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It is important that trauma-screening questions are direct and behaviorally specific. For example, questions that use legal terms (e.g., "Have you ever been raped?") yield lower endorsement rates than questionnaires that use behaviorally specific terms (e.g., "Has a man or boy ever made you have sex by using force or threatening to harm you or someone close to you") (Koss, Gidycz, & Wisniewski, 1987). It is also essential that clinicians assess for disorders that co-occur with PTSD, such as major depression, panic disorder, and substance abuse.
Finally, it is important to assess factors that may influence adjustment, such as social support, coping skills, and available resources. For a more detailed description of assessment of trauma and PTSD instruments, please refer to Research Tools and Resources, Screening Measures for Violence.
Treatment of PTSD Related to Sexual Assault and Rape
There have been several reviews of treatment for rape and sexual assault (e.g., Falsetti, 1997--civilian PTSD treatment is reviewed; Foa, Rothbaum & Steketee, 1993; Foa & Rothbaum, 1998) that provide the primary material for this web brief. The interested reader should consult these sources for more information.
In general, treatments that are effective in reducing PTSD symptoms associated with rape and sexual assault are behavioral and cognitive behavioral. This is not to say that other treatments are ineffective. However, empirical studies must be conducted to determine efficacy. The following treatments are reviewed: stress inoculation training, prolonged exposure, cognitive processing therapy, multiple channel exposure therapy, and eye movement desensitization and reprocessing.
Stress Inoculation Training
Stress inoculation training (SIT) is a behavioral treatment developed by Meichenbaum (1974) and adapted by Kilpatrick, Veronen, & Resick (1982) to treat the fear and anxiety symptoms often experienced by rape victims. SIT consists of three phases: education, skill building, and application.
During the education phase, individuals learn how fear develops as a learned response to trauma; they learn to identify cues in the environment that trigger fear (e.g., dark places that resemble the location of the sexual assault; being alone); and they learn relaxation exercises such as progressive muscle relaxation (PMR).
In the skill- building phase, clients learn to control their fear reactions via exercises designed to reduce physiological sensations (e.g., diaphragmatic breathing, PMR) and fearful thoughts (e.g., thought stopping, mental rehearsal, guided self-talk, and role playing) (Falsetti, 1997).
In the application phase, clients apply the skills they have learned to engage in fearful behavior, control self-criticism and manage avoidance behavior. Clients are taught to reward themselves for their progress.
SIT usually takes 10-14 sessions. Several studies have shown SIT to be beneficial for female rape victims. Two uncontrolled studies found that SIT was effective in reducing fear, intrusion, and avoidance responses in a group of female rape victims (Kilpatrick et al., 1982- Veronen & Kilpatrick, 1982). A controlled study (Resick, Jordan, Girelli, Hutter, & Marhoefer-Dvorak, 1988) also showed that SIT produced improvements in rape-related fear and anxiety compared to a wait-list control condition. Finally, SIT has been shown to be effective in reducing PTSD symptoms in rape victims compared to a wait-list control condition (Foa, Rothbaum, Riggs, & Murdoch, 1991).
Prolonged Exposure
Prolonged Exposure (PE), also known as flooding, is a form of exposure therapy that is based on learning and information processing theories. One of the primary goals of PE is to have individuals repeatedly confront fearful images and memories of their traumatic event so that fear and anxiety decrease (Falsetti, 1997; Foa & Rothbaum, 1998).
During PE, the therapist helps the individual recount the trauma memory in an objectively safe environment (therapist office). Clients are encouraged to describe their rape experience in detail. The oral narrative is repeated several times during each session to reduce fear associated with the memory. Clients also are asked to tape record sessions and listen to the tapes to facilitate exposure. In general, the technique is similar to watching a frightening movie repeatedly. Although at first the movie may be very scary, eventually, after repeated viewing (i.e., 20 times), it is not as scary.
