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Post
Traumatic Stress Disorder in Rape Victims: A Review of Cognitive-Behavioral &
Hypnotic Treatment Approaches
Jeffrey W. Braunstein, Ph.D.
People who suffer
from Post Traumatic Stress Disorder usually encounter a traumatic event that DSM
IIIR (APA, 1987) has defined as "an event that is outside the range of usual
human experience and that would be markedly distressing to almost anyone."
These abnormal events can cause the person to experience symptoms that are
directly associated with the traumatic event. Typical events that elicit
traumas are rapes, physical or psychological abuse, and involvement in war.
To meet the criteria
for PTSD a person must suffer from three primary symptoms resulting from the
trauma: a regular re experiencing of the event, avoidance or numbing, and
increased arousal. Some of the specific symptoms of the re experiencing of the
trauma occur in the form of flashbacks. These flashbacks can be experienced
during times when the victim is awake and include vivid and detailed
reenactments of the event. Children exhibit these symptoms by acting out the
traumatic experience during times of play. Re experiencing of the event can
also take place during the victim's dreams. The criteria for reexperincing also
includes exposure to stimuli associated with the event, that causes great
distress.
Victims of PTSD
also suffer from avoidance and numbing due to the distressing trauma. Victims
usually develope avoidance behavior to stimuli that are associated with the
trauma for fear of re experiencing the event. Victims also demonstrate
avoidance by forgetting certain important parts of the traumatic event.
Numbing, as a consequence of the trauma, can result in a loss of interest in
activities that were once important to the person, such as work, sex, or any
other pleasurable activity. For example, Barlow (1993) found that rape victims
had less sexual satisfaction than control subjects. In support of these
findings, Schwartz (1993) reported that some victims exhibit Sexual Compulsivity
as a primary symptom of PTSD. These victims are hypersexual and experience
bingeing and addiction to sex. Schwartz explains that during the course of
development, children who have been sexually abused view the compulsive event as
natural sexual behavior. During adulthood, these people are compelled to
reenact these behaviors and find them pleasurable but are also ashamed of them.
These victims also experience an endorphin release (resulting in a "high") due
to the flashbacks that occur when practicing these behaviors, thus perpetuating
the addiction. Depersonalization (detachment from ones body) can also result
due to the numbing associated with PTSD.
Symptoms of
increased arousal are prevalent in victims of PTSD. These people usually find
it very hard to fall or stay asleep. They also may exhibit unprovoked fits of
anger and have a very high startle response. Their ability to concentrate can
also be greatly affected.
Victims of sexual
assault and rape are usually female. Men are also the victims of rape and
usually the assault is precipitated by another man. Women who have been
sexually assaulted are very reluctant to report the crime which confounds
statistical methods and surveys used to determine the prevalence of rape in this
country. Unreported rape, known as hidden rape is thought to be very prevalent
on college campuses but remains unreported due to the victims feelings of shame
or doubt regarding the incident. Many victims feel that they were responsible
in some way for the assault and blame themselves, thus delaying or failing to
report the assault. Research concerning the prevalence of PTSD, as a result of
rape, is not conclusive. "Within a sample population, Kilpatrick (1987) found
that 57% of rape victims developed PTSD during the course of their lives.
Kilpatrick, Edmunds, and Seymour (1992) later found that only 31% of rape
victims developed PTSD. In contrast to these findings, Foa, Riggs, Murdock, and
Walsh (1992) found that 94% of rape victims who were assessed within 2 weeks of
their rape met the criteria for PTSD." (Ochberg, 1988, p.121). This wide
discrepancy in prevalence rates could be attributed to the possible delayed
onset of the disorder and the responsibility that the victim may feel due to the
nature of the crime.
These prevalence
rates show that not all victims develop PTSD after being raped. The victim's
recovery environment, and individual characteristics are important factors in
predicting if and to what extent a person will suffer from a psychological
disorder after a rape. Figley (1985) reported that the demographic
characteristics of rape victims can be used as predictors. He found that
married victims, and non-Caucasians have higher rates of disturbances.
According to Figley (1985) age is also an important factor. Children have
higher recovery rates and less psychological disturbances than adults. Rape
victims who have had pre-existing psychological disorders, or physical ailments
have a greater chance of developing disturbances that are associated with their
rape (Figley 1985). In addition, Figley (1985) reported that the greater the
severity of the assault, the harder it is to adjust to the trauma. A victim's
environment is crucial to the recovery of the victim. Scrignar (1984) states
that the social supports and the attitudes of society are important factors in
recovery. Victims who are not blamed, (by either society or family) and who had
received high levels of emotional support had a better prognosis for recovering.
