficult because her stepfather was verbally and physically aggressive toward her mother. At this time. by the third session she had begun to acknowledge that the traumatic experience negatively skewed her views of sexual intercourse. During this time. both her parents remarried and her stepparents were involved in rearing her.” She reportedly had many friends. At the time of intake. she distanced herself from and was ridiculed by many of her friends following the sexual assault. In addition. Also at intake. and trust of others.” She was a successful student and obtained a bachelor’s degree in psychology. 2011 . however. she had been unable to facilitate any improvement in her current functioning.445 Wilson and Jones irritability. She indicated she was confused by her present feelings and reported she had spent considerable time attempting to determine the cause of her current issues. Mary’s current symptoms and complaints had interfered with her daily life and had led to substantial distress. She reported that she had been experiencing those feelings for approximately 1 year before contacting the clinic. Eventually. Throughout the years. Downloaded from ccs. Mary continued her education and obtained a master’s degree in clinical psychology. irritability. Despite considering herself a sociable young woman. which resulted in a troubled home life for Mary. such as her boyfriend and professors. Mary indicated that she had decided to come to therapy because those around her. Mary described her home life as “hostile and confusing. Mary’s history of victimization was further complicated by a feeling of disappointment in her ability to help herself and the stress of being a counselor-in-training. Mary reported observing her stepfather inflict physical and emotional abuse on her mother during her childhood. she indicated it was due to “adjusting to college life. she found herself questioning whether she still wished to pursue counseling. She also reported being sexually abused when she was a child by another female child. who was an acquaintance.sagepub. including emotional neglect and an emotionally tumultuous environment. Educational and Social During college. Consequently. In addition to sexual victimization. Although Mary’s presenting complaints did not specifically mention the sexual assault. her mother was often sad and stressed. had begun to comment on her anger. Mary’s parents divorced. Mary was dedicated to her work and was a successful student. whom she had been dating for approximately 3 years. Mary described herself as an “overachiever” and “hard worker. For example. she had begun to question her abilities as a counselor and was unsure whether she wished to continue pursuing a degree in counseling. it was revealed that Mary had been sexually assaulted by a male acquaintance approximately 4 years back. Mary’s mother divorced her second husband when Mary was an adolescent. romantic and interpersonal relationships. and depressed mood.

The BDI-II has demonstrated high convergent validity (e. and extremely). Mental Health. Steer. Brown. and . Mary’s intake BDI-II score of 18. Avoidance subscale of 28. quite a bit. such as hopelessness.446 Clinical Case Studies 9(6) Mary reported that several of her close relationships (e. As previously mentioned.. and Anxiety Disorder Interview Schedule–IV (ADIS-IV. as seen in Figure 1..84 to . 2004). Mary sought brief counseling for “mild depression” in the past. and Hyperarousal subscale scores. She described being in good health. & Barlow.79 to . 1997). 5 Assessment A thorough pretreatment assessment. Symptom Checklist-90–Revised (SCL-90-R.91 among clinical patients and .94 for the Intrusion subscale. IES-R The IES-R (Weiss & Marmar. not at all. Responses..94 (Weiss & Marmar. and Substance Use Mary neither reported significant medical history nor any major concerns about her physical health. and mild sleep disturbance. Medical. her total score of 42 indicated a moderate level of posttrauma-related distress. which range from 0 to 3.. Derogatis.com by Andreea Nicoleta Nicolae on October 12.87 for the Avoidance subscale.g. using a multiple choice format that provides a list of increasingly severe responses.e. 1997). At intake. a little bit. . Clients are asked to rate how distressing each IES item was during the previous 7 days using a scale from 0 to 4 (i. Beck. BDI-II The BDI-II (Beck et al. 2011 . fluctuations in her weight. DiNardo. r = . 2003. sadness.89 to . Previous studies have demonstrated Cronbach’s alphas ranging from . Weiss & Marmar. and 29 to 63 are in the severe symptomatology range. She indicated that several members of her family have experienced anxiety and depression symptoms. Beck et al. 1997). 14 to 19 are considered in the mild range. and sleep patterns.g. Mary’s responses revealed an Intrusion IES subscale of 14.71 with the Hamilton Psychiatric Rating Scale for Depression) and high internal consistency (e. Impact of Events Scale–Revised (IES-R. 1996). The responses are then used to obtain Avoidance.g. Mary did report experiencing tension headaches. and Hyperarousal subscale of 0. The test–retest reliability across a 6-month period ranged from . 1996) is a 21-item self-report instrument used to assess the severity of depressive symptomatology during the most recent 2 weeks. Total scores of 0 to 13 are considered in the minimal range. 1997) is a 22-item self-report measure designed to measure distress following a traumatic event. was in the mild range of severity. & Brown.91 for the Hyperarousal subscale (Creamer. moderately. Intrusion. & Failla.87 to . . She endorsed using marijuana when she was an adolescent. classmates and boyfriend) had become strained in recent months.. Furthermore. 20 to 28 are in the moderate range. Clients are asked to respond to an array of domains. However. she reported no significant alcohol or drug history in her family. was conducted during the intake sessions to assess Mary’s current level of functioning.sagepub. In addition. Downloaded from ccs. are then summed to obtain an overall score.. 1996). Weiss & Marmar. At the time she sought treatment. including the Beck Depression Inventory–II (BDI-II.93 among college students. 1997). Mary indicated that she did not use drugs and rarely consumed alcohol. Bell.