As part of exposure, clients are also asked to confront situations that are not dangerous but that have been associated with danger at the time of the trauma (e.g., dating, going out with friends- dark places). This is called in-vivo exposure, as it generally involves exposure to objects or situations in real life, whereas recounting the thoughts, memories, or images of the rape is called imaginal exposure (Falsetti, 1997).
PE has been shown to be an effective treatment for rape victims with PTSD. PE has been shown to be superior to no treatment, traditional counseling, and SIT in reducing PTSD symptoms in a group of rape victims (Foa et al., 1991). Foa, Hearst-Ikeda, and Perry (1995) also found that brief PE (in combination with relaxation training and cognitive techniques) applied shortly following sexual assault decreased PTSD symptoms in recently assaulted rape victims. More recently, Foa et al. (1999) compared PE, SIT, and their combination in a group of women who had experienced sexual or physical assault and met criteria for PTSD. Results showed that at follow-up, PE was superior to SIT and PE-SIT on measures of PTSD, depression, anxiety, and adjustment. It should be noted, however, that the exposure component of SIT was left out in this study (so as not to confound the individual treatments), which may have reduced the effectiveness of SIT.
Cognitive Processing Therapy
Introduction
There are several treatments available for rape victims. This brief will provide a limited review of available treatments for posttraumatic stress disorder (PTSD) associated with rape and/or sexual assault. The focus of this review is on treatments with demonstrated empirical support.
Assessment
Before effective treatment can be implemented with rape victims, a thorough assessment must be conducted. The assessment should entail a detailed trauma history, including information about the lifetime number and types of trauma experienced by the victim, as well as an evaluation of trauma characteristics, such as whether the person experienced life threat or injury during the rape--factors that are associated with increased PTSD.
There are several treatments available for rape victims. This brief will provide a limited review of available treatments for posttraumatic stress disorder (PTSD) associated with rape and/or sexual assault. The focus of this review is on treatments with demonstrated empirical support.
Assessment
Before effective treatment can be implemented with rape victims, a thorough assessment must be conducted. The assessment should entail a detailed trauma history, including information about the lifetime number and types of trauma experienced by the victim, as well as an evaluation of trauma characteristics, such as whether the person experienced life threat or injury during the rape--factors that are associated with increased PTSD.
It is important that trauma-screening questions are direct and behaviorally specific. For example, questions that use legal terms (e.g., "Have you ever been raped?") yield lower endorsement rates than questionnaires that use behaviorally specific terms (e.g., "Has a man or boy ever made you have sex by using force or threatening to harm you or someone close to you") (Koss, Gidycz, & Wisniewski, 1987). It is also essential that clinicians assess for disorders that co-occur with PTSD, such as major depression, panic disorder, and substance abuse.
Finally, it is important to assess factors that may influence adjustment, such as social support, coping skills, and available resources. For a more detailed description of assessment of trauma and PTSD instruments, please refer to Research Tools and Resources, Screening Measures for Violence.
Treatment of PTSD Related to Sexual Assault and Rape
There have been several reviews of treatment for rape and sexual assault (e.g., Falsetti, 1997--civilian PTSD treatment is reviewed; Foa, Rothbaum & Steketee, 1993; Foa & Rothbaum, 1998) that provide the primary material for this web brief. The interested reader should consult these sources for more information.
In general, treatments that are effective in reducing PTSD symptoms associated with rape and sexual assault are behavioral and cognitive behavioral. This is not to say that other treatments are ineffective. However, empirical studies must be conducted to determine efficacy. The following treatments are reviewed: stress inoculation training, prolonged exposure, cognitive processing therapy, multiple channel exposure therapy, and eye movement desensitization and reprocessing.
Stress Inoculation Training
Stress inoculation training (SIT) is a behavioral treatment developed by Meichenbaum (1974) and adapted by Kilpatrick, Veronen, & Resick (1982) to treat the fear and anxiety symptoms often experienced by rape victims. SIT consists of three phases: education, skill building, and application.