Assessing PTSD in
rape victims can be very difficult because frequently, the victim does not
realize the relation between their psychological problem and the rape.
Additional difficulty in assessment results because of typical comorbidity
associated with the original trauma. Typical comorbid disorders associated with
PTSD are depression, substance abuse, and other anxiety disorders. Rape victims
also may conceal the rape from the therapist and may not acknowledge it unless
they are directly asked.
Even though PTSD can
be difficult to detect, there are various assessment techniques and tools that
can be used to detect the presence of PTSD in rape victims. Structured
Interviews can be used such as: the Structured Clinical Interview (SCID), the
Diagnostic Interview Schedule (DIS) and the Anxiety Disorder Interview
Schedule-Revised (ADIS-R). Barlow (1993) prefers the AIDS-R because of its high
rate for detection of comorbid disorders. Self Report assessment tests such as
the Derogatis Symptom Checklist, the State-Trait Anxiety Inventory, and Impact
of Events Scale are assessment tools that measure the level of psychological
distress caused by the traumatic event.
There are various
treatments for PTSD in rape victims. I will be focusing on the psychodynamic
use of hypnosis and cognitive behavioral therapies that have had great success
in alleviating the symptoms of this debilitating disorder.
Psychodynamic
oriented psychologists view trauma as pieces of the traumatic event that reside
in memory. These "pieces" are referred to as symptoms. The symptoms that are
stored in memory represent the lack of control that the victim experienced
during the event. The victim cannot forget these symptoms because of their
inability to discuss the event in a relaxed manner. They also cannot release
the emotions associated with the event, and this further contributes to their
inability in releasing their symptoms. This results in the symptoms remaining
in their memory until treatment is received. "Until such "conscious
integration," or verbally structured memory consolidation, can take place, the
traumatic event does not yet exist in organized verbal memory form and thus
cannot yet be "forgotten" in verbally controlled ways. Instead, disruptive,
unbidden, imagery-loaded "flashbacks" are the primary memory vehicles."
(Peebles, 1989, p. 197).
Treatment for rape
induced PTSD includes both psychotherapy in conjunction with hypnosis. During
hypnosis, the patient summons the memory of the event and relives the trauma.
This is known as "abreaction". The reliving while under suggestion allows the
patient to discuss the rape verbally and discharge the emotions that cannot be
released during the normal state of consciousness. Ebert (1988) reported that
hypnotic suggestion can also be used to help patients sleep better. This aids
in restoring some of the lost everyday functioning typically experienced by PTSD
patients due to sleep disturbances.
Hypnosis also enables
the therapist to change the recollections of terror, anxiety, and helplessness
that are associated with the specific symptoms. While under hypnotic
suggestion, the therapist can instead associate the symptoms with safer thoughts
such as relaxation, confidence, and control. This allows the patient to recall
the memory during normal consciousness. This enables the victim to deal with
the memory and not avoid it, thus allowing them to express the emotions, discuss
the event and conquer the trauma. According to Peebles (1989) the more active
of a role a therapist takes in guiding the patient through the reliving of the
rape, the greater the ability that the therapist has in changing the emotions
associated with the trauma and allowing for easier and more manageable recall.
Peebles (1989) quoting Freud and Bruer (1895/1955) stated that "each individual
hysterical symptom immediately and permanently disappeared when we had succeeded
in bringing clearly to light the meaning of the event by which it was
provoked." (Peebles, 1989, p.201). Peebles (1989) stated "as verbal labels for
her memories were provided in the abreaction, the patient no longer had the need
for bodily symptoms for memory communication." (Peebles, 1989, p. 202).
Behavioral methods
for the treatment of PTSD in rape victims are based on the assumption that the
victims symptoms are a conditioned response to the traumatic event. Certain
objects, people, or situations become associated with the trauma and become
additional conditioned stimuli that trigger these symptoms. As reviewed by
Richards and Rose (1991) behavioral models of PTSD take the position that the
avoidance to these stimuli perpetuate the disorder by not enabling the victim to
become exposed to the emotions and situation associated with the trauma.
Cognitive therapies for PTSD try to identify, explain, and change the thoughts
of fear and terror that are associated with PTSD symptoms. The combination of
cognitive and behavioral therapies have been used with victims of PTSD and have
had great success.
According to Barlow
(1993) the three main components of most Cognitive-Behavioral therapies consist
of Stress Inoculation training, Prolonged Exposure, and Cognitive Processing
Therapy. These components are taught and administered to patients in order to
stop avoidance, change maladaptive cognitions, and teach coping skills that will
extinguish the symptoms and return the victim to healthy living.