86.70 to. Mary’s score of 60 on the Depression subscale was slightly elevated. Positive Symptom Index = 58. Anxiety = 50. & Hope. and somatoform disorders. Clients are asked to rate on a 5-point scale (0 = not at all.93 (Horowitz. Research has demonstrated alpha coefficients for the subscales ranging from . 2006).com by Andreea Nicoleta Nicolae on October 12.67-. Treatment outcome assessment: BDI-II scores Note: BDI-II = Beck Depression Inventory–II. Obsessive-Compulsive = 58. ADIS-IV The ADIS-IV (Brown et al. 90 and test–retest coefficients ranging from . Scores above 70 on any given subscale indicates clinical-level symptomatology. 4 = extremely) how frequently each symptom had occurred in the past week. Phobic Anxiety = 44. 2000) that assesses for the necessary information to make differential diagnosis among anxiety. Handel. Rosenberg. Thus. . Hostility = 54. 2004) is a structured interview based on the DSM-IV-TR (APA. during the PTSD/Acute Stress module. Simonds. and Positive Symptom Distress Index = 53.sagepub. & Villasenor..447 Wilson and Jones Figure 1. Mary endorsed experiencing an Downloaded from ccs. mood. The interview uses a “branching format” that starts with screening questions to determine whether symptom-specific questions are relevant.e. 1997) is a 90-item self-report instrument that assesses a wide range of symptomatology. Hayes. Mary’s scores on the nine domains of the SCL-90-R were as follows: Somatization = 35. Their responses are used to obtain nine subscale scores as well as three global index scores that reflect the overall severity and intensity of psychopathology. 1988. Paranoid Ideation = 54. 2011 . Notably. Baer. 2008).68 to . DiLillo. SCL-90-R The SCL-90-R (Derogatis. The ADISIV has demonstrated moderate to high interrater reliability (i. Interpersonal Sensitivity = 53.. and Psychoticism = 58. Depression = 60. & Archer. Ureno. Her scores on the three global index scores were as follows: General Severity Index = 56.

