Rape and Sexual Assault

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Edna Foa and Barbara Olasov Rothbaum (1988) outline a comprehensive cognitive-behavioral treatment (CBT) approach to PTSD from rape and sexual assault. Earlier analyses of posttraumatic reactions to rape have been referred to as rape trauma syndrome (Burgess & Holmstrom, 1974). Foa and Rothbaum outline these common affective and functional sequelae to rape in addition to PTSD core symptoms:

Anxiety: intense fears of rape-related situations and generalized anxiety

Depression: may be more common than in victims of other forms of crime

Anger

Dissociation

Social problems: restricted social life, activities, marital problems, and family problems

Sexual problems: considered common: decreased sexual satisfaction, decreased arousal and desire, and sometimes total avoidance of sex

Foa and Rothbaum (1998) suggest the use of general CBT techniques, including imaginal exposure, in vivo exposure, breathing retraining, cognitive restructuring, thought stopping, guided self-dialogue, deep muscle differential relaxation, and covert modeling and role playing. They mention some important treatment considerations for rape trauma victims that are critical to address. They begin by warning that rape victims are particularly and extremely avoidant, and if this issue is left unaddressed, it may significantly interfere with treatment. Suggestions for dealing with these high levels of avoidance include validation of the client's feelings, perhaps allowing for more cancellations and support clients when they do avoid treatment as a way to get them to come in for treatment. A supportive attitude and understanding is critical. Another complicating factor is that unlike with Panic Disorder and many other phobias, the fears and anxieties that a rape victim often feels are "strongly rooted in reality" (Foa & Rothbaum, 1998, p. 95).

Clinician Alert

Foa and Rothbaum (1998) suggest the following therapeutic do's (as opposed to don'ts):

• Do be active and directive in encouraging the client to attend to sensations, comply with therapeutic instructions, learn new skills, and practice them during homework.

• Do be supportive and sensitive when your client confronts assault-related memories, feelings, and thoughts about her assault.

• Do remember that the treatments programs are time limited. However, if a client needs further help, it is important that you help her to find appropriate resources or continue to work with her yourself.

It is important to assess the reality of a patient's fears when constructing the in vivo hierarchy. However, it is also important to not get into the crystal ball game and try to determine which situations may be potentially safe versus dangerous in an absolute sense, but, instead, determinations should be based on the concept of an "acceptable level of risk" (p. 96) for the client's anxiety tolerance. Foa and Rothbaum warn that it can be difficult to use cognitive techniques for distorted cognitions regarding danger when they are connected to actual events. Some situations are clearly safe, and others are more ambiguous. The clinician should engage in open and frequent discussions about this issue.

Three treatment schedules are outlined for rape trauma treatment: (1) a prolonged exposure (PE) protocol, (2) a PE protocol with cognitive restructuring, and (3) a PE protocol with stress-inoculation training (SIT). Each of these are similar in structure and form to prolonged exposure, cognitive restructuring, and SIT used with other disorders with some specific alterations and additions relative to rape and sexual assault. For example, in all of the schedules, pretreatment assessment should proceed with the assault information and history interview in order to obtain specifics relevant to structuring treatment. Handouts are typically used in CBT treatment. Foa and Rothbaum (1998) recommend using the handout or information pamphlet Common Reactions to Assault as part of the patient education materials.

The PE alone schedule is recommended as a first-line approach, particularly for uncomplicated PTSD as opposed to complex PTSD. The PE plus cognitive restructuring schedule is suggested for patients who have both anxiety and a significant amount of guilt, shame, and debilitating anger. Dealing with negative automatic thoughts, dysfunctional beliefs, and cognitive distortions is an integral part of this approach, and Foa and Rothbaum (1998) suggest the use of a client-self-report daily diary as a means to record cognitive components. This provides a ready list of specific cognitions that are particularly relevant to the

Professional, Student, and Lay-Person Alert

I believe that this issue of generic cognitive distortions is extremely important when approaching treatment from a CBT perspective. In my experience, some potential therapy clients have a negative reaction to what they feel is a cookbook form of therapy in CBT. Of course, this is an arguable point, but the empirical validity and efficacy of CBT is well established in the literature. However, whether it is an effective treatment is often not the point for prospective patients or patients in the early stages of treatment. Posttraumatic Stress Disorder patients may be sensitive to feeling dehumanized, and these potential reactions must be factored in and discussed early on in treatment if they become apparent. Some professionals, too, have this reaction to CBT techniques as it seems to violate some of their schemas and scripts for what therapy or treatment should look like and feel like. Cognitive-behavioral therapy works; however, getting it into place and getting patients to buy in can be extremely difficult. I have seen effective practitioners of CBT who were as warm and nondehumanizing as anyone in the field. But it is important to keep in mind that a professional can be extremely warm and accepting but be using an ineffective treatment approach. It is also important to not fall into a cognitive distortion of our own when thinking about CBT. It is effective, and many well-trained, supportive, and empathic professionals have been able to help patients get better and feel better using this approach. As patients and consumers, we must not make the mistake of confusing the order and structure of CBT with coldness and lack of empathy. As professionals, we must not let the order and structure of CBT overshadow the basic clinical skills of empathy and support and get caught hiding behind technique.

client and not just generic cognitive distortions. Finally, Roa and Rothbaum suggest the PE and SIT combined approach for patients who are dealing with very high levels of arousal, feelings of being out of control, and who are extremely hesitant to engage in exposure. Stress-inoculation therapy is suggested as a means to help the patient gain a sense of control before exposure proceeds.

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