In preparation for
treatment, patients receive an education and explanation of their illness. This
leads to a greater understanding of PTSD and also provides the reasons behind
the treatment. This educational component first reviews the patients history of
the disorder. Next the patient is told that all of the symptoms that they are
experiencing are normal reactions and are typical of people who have lived
through a very traumatic event.
Stress Inoculation
Training (SIT) teaches patients a variety of coping skills that are used to
conquer their fears. SIT first has the patient identify and define their
symptoms in physical, behavioral, and cognitive terms. Coping skills are then
taught with a full explanation of their function.
One of the first
coping skills used to help alleviate physical symptoms is muscle relaxation.
According to Scrignar (1984) the most prominent muscle relaxation technique used
is Progressive Muscle Relaxation (PMR). This involves the patient to tense a
part of their body and then to relax it while focusing on the feelings of
relaxation. This tensing and relaxing procedure is applied to all the major
muscle groups. Scrignar (1984) reports that 10-15 hours of practice usually
leads to proficient use of this technique. The therapist also provides a tape
of this relaxation technique that the client uses to practice with at home.
Another coping skill
that is used to help combat physical symptoms is controlled breathing. Scott
(1992) explains that most people who suffer from anxiety disorders are chest
breathers. Diaphragmatic breathing should be taught in its place.(Barlow,
1993). Diaphragmatic breathing focuses on the use of the stomach during the
course of breathing. It is a much more relaxed way of breathing and should be
practiced along with PMR (Barlow 1993).
Visualization of
feared situations and stimuli is another coping skill that is used. The client
has to imagine the feared scenario (rape) and in their mind confront this
anxious scene with success. This skill helps the patient to deal and not avoid
the anxious situations when they occur. Barlow (1993) stated that "Because
people vary widely in their ability to visualize such situations, the time
needed to master this skill is quite variable." (Barlow, 1993, p. 57).
Another skill that
aids in stopping the avoidance behavior of feared situations is role playing.
Role playing involves both therapist and client to act out the feared situation
and just as in the visualization skill, confront it with success. This skill
should be practiced at home with family and friends.
A coping skill used
to conquer the cognitive components of PTSD symptoms is the use of Thought
Stopping. The skill of thought stopping is taught to clients by having them
imagine the feared situation and then on the therapist's command, (by yelling
stop) stop thinking about the situation. This skill is elaborated by having the
patient stop the thoughts of the situation by themselves, first vocally and then
subvocally. "She then learns to use thought stopping covertly and to substitute
a relaxed state for the anxious state" (Barlow, 1993, p. 58). Scrignar (1984)
reports that most patients find this technique very helpful.
Another coping skill
used to conquer maladaptive cognitons is through Guided Self-Dialogue. The
patient is taught how to identify these maladaptive thoughts by focusing on
their internal dialogue. Once identified, the client learns how to substitute
more adaptive and positive cognitions.
All of these coping
skills that have been mentioned must be practiced between therapy sessions as
homework. This practicing reinforces the skills that are learned and allows the
patient to utilize them during an anxious situation.
The second main
component of cognitive-behavioral therapy is the use of Prolonged Exposure.
This component of treatment requires that the client be exposed to feared
situations allowing the patient to recall the event and incorporate the newly
learned coping skills. This process is repeated until the situation is no
longer viewed as fearful. The typical method of exposure is in vivo
exposure. In vivo exposure places the client in situations that most
closely resemble a real-life depiction of the feared event. Scrignar (1984)
warns that when using exposure treatments, "Care must be taken neither to bring
patients along too quickly nor to push them into phobic situations without their
agreement, because they may experience an anxiety or panic attack. When this
happens, the unexpected anxiety retards treatment and the patient may refuse to
cooperate in the future." (Scrignar, 1984, p. 121).
The third component
for treatment is Cognitive Processing Therapy (CPT). This component features
both exposure and cognitive restructuring. Cognitive restructuring is used to
correct maladaptive thoughts. Correcting these thoughts involves constructing
new memories that will replace old cognitions.
Exposure in CPT is
different than normal exposure techniques that focus on physically recreating
the feared situation. CPT instead involves the rape victim to write out the
rape scene in great detail, providing information on the emotions that were
experienced as well as the physical actions. The client then reads the written
scene aloud to the therapist. The reading of the rape allows the victim to
discuss the feelings that they have chosen not to confront. These feelings are
labeled as "stuck points" and are discussed with the hope that confronting them
will lessen their impact. Copings skills and helpful cognitions are then used
to replace maladaptive thoughts that were associated with these stuck points.
Sexual Compulsivity,
as a result of PTSD can be treated using a combination of therapies that I have
previously discussed. This treatment involves the combination of hypnosis,
cognitive-behavioral therapy, and Social Skills training.