as outlined by Resick and Schnicke (1993). she believed that it was her fault.” Subsequently.com by Andreea Nicoleta Nicolae on October 12. and feelings of incompetency and emotional distress. fluctuations in weight. were mild in nature. Treatment was delivered in 1-hr weekly individual sessions over a span of 12 weeks. 2011 . The clinician who delivered the treatment was a clinician-in-training who worked at a training clinic associated with a PhD program in clinical psychology. mild major depressive disorder (APA. concentration difficulty. At the time of treatment. sleep disturbance. she had already obtained a master’s degree and had completed an adult psychopathology course that covered CPT with trauma clients. and hyperarousal (e.. In addition. Furthermore. Moreover. dreams of the event.. DSM-IVTR criteria for recurrent. irritability or outbursts of anger. building rapport and establishing a therapeutic relationship. To integrate the rape into her schema. These initial sessions were followed by a 12-session treatment phase. these symptoms had also resulted in interference with her daily life and substantial distress. Furthermore. a chronic PTSD diagnosis was made. and symptomotology made her an excellent candidate for CPT. Thus. avoidance (e. she had experienced at least one prior episode of depression. During the major depression module. Mary’s distress was beginning to affect her ability to function as a graduate student and counseling trainee. In addition. 2000) were met. loss of interest in sex. she endorsed intrusive recollections of the sexual assault. irritability. degree of distress. It is possible that the majority of her symptoms (e. such as difficulties in trusting others. 6 Case Conceptualization On the basis of the intake interview and assessment measures.g.. which included working with clients.” and “occurs in a dark alley with no witnesses. and emotional distress and physical response to reminders of the trauma. Therefore. Also. Furthermore. guilt.g. significantly interfered with her life. psychomotor agitation. Mary endorsed evidence of intrusions (e. feelings of detachment from others. five sessions were spent collecting the aforementioned intake and assessment information. and a loss of interest in sex. The onset of these symptoms coincided with the beginning of her training in the doctoral counseling program. Downloaded from ccs. Mary experienced great distress when attempting to understand this event because it contradicted her preexisting schema. were related to changes in her cognitive schema and were affecting her ability to perform adequately as a therapist. 7 Course of Treatment and Assessment of Progress After Mary presented for therapy. Many of the problems she was experiencing. Mary endorsed significant weight change. psychomotor agitation) symptomatology following the sexual assault 4 years earlier. and a sense of foreshortened future. Mary’s previous schema regarding rape was consistent with those of many women who have been attacked. she received weekly supervision from a licensed clinical psychologist who is a trauma specialist. guilt. Likely she was also experiencing vicarious traumatization..sagepub. and her current depression symptoms. Specifically.g. and sleep disturbance) resulted from her attempts to integrate the traumatic event into her existing schema.448 Clinical Case Studies 9(6) avoidance of thoughts/feelings and activities/situations as well as loss of interest in significant activities. and feelings of worthlessness and guilt. restricted range of emotions. it was revealed that Mary had been experiencing pessimism. Mary also reported difficulties in falling or staying asleep.g. she indicated that these symptoms had onset since the sexual assault. and discussing Mary’s expectations for therapy. a loss of interest in significant activities. although clinically significant. lack of interest in sex). Mary’s presenting schema. and led to severe distress.” is committed by “bad men that do not know the women they attack. she viewed rape as an event that happens to women who are “not careful. and difficulty in concentrating. self-criticalness. nightmares).

Mary then read her homework assignment aloud. the specific aspects of CPT with trauma survivors were discussed and reviewed.e. Mary was also given a worksheet on and introduced to the term “stuck points. In regards to others and the world. A-B-C sheets). anxiety) and maladaptive behaviors (e.g. and that she will never feel intimate with someone ever again. and she felt “vulnerable. In addition. she indicated that “[her] boyfriend initiating sex” was a distressing event for her. and outcomes as well as identify stuck points related to the rape.com by Andreea Nicoleta Nicolae on October 12. power/control. a general explanation of rape reactions based on the cognitive information processing theory and education of symptoms of PTSD and depression. Mary realized that she was afraid of having sex because she felt she does not have control over the situation. she felt as though she was being raped again because she was not in total control of the situation. Mary and the therapist explored her emotional reactions to the rape and discussed her stuck points. Mary reported that completing the homework assignment was challenging. and the witnesses for standing by while the event occurred. esteem. The areas she was asked to consider when completing the homework included what effects the rape had on her thoughts about herself. she felt better once the therapist validated her feelings. At the conclusion. but [she] had sex with him anyway. the supervisor reviewed detailed documentation and viewed videotaped portions of each session to ensure the treatment was appropriately administered. that she was not safe. Mary was given the first homework assignment. Examples of stuck points that were identified included “you cannot be raped by a friend.” and this acknowledgment made her feel weak and pathetic. Specifically. Mary’s beliefs included “I owe him. Mary indicated that although she was angry at herself. Treatment Session 2: Meaning of the Rape Event The second session began with a brief education about emotional reactions and individual differences in the interpretation of events. 2011 . The therapist then emphasized the importance of session attendance and completion of homework assignments because avoidance is a very common reaction. Although she trusted and loved her boyfriend.” and “I don’t want to do this. The goal of the exercise was to help Mary understand the connection between events. and common” when she wrote down her thoughts and shared them in session. Mary believed that other people could never be trusted. ashamed and annoyed with [herself]..” After discussing her homework..” The outcome of the situation was that Mary felt “frustrated. When this occurred. dirty. Treatment Session 1: Introduction and Education The treatment phase commenced with an introduction to the planned course of treatment. In preparation for the next session.449 Wilson and Jones As part of this supervision. Treatment Session 3: Identifying Thoughts and Feelings At the beginning of the third session. Mary was asked to discuss the A-B-C sheets she had completed for homework. and consequences (i. so therefore I was not raped” and “I should be able to protect myself. and intimacy.” These distressing beliefs had resulted in Mary feeling guilty and attempting to convince herself that she was not raped. trust.sagepub.” “Let’s just get this over with. At this point.. her beliefs. and the world in relation to perceived safety. avoidance). For the next homework Downloaded from ccs. so I must be an accessory to the crime. others.g. which involved writing about what it meant to her that she was raped. the perpetrator.” which are conflicting beliefs that create unpleasant feelings (e. Mary indicated recognizing that she was “not invulnerable. her beliefs. Mary was asked to complete worksheets examining the links between activating events. For example.