During the education phase, individuals learn how fear develops as a learned response to trauma; they learn to identify cues in the environment that trigger fear (e.g., dark places that resemble the location of the sexual assault; being alone); and they learn relaxation exercises such as progressive muscle relaxation (PMR).
In the skill- building phase, clients learn to control their fear reactions via exercises designed to reduce physiological sensations (e.g., diaphragmatic breathing, PMR) and fearful thoughts (e.g., thought stopping, mental rehearsal, guided self-talk, and role playing) (Falsetti, 1997).
In the application phase, clients apply the skills they have learned to engage in fearful behavior, control self-criticism and manage avoidance behavior. Clients are taught to reward themselves for their progress.
SIT usually takes 10-14 sessions. Several studies have shown SIT to be beneficial for female rape victims. Two uncontrolled studies found that SIT was effective in reducing fear, intrusion, and avoidance responses in a group of female rape victims (Kilpatrick et al., 1982- Veronen & Kilpatrick, 1982). A controlled study (Resick, Jordan, Girelli, Hutter, & Marhoefer-Dvorak, 1988) also showed that SIT produced improvements in rape-related fear and anxiety compared to a wait-list control condition. Finally, SIT has been shown to be effective in reducing PTSD symptoms in rape victims compared to a wait-list control condition (Foa, Rothbaum, Riggs, & Murdoch, 1991).
Prolonged Exposure
Prolonged Exposure (PE), also known as flooding, is a form of exposure therapy that is based on learning and information processing theories. One of the primary goals of PE is to have individuals repeatedly confront fearful images and memories of their traumatic event so that fear and anxiety decrease (Falsetti, 1997; Foa & Rothbaum, 1998).
During PE, the therapist helps the individual recount the trauma memory in an objectively safe environment (therapist office). Clients are encouraged to describe their rape experience in detail. The oral narrative is repeated several times during each session to reduce fear associated with the memory. Clients also are asked to tape record sessions and listen to the tapes to facilitate exposure. In general, the technique is similar to watching a frightening movie repeatedly. Although at first the movie may be very scary, eventually, after repeated viewing (i.e., 20 times), it is not as scary.
As part of exposure, clients are also asked to confront situations that are not dangerous but that have been associated with danger at the time of the trauma (e.g., dating, going out with friends- dark places). This is called in-vivo exposure, as it generally involves exposure to objects or situations in real life, whereas recounting the thoughts, memories, or images of the rape is called imaginal exposure (Falsetti, 1997).
PE has been shown to be an effective treatment for rape victims with PTSD. PE has been shown to be superior to no treatment, traditional counseling, and SIT in reducing PTSD symptoms in a group of rape victims (Foa et al., 1991). Foa, Hearst-Ikeda, and Perry (1995) also found that brief PE (in combination with relaxation training and cognitive techniques) applied shortly following sexual assault decreased PTSD symptoms in recently assaulted rape victims. More recently, Foa et al. (1999) compared PE, SIT, and their combination in a group of women who had experienced sexual or physical assault and met criteria for PTSD. Results showed that at follow-up, PE was superior to SIT and PE-SIT on measures of PTSD, depression, anxiety, and adjustment. It should be noted, however, that the exposure component of SIT was left out in this study (so as not to confound the individual treatments), which may have reduced the effectiveness of SIT.
Cognitive Processing Therapy
Cognitive processing therapy (CPT) is a multicomponent treatment package developed by Resick and Schnicke (1993) for treatment of rape victims suffering from PTSD and depression. CPT is based on an information-processing model and combines elements of exposure therapy and cognitive restructuring.