According to Schwartz
(1992), the client must relive the traumatic experience and make changes in
"thinking errors" (maladaptive cognitions) that resulted due to the traumatic
event. These thinking errors resulted from the client interpreting the abusive
event as normal sexual behavior. Schwartz recommends that hypnosis should be
used to enable the patient to relive childhood traumas. The therapist has the
client restructure these memories and helps the patient realize that these
actions and behaviors are not proper.
Schwartz (1992)
reports that the second step in alleviating the symptoms of PTSD, and the
destructive behavior, is the teaching of adaptive social skills. Learning these
social skills enables the client to develop normal sexual intimate contact.
This leads to its own "high" and replaces the old destructive high which
resulted from engaging in past behaviors. The client learns social skills (such
as dating) that will help foster new satisfying, healthy relationships. The
patient learns how to interpret body language, facial gestures, and
conversations that will help facilitate the process of meeting new people.
Schwartz (1992) states that, "Most sexual compulsives are extremely
self-centered, concentrating almost exclusively on themselves and their
problem. Individuals are given specific suggestions to focus their attention on
various aspects of their partners feelings, thoughts and behavior." (Schwartz,
1992, p. 336). The patient throughout this process must identify and change
maladaptive cognitions (cognitive restructuring ).
The final stage of
this treatment is Sexual Arousal Conditioning. This stage involves
reconditioning the client to view normal sexual situations as arousing instead
of the destructive, maladaptive sexual situation that he viewed as normal during
his childhood. According to Schwartz (1992) the reconditioning process begins
with the client masturbating to normal sexual events. After ejaculation, the
client for 30 minutes must describe in detail a past arousing sexual destructive
event. This process reconditions the client to view his past situations as
boring because they are imagined after his ejaculation and he is no longer
aroused. The new events that lead up to ejaculation are now viewed as the
normal arousing stimuli. Another method for reconditioning involves the patient
to first describe past arousing situations and then immediately describe what he
feels the consequence of these situations would be. This process conditions the
client to view his past behavior as immoral and destructive.
Relapse prevention is
a topic that must be addressed during the course of this treatment. Schwartz
(1992) feels that the patient should understand that the treatment is not a
cure-all and that they may still view the problem behavior as attractive.
Schwartz emphasizes that clients must realize that they must make a conscious
effort to control these feelings and practice the skills that were taught during
treatment. Schwartz (1992) reports that the effectiveness of this treatment is
still not known but states that "combining trauma-based, cognitive -behavioral ,
and addictive behavior treatment strategies will likely increase the
effectiveness of the clinician who utilizes only one of these models."
(Schwartz, 1992, p. 338).
There are various
treatments for PTSD, but they can only be effective if the clinician correctly
assesses the problem. Typical confusion results due to PTSD's high rate of
comorbidity which results in a misdiagnosis of the symptoms. The prognosis for
a full recovery worsens as the symptoms remain untreated.
References
Barlow, D.H. (1993).
Clinical Handbook of Psychological Disorders.
New York: The Guilford Press.
Choy, T., & Bosset, F.
(1992). Post-Traumatic Stress Disorder: An Overview.
Canadian Journal of Psychiatry,
37, 578-581.
Ebert, B.W. (1987). Hypnosis
and Rape Victims. American Journal of Clinical
Hypnosis, 31,
50-55.
Figley,
C. (1985). Trauma and Its Wake. New York: Brunnerl Mazel.
Ochberg,
F. (1988). Post Traumatic Therapy and Victims of Violence. New York:
Brunner/Mazel.
Peebles, M. J. (1989).
Through a Glass Darkly: The Psychoanalytic use of Hypnosis with Post Truamatic
Stress Disorder. The International Journal of Clinical and Experimental
Hypnosis, 37, 192-203.
Richards, D. A., and Rose, J.S.
(1991). Exposure Therapy For Post Traumatic Stress Disorder. British
Journal of Psychiatry, 158, 836-840.
Schwartz, M.F. (1992). Sexual
compulsivity as Post Traumatic Stress Disorder:
Treatment Perspectives.
Psychiatric Annals, 22, 333-338.
Schwarz, R.A., & Prout, M.F.
(1991). Integrative Approaches in the Treatment of Post-Traumatic Stress
Disorder. Psychotherapy, 28, 364-372.
Sconnenberg,
S.M., (1988). Victims of Violence and Post Traumatic Stress Disorder. The
Violent Patient, 11, 581-588.
Scott, M.J., Stradling, S.
(1992). Counseling For Post Traumatic Stress Disorder.
London: Sage Publications.
Scrignar,
C. B. (1984). Post Traumatic Stress Disorder. New York: Praegar
Publishers.
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