The therapist then Downloaded from ccs.sagepub. and that the therapist was there to assist her if she became distressed while discussing the rape. Mary believed that she would never be safe because “bad things happened even when [she] tried to protect [herself]. Mary appeared relieved by this and began to discuss the rape in more detail and with more emotion. Mary chose two stuck points: “[she] should have prevented the event from happening at all” and “others cannot be trusted because several people witnessed the rape without stopping it. In discussing the rape with the therapist. Treatment Session 6: Challenging Questions As soon as the sixth session began.” she had to abstain from emotionally reacting (e. crying) to the rape..” However. For homework.com by Andreea Nicoleta Nicolae on October 12. in regard to Mary stopping the rape. however.g. that it was healthy to express her feelings. The therapist reinforced Mary’s effort. Mary’s voice was monotone and she appeared disengaged. Mary indicated that it was harder to read the second account aloud because it contained more details. In doing so. While reading the account. Mary shared the most horrific part of the event for her: “Even though [she] had removed [herself] from the situation in which the perpetrator was acting inappropriate. These worksheets listed a series of questions aimed at helping the client challenge his or her maladaptive beliefs. Treatment Session 5: Identifying Stuck Points To begin the fifth session. Mary indicated that the rape stopped when she fought away from the perpetrator. Thus. While reading the new version. Mary indicated she had remembered numerous details she had refrained from thinking about since immediately following the event. Mary then read the “challenging questions” worksheets she had been asked to complete as homework.” Therefore. her account lacked many details and appeared emotionless. Mary had succeeded in preventing the rape from continuing. Mary was asked to read her new account of the rape. 2011 . she felt it was more helpful to do so because it was a more accurate representation of what happened. Treatment Session 4: Remembering the Rape At the beginning of the fourth session.” Therefore. Mary indicated that she frequently refrained from “becoming emotional” because she was afraid she would not be able to stop and “will simply go crazy.” After completing the homework. She indicated that she felt “dirty and angry” while reading the narrative. another stuck point for Mary involved her belief that to keep herself from “going crazy. Mary indicated that she had never considered that detail and appeared reassured by the therapist’s comment. he followed [her] and raped [her]. Mary was asked to explore two stuck points by completing two “challenging questions” worksheets. the therapist pointed out that during her narrative. but asked whether she withheld her emotional reaction. Mary shared that the therapist’s comment during the previous session.450 Clinical Case Studies 9(6) assignment. had alleviated a lot of the self-blame she had been experiencing. The therapist informed Mary that she was safe. Mary indicated that the list of questions had helped her acknowledge many facts she had ignored and that many of her beliefs regarding the rape were distorted. Mary was asked to write a full account of the rape and include as many sensory details as possible. Mary was asked to start over and write a new account of the rape. The therapist reinforced Mary’s hard work and pointed out that it was Mary’s detailed account that had in fact revealed her successful stop to the rape. Although Mary had completed the assignment. For homework. This distorted idea related to Mary’s belief that because she was in training to become a therapist. she had to be in control of her emotions at all time. Mary was asked to read her account of the rape out loud. Mary expressed more emotion and shared more details throughout the recount. On inquiry.