The goal of CPT is to help integrate the rape by processing emotions and confronting cognitive distortions and maladaptive beliefs concerning the rape. Exposure involves writing narratives of the rape in detail and reading the narratives aloud in session and for homework. Clients write about the meaning of the rape, and themes of safety, trust, power, esteem, and intimacy are addressed. Clients are provided basic education about feelings, given information about how self-statements affect emotions, and are encouraged to identify "stuck points" (i.e., inadequately processed emotions about the trauma) in their narratives. Specific cognitive strategies are used to challenge maladaptive beliefs about the rape (e.g., self blame), helping the victim accommodate her experience in a healthy manner and maintain a balanced and realistic perception of the world.
CPT can be conducted in individual or group format and completed in 12 weekly sessions. In an uncontrolled trial of CPT, Resick and Schnicke (1992) reported significant improvements on measures of PTSD and depression in female sexual assault victims compared to a wait-list control condition. For the CPT condition, rates of PTSD went from a pretreatment rate of 90% to a posttreatment rate of 0%. Rates of major depression also decreased from 62% to 42% (see Figure 1 - Adobe Acrobat required to view or print this document). A large controlled study is currently underway to further test this treatment.
Multiple Channel Exposure Therapy
Multiple channel exposure therapy (MCET) is a treatment adapted from CPT (Resick & Schnicke, 1992), SIT (Kilpatrick et al., 1982), and Mastery of Your Anxiety and Panic (Barlow & Craske, 1988). MCET is used to treat both panic attacks and PTSD, conditions that often co-occur in rape victims. MCET was originally developed for the treatment of civilian trauma in general (e.g., domestic violence, physical assault, rape), and may be adapted for rape victims specifically.
Because exposure therapy may cause initial high levels of physiological arousal (i.e., panic symptoms), individuals who experience panic attacks may not be able to tolerate this treatment initially. Thus, MCET focuses on panic symptom reduction before trauma exposure work begins. Clients are provided education about panic and trauma, taught diaphragmatic breathing exercises to reduce panic, and learn methods to counteract negative and distorted thinking.
Individuals are then instructed to bring about panic symptoms through structured exposure exercises, such as tensing one's muscles, holding one's breath, spinning in a chair, hyperventilating, and shaking one's head from side to side. Clients gradually learn that the sensations they fear (i.e., panic symptoms) are not actually harmful or dangerous, but rather the interpretations of these symptoms are problematic. Following successful panic reduction, individuals begin writing about their rape following the procedures outlined in CPT. Cognitive strategies are also adapted from CPT to facilitate emotional processing of the trauma. Finally, in vivo exposure to environmental cues associated with the rape (e.g., sights, sounds, smells, locations) is conducted after the rape has been processed emotionally.
MCET lasts 12-weeks and can be conducted in individual or group format. Although data await publication, preliminary evidence shows that MCET is effective in reducing both PTSD and panic symptoms in female civilian trauma victims (see Figure 2 - Adobe Acrobat required to view or print this document) compared to a minimal attention control group (Falsetti & Resnick, 1998). Among women who received MCET in a group format, rates of PTSD went from a pretreatment rate of 100% to a posttreatment rate of 8.3%. Rates of panic attacks also decreased from a pretreatment rate of 100% to 50% one-month posttreatment. Treatment studies specifically with sexual assault and rape victims are needed.
Summary
There are several treatments available for the treatment of rape-related PTSD. Prior to treatment, it is essential to conduct a thorough assessment, including a detailed trauma history, event characteristics, comorbid psychiatric conditions, and factors influencing post-rape adjustment. The majority of treatments for rape-related PTSD with demonstrated empirical support are behavioral or cognitive-behavioral. Studies show that PE and SIT are effective in reducing symptoms of PTSD in female rape victims. Moreover, combination treatments, such as CPT and MCET, appear to be promising interventions for reducing rape related-PTSD, but await further empirical scrutiny. Finally, EMDR enjoys modest empirical support for the treatment of rape-related PTSD, but it is unclear at this time the specific mechanisms responsible for its efficacy.