However. Mary was also asked to complete a “challenging beliefs” worksheet that combined the “A-B-C. For example. She also reported that since completing the worksheet she had examined all her rape-related thoughts and she found that many of her daily beliefs were distorted. Not all the pretreatment measures were administered at posttreatment because the initial battery of measures was more comprehensive to elucidate her presenting complaints. Mary found that the relevant topic sessions were very helpful because she had experienced stuck points related to all five topics. at the conclusion of therapy. Mary was given a handout during each session that detailed the topic for that given day. and at 3 and 6 months post therapy (see Figure 2).g. Specifically. Mary’s responses revealed an Intrusion IES subscale of 14. Treatment Sessions 8 to 12: Five Relevant Topics During the last five sessions. Mary realized she had disregarded important aspects of the situation (e. Mary believed that she “should have control of [herself] at all times or bad things will happen.g. and intimacy) of psychological and interpersonal functioning that may be affected by rape were explored. However. she said “no” to the perpetrator) and had been overgeneralizing from the single rape event (e. which included the BDI-II and IES-R. “sexual intercourse is bad”). Mary realized her ideas of control had become distorted. Mary’s scores revealed an Intrusion IES subscale of 1.e. with the exception of a slight spike during the 4th week. Mary indicated that the worksheet had helped her examine many aspects of the rape she had not considered since it occurred. it is not unexpected that she would demonstrate a minor elevation in depression symptomatology. when anything bad happened. power and control. The BDI-II was administered on a weekly basis at the beginning of the session and during 3. At intake. were obtained during each therapy phase to assess progress as well as 3 and 6 months post therapy. Once intake was complete and the appropriate diagnoses were identified. In preparation for the last session. To do so..” Mary felt that it was “too risky to express emotions. and unhealthy. extreme.” After discussing the “control” handout and completing the homework.com by Andreea Nicoleta Nicolae on October 12.and 6-month follow-up assessments. For example. As seen in Figure 1. Mary was also asked to write about what it means that she was raped and it was discussed as a means to summarize the gains she had made throughout therapy. then more specific and appropriate measures were used to monitor progress and outcome. safety. Mary’s BDI-II scores evidenced a steady decline in severity across the 12-week therapy phase. esteem.” “challenging thoughts. Mary was asked to generate examples of faulty thinking patterns relating to her stuck points. because Mary had been asked to write a full account of the rape event in preparation for the fourth session. she assumed it was her fault. Treatment Session 7: Faulty Thinking Patterns The session began with a discussion of the “faulty thinking patterns” worksheet that Mary had completed for homework. Avoidance subscale of 28. Her control issues were also problematic because to “remain in control.451 Wilson and Jones introduced the concept of faulty thinking patterns and Mary was asked to complete a “faulty thinking patterns” worksheet for homework.. and Hyperarousal subscale of 0.” Therefore. trust. Downloaded from ccs. 2011 . Mary was also administered the IES-R during the intake phase.” and “faulty thinking patterns” worksheets from previous assignments. Assessment of Progress Outcome measures. In preparation for each session. five areas (i. The therapist reinforced her application of the homework to everyday situations and encouraged her to continue to do so.sagepub.. at the conclusion of therapy.

many of the techniques Mary learned were then used to address her difficulties related to her position as a clinician-in-training. Treatment outcome assessment: IES-R scores Note: IES-R = Impact of Events Scale–Revised. and an exceptional knowledge base of cognitive processing theory and therapy procedures. Mary’s acquired skills of examining distorted cognitions were helpful when challenging some of her own maladaptive cognitions (e.452 Clinical Case Studies 9(6) Figure 2. as measured by both the BDI and IES-R. and Hyperarousal subscale of 0. Thus. 8 Complicating Factors Throughout treatment. Avoidance subscale of 3.com by Andreea Nicoleta Nicolae on October 12.sagepub. However. The decreases in her symptomatology. she was better able to explore other difficulties she was experiencing. the focus was shifted from the rape to difficulties with her boyfriend.g. Therefore. “I don’t need help because I am a counselor”).. Mary and the therapist agreed it was appropriate to continue therapy. She evidenced marked insight. She was also compliant and dedicated to treatment because she was aware that treatment outcome is often associated with attendance and treatment compliance. Mary began experiencing relationship difficulties with her longtime boyfriend. In addition. during the last week of the 12-week treatment phase. however. Thus. In addition. she easily grasped the concepts that were presented in session. She frequently appeared embarrassed because she was seeking help despite her educational background. Mary’s educational background as a counselor was both helpful and problematic. reflecting a substantial decrease in PTSD symptomatology. at the conclusion of the treatment phase. The therapist believes that because Mary had effectively processed the rape through the CPT protocol and adjusted her distorted beliefs. 9 Managed Care Considerations CPT for Rape Victims is ideal for managed care environments because it can be completed in twelve 1-hr sessions and can be delivered in group formats. more recent studies support Downloaded from ccs. 2011 . were maintained at 3 and 6 months post therapy. she became very frustrated at times when she was unable to express her feelings or label her emotions.

Follette et al. However. it is likely that as Mary progressed through her clinical training and practicum hours. which is an aspect of self-care (McCann & Pearlman. 1993). it is important to note that she received weekly supervision.. 11 Treatment Implications of the Case Multiple implications can be derived from the current case study when the findings are considered in tandem with previous research. 1990). graduate-level clinicians are encouraged to deal with their own trauma histories because of the greater likelihood of experiencing psychological and interpersonal difficulties when working with trauma clients. Thus. it is imperative that researchers and counselors continue to expand on this efficacious treatment and explore its effectiveness in a more diverse population (e. especially because the acting therapist in the current case study was a counselor-in-training. However. male survivors of rape). & Feuer. versatility. First. 1993) in assisting a counselor-in-training with confronting her own trauma history. Weaver. and had already obtained a master’s degree. In addition. Because of the high prevalence of sexual assault and the welldemonstrated link to psychological consequences. and effectiveness of CPT for Rape Victims (Resick & Schnicke. Following treatment. the current case study provides further support for the efficacy of CPT for Rape Victims (Resick & Schnicke. it is encouraging that such a successful treatment protocol has been established. was maintained 3 and 6 months following the completion of CPT (see Figures 1 and 2). 12 weeks). As referenced earlier. the current case study expands on previous research that emphasizes the importance of personal therapy for therapists with trauma histories. the current case confirmed that the treatment protocol can be completed in a brief period of time (i.453 Wilson and Jones the efficacy of the treatment by demonstrating significant decreases in distress at posttreatment as well as 3. Nishith. had been oriented to CPT. and it was easy-to-follow and sufficient for preparing the therapist for each session. To address these issues. Therefore. The client had been experiencing symptoms that are indicative of vicarious traumatization. 1993) when working with adult female sexual assault survivors. the effects of her own victimization became more apparent. 1990). a noteworthy advantage of CPT for Rape Victims (Resick & Schnicke.e. 12 Recommendations to Clinicians and Students The findings of the current case study support at least two important recommendations for clinicians. First.sagepub. Mary began to realize that many of her beliefs about herself post rape were distorted and had begun to affect her confidence in her capacity to become a successful therapist. the current case study provides support for the use of CPT for Rape Victims (Resick & Schnicke. Ultimately. Mary evidenced a reduction in both depression and PTSD symptomatology.g. 2002). such as sleep difficulty and helplessness (McCann & Pearlman. Therefore. she began to question her abilities as a counselor. Second.com by Andreea Nicoleta Nicolae on October 12. A third implication is the flexibility. the therapist encouraged her to apply the skills she had learned to challenge her cognitions related to her abilities as a therapist.and 9-month follow-ups (Resick. as well as cognitive distortions related to her ability to perform as a counselor. (1994) attributed the lower levels of distress among law enforcement and mental health professionals to the higher percentage of mental health staff that sought therapy for their own difficulties. by seeking Downloaded from ccs. 10 Follow-Up The overall reduction in depression and posttraumatic symptoms. 2011 . Thus. Astin.. through therapy. Therefore. 1993) is its clear procedures and efficient treatment format. The manual was an excellent resource for the therapist. as measured by the BDI-II and IES-R.