The goal of CPT is to help integrate the rape by processing emotions and confronting cognitive distortions and maladaptive beliefs concerning the rape. Exposure involves writing narratives of the rape in detail and reading the narratives aloud in session and for homework. Clients write about the meaning of the rape, and themes of safety, trust, power, esteem, and intimacy are addressed. Clients are provided basic education about feelings, given information about how self-statements affect emotions, and are encouraged to identify "stuck points" (i.e., inadequately processed emotions about the trauma) in their narratives. Specific cognitive strategies are used to challenge maladaptive beliefs about the rape (e.g., self blame), helping the victim accommodate her experience in a healthy manner and maintain a balanced and realistic perception of the world.
CPT can be conducted in individual or group format and completed in 12 weekly sessions. In an uncontrolled trial of CPT, Resick and Schnicke (1992) reported significant improvements on measures of PTSD and depression in female sexual assault victims compared to a wait-list control condition. For the CPT condition, rates of PTSD went from a pretreatment rate of 90% to a posttreatment rate of 0%. Rates of major depression also decreased from 62% to 42% (see Figure 1 - Adobe Acrobat required to view or print this document). A large controlled study is currently underway to further test this treatment.
Multiple Channel Exposure Therapy
Multiple channel exposure therapy (MCET) is a treatment adapted from CPT (Resick & Schnicke, 1992), SIT (Kilpatrick et al., 1982), and Mastery of Your Anxiety and Panic (Barlow & Craske, 1988). MCET is used to treat both panic attacks and PTSD, conditions that often co-occur in rape victims. MCET was originally developed for the treatment of civilian trauma in general (e.g., domestic violence, physical assault, rape), and may be adapted for rape victims specifically.
Because exposure therapy may cause initial high levels of physiological arousal (i.e., panic symptoms), individuals who experience panic attacks may not be able to tolerate this treatment initially. Thus, MCET focuses on panic symptom reduction before trauma exposure work begins. Clients are provided education about panic and trauma, taught diaphragmatic breathing exercises to reduce panic, and learn methods to counteract negative and distorted thinking.
Individuals are then instructed to bring about panic symptoms through structured exposure exercises, such as tensing one's muscles, holding one's breath, spinning in a chair, hyperventilating, and shaking one's head from side to side. Clients gradually learn that the sensations they fear (i.e., panic symptoms) are not actually harmful or dangerous, but rather the interpretations of these symptoms are problematic. Following successful panic reduction, individuals begin writing about their rape following the procedures outlined in CPT. Cognitive strategies are also adapted from CPT to facilitate emotional processing of the trauma. Finally, in vivo exposure to environmental cues associated with the rape (e.g., sights, sounds, smells, locations) is conducted after the rape has been processed emotionally.
MCET lasts 12-weeks and can be conducted in individual or group format. Although data await publication, preliminary evidence shows that MCET is effective in reducing both PTSD and panic symptoms in female civilian trauma victims (see Figure 2 - Adobe Acrobat required to view or print this document) compared to a minimal attention control group (Falsetti & Resnick, 1998). Among women who received MCET in a group format, rates of PTSD went from a pretreatment rate of 100% to a posttreatment rate of 8.3%. Rates of panic attacks also decreased from a pretreatment rate of 100% to 50% one-month posttreatment. Treatment studies specifically with sexual assault and rape victims are needed.
Summary
There are several treatments available for the treatment of rape-related PTSD. Prior to treatment, it is essential to conduct a thorough assessment, including a detailed trauma history, event characteristics, comorbid psychiatric conditions, and factors influencing post-rape adjustment. The majority of treatments for rape-related PTSD with demonstrated empirical support are behavioral or cognitive-behavioral. Studies show that PE and SIT are effective in reducing symptoms of PTSD in female rape victims. Moreover, combination treatments, such as CPT and MCET, appear to be promising interventions for reducing rape related-PTSD, but await further empirical scrutiny. Finally, EMDR enjoys modest empirical support for the treatment of rape-related PTSD, but it is unclear at this time the specific mechanisms responsible for its efficacy.
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