including exercise. Similar to other areas of psychology. many researchers argue that some therapists may experience personal growth from working with trauma survivors (Arnold. clinical psychologists in training. Although the current article highlights some potential negative implications for therapists with trauma histories. (c) therapists should be provided confidential counseling services to aid them in dealing with their reactions to their clients’ traumas as well as their own previous traumatic experiences. Trauma therapists should be encouraged to exercise self-awareness and self-care throughout their career.454 Clinical Case Studies 9(6) therapy for her own trauma. Therefore. especially in terms of posttrauma functioning (Prati & Pietrantoni. Overall. (2000). Diagnostic and statistical manual of mental disorders (4th ed. 1993) when working with sexual assault survivors. there is variability in outcomes among therapists who themselves are trauma survivors. In regards to the second recommendation. it is likely that she was experiencing a form of vicarious traumatization that further complicated her own difficulties. therapists are encouraged to promote and explore their own spirituality and faith. 1993) as an effective intervention for the sexual assault survivor in the current case study. Mary. however. Third.com by Andreea Nicoleta Nicolae on October 12. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article. Washington. Funding The author(s) received no financial support for the research and/or authorship of this article. (b) training programs should include self-awareness and self-care programs in psychology graduate school curriculum.. 2008): (a) graduate students should be encouraged to seek social support from classmates and supervisors throughout their training. healthy eating. & Cann. Tedeschi. Although little is empirically known about what factors and resources promote better job satisfaction and well-being in mental health professionals. and relaxation techniques. who was a female counselor confronting her own victimization history. the findings support CPT for Rape Victims (Resick & Schnicke. Because of the timing of the symptom onset and the nature of her symptomatology. and (f) because spirituality is a positive coping behavior. Following the completion of CPT for Rape Victims. the current findings coupled with previous research suggest that clinicians should give strong consideration to use CPT for Rape Victims (Resick & Schnicke. Mary experienced an overall reduction in depression and PTSD symptoms. DC: Author. text rev. and clinical psychology training programs (see Killian. Calhoun. (d) therapists should be encouraged to frequently debrief with colleagues or supervisors when dealing with a difficult case. 2011 .). such as during graduate school. (e) mental health professionals are encouraged to practice self-care strategies. 2009). the following are recommendations for mental health professionals.sagepub. this important element of personal support should be introduced and emphasized as a part of the education and training core curriculum of psychology graduate school. The current case study lends support for counselors acknowledging their own signs of psychological distress and seeking help with confronting their own traumas. 2005). Mary was improving her overall ability to function as a healthier and more competent therapist. References American Psychiatric Association. Downloaded from ccs. as well as decrease cognitive distortions related to her own abilities. it is recommended that therapists explore and work through their own past traumas early in their careers. the current article presents the case of a clinician-in-training. who was experiencing depression and PTSD symptoms following a rape.

P. & Feuer. Calhoun. DiLillo. Behaviour Research and Therapy. S. & Grootenhuis. B. D. D. 558-565. A. S. McCann. D. (2003). Maltreatment. B. 417-424. Department of Justice.. (1997). A. Inventory of interpersonal problems: Psychometric properties and clinical applications. Sensitivity of the Anxiety Disorder Interview Schedule IV in detecting potentially traumatic childhood maltreatment. Hayes. Polusney. Psychometric properties of the Impact of Event Scale-Revised. Vicarious posttraumatic growth in psychotherapy. Collins. M. & Cann. D. & Long. L. & Itzhaky. Brown. Resick. Department of Justice. Bronner. Vicarious traumatisation: A framework for understanding the psychological effects of working with victims. Baer. Mental health and law enforcement professionals: Trauma history. 14. A. D. Pearlman. Unpublished manuscript. 3. (2009). Weaver. (2002). A. 275-282.455 Wilson and Jones Arnold. A. (1994).. de Vries... Journal of Humanistic Psychology. vicarious traumatization. 354-388. A comparison of cognitiveprocessing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. D. Implications of treating family violence for the therapist: Secondary traumatization. A. H. S. K. San Antonio. L. Creamer. Journal of Clinical and Counseling Psychology. Phelps. DC: U. Lloyd.d. Rosenberg. A. Last.. S. 313-330. S. G. K.. & MacIan. A. 131-149.. G.). Astin. Peek. (2000). and self-care in clinicians working with trauma survivors. Journal of Family Violence. 1489-1496. A. A.. 18. B. A community-based survey of posttraumatic stress disorder in the Netherlands. (2008). San Antonio.. Downloaded from ccs. Professional Psychology: Research and Practice. Journal of Traumatic Stress. M. 10. 41. Journal of Psychopathology and Behavioral Assessment. Ureno. R.. (2009). Catalano. L. Journal of Aggression. Nishith. B. 867-879. Ben-Porat. Beck. P.. TX: Psychological Corporation. and impact of providing services to child sex abuse survivors.. TX: Psychological Corporation.. A. L. M. M. L.. Journal of Traumatic Stress. M. (1996). M. Fisher. 885-892. San Antonio. & Brown. T. (1988). M. & Turner. A.com by Andreea Nicoleta Nicolae on October 12.. 28. R. 239-263. W.. psychological symptoms... Bureau of justice statistics national crime victimization survey: Criminal victimization. C.. & Milbeck. DiNardo. L. Vicarious traumatization: Effects of therapist spirituality. Journal of Psychiatric and Mental Health Nursing. L. Caring for carers in the aftermath of trauma. Horowitz. C. (1992). A. and client-therapist gender matching.S. & Barlow. Journal of Consulting and Clinical Psychology. 24. 867-879. & Hope. E. Journal of Consulting and Clinical Psychology. (2009).. Creamer. G. A. Traumatology.W. 14. V. K. S. L. T. P.. Cognitive processing therapy for sexual assault victims. M.. Tedeschi. & Trauma. 26. (2004). P. Resick. F. & Schnicke. (2009). A. Killian. London. G... & Saakvitne. F. K. Journal of Consulting and Clinical Psychology. TX: Psychological Corporation. and growth. DC: National Institute of Justice. and coping strategies as factors contributing to posttraumatic growth: A meta-analysis. N. Prati. Washington. 507-515. (2004). Norton. 56. R.. E. Anxiety disorders interview schedule adult version (ADIS-IV): Client interview schedule. 2011 . T. 25. (1995). 70. P. Vicarious traumatization: An empirical study of the effects of trauma work on trauma therapists. Trauma and the therapist: Counter transference and vicarious traumatization in psychotherapy with incest survivor. Pearlman. K. G. S.. Beck Depression Inventory-II (BDI-II). Steer. Symptom Checklist-90-Revised (SCL-90-R). (2003). A. S. A.. D. Journal of Loss & Trauma. 45. (n... (2005). A. Washington.. & Pietrantoni. perceptions of countertransference. Follette. (1995). Working with the psychological effects of trauma: Consequences for mental health-care workers—A literature review. V.sagepub. (1990). H. L.. 32-44. 131-135.. Bronner. Derogatis.. 70. M. R. Bureau of Justice Statistics.. & Forbers. Optimism. O’Malley Reyntjens. M. M. The sexual victimization of college women. M. Cullen. burnout. & Villasenor.. & Rubin. K. 22. L.. T. UK: W. & Failla.. 74-78. & Pearlman. social support... 2003. (2006). Helping till it hurts? A multimethod study of compassion fatigue. Bell.

com by Andreea Nicoleta Nicolae on October 12. (1993). Resiliency factors in the relation between childhood sexual abuse and adulthood sexual assault in college-age women. H. (1995). & Archer. MD: Sidran Press. & Frazier. B. 16. Self-care and the vulnerable therapist. His research targets the topic of child and adult stress and coping. 168-189). 78-86. Journal of Child Sexual Abuse. C. Rudolph. L. A.. In J. Jones is a professor of psychology at Virginia Tech and a clinical psychologist who specializes in clinical child psychology and trauma psychology. Spinazzola. Walsh. Montreal. Stamm (Ed.. 19. E (1997). Secondary traumatic stress: Self-care issues for clinicians (pp. F. J. P. The Impact of Event Scale-Revised. H. G.).. CA: Sage. Vicarious trauma: The effects on female counselors of working with sexual violence survivors. & van der Kolk.. Coping with common stressful life events. W. parental incarceration. Assessing psychological trauma and PTSD (pp. Downloaded from ccs. and other traumatic experiences and the impact of psychophysiological mechanisms and psychosocial factors on aggression and violence in terms of perpetration and victimization. Handel. 49-64. 2011 .. Weiss. (2008). Bios Laura C. is also examined.. Williams. A. H. Russell T. Newbury Park. Keane (Eds.. C. P.sagepub. 230-246). M. J. (2007).. Knight. P. technological and mass violence). Wilson is a doctoral candidate in the clinical psychology program at Virginia Tech. M. Quebec. R. 15. R. providers and administration. J... Stamm.. Lutherville. K. Schauben. & Stamm. New York. & Schnicke. D. Compassion fatigue: A concern for mental health policy. A. Assessment. natural. E.. M.e. & Marmar. NY: Guilford.. Blaustein. (1995). & Sommer. M.). K. J. Simonds. W. Psychology of Women Quarterly. Her research interests include the developmental consequences of child abuse. B. In B. as well as major traumas (i. (1997). Incremental validity of the Minnesota Multiphasic Personality Inventory-2 and Symptom Checklist-90-Revised with mental health inpatients. 1-17. Wilson & T. Poster presented at the 13th Annual Meeting of the International Society for Traumatic Stress Studies.456 Clinical Case Studies 9(6) Resick. B. Canada. Cognitive processing therapy for rape victims: A treatment manual.