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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:
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Therapists as Trauma
Survivors: A Case Study
Detailing Cognitive
Processing Therapy
for Rape Victims With a
Psychology Graduate Student

Clinical Case Studies

9(6) 442456
The Author(s) 2010
Reprints and permission: http://www.
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1534650110386106
http://ccs.sagepub.com

Laura C. Wilson1 and Russell T. Jones1

Abstract
This case study describes the treatment of a female psychology graduate student, referred
to as Mary, who presented with complaints of mild symptoms of depression and a lack of
motivation. It was revealed that Mary had been sexually assaulted 4 years before presenting
for therapy and was diagnosed with depression and posttraumatic stress disorder. Because of
the timing of the symptom onset and the nature of her symptomatology, it is likely that she was
experiencing a form of vicarious traumatization that further complicated her own difficulties.
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. The secondary aim of the current study is
to discuss Marys progress through 12 sessions of manualized cognitive processing therapy for
rape victims as further support for its efficacy.
Keywords
vicarious traumatization, trauma, rape, PTSD, cognitive processing therapy

1 Theoretical and Research Basis

On the basis of U.S. Department of Justice report, there were 198,850 sexual assaults reported
to the police in the United States in 2003 (Catalano, 2004). However, empirical research suggests that sexual victimization is grossly underreported and is even more common than statistics
portray (Fisher, Cullen, & Turner, 2000). Because counselors and other mental health professionals are not immune to victimization, the alarmingly high rate of victimization implies that
many therapists may be trauma survivors themselves. The psychological consequences of a
therapists own victimization history (e.g., avoidance of trauma-related stimuli), coupled with
the inherently stressful nature of therapeutic work, have the potential to lead to substantial

Virginia Tech, Blacksburg

Corresponding Author:
Laura C. Wilson,Virginia Tech, 109 Williams Hall, Blacksburg,VA 24061
Email: lawilso3@vt.edu

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work-related stress, burnout, and possible psychopathology (e.g., depression; Phelps, Lloyd,
Creamer, & Forbers, 2009). Furthermore, therapists often help individuals deal with stressful
experiences that they themselves have previously or are currently dealing with. For example,
many clinicians in Blacksburg, Virginia, have been and continue to be confronted with assisting
clients affected by the Virginia Tech shootings, when they themselves have also been affected.
Thus, 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. In addition, this case study will outline recommendations for graduate student trainees
who have experienced trauma.
Sexual assault has been linked to a plethora of adverse outcomes, including posttraumatic
stress disorder (PTSD), depression, substance abuse, low self-esteem, and interpersonal problems
(Walsh, Blaustein, Knight, Spinazzola, & van der Kolk, 2007). For example, one study found the
occurrence rate of PTSD in rape survivors to be 33.3%, with sexual assault as the type of trauma
most likely to result in PTSD (Bronner et al., 2009). 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.

Cognitive Processing Therapy (CPT) Following Sexual Assault

CPT for Rape Victims was initially developed by Resick and Schnicke (1992, 1993) to address
PTSD and depression symptoms following sexual assault. The treatment, conducted in both individual and group formats, expands on previous therapies by combining cognitive- and exposurebased techniques, which are adapted for the specific challenges that sexual victimization survivors
tend to face (e.g., trust and safety concerns). The overall aim of the therapy is to facilitate the
incorporation of the traumatic event (i.e., rape) into the clients preexisting cognitive schemas.
To do so, it is the therapists responsibility to guide their clients so they acknowledge that the
rape occurred, recall the details of the event, and allow themselves to experience their emotional
reaction. 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, others, and the world.
In regard to treatment efficacy, Resick and Schnicke (1992, 1993) found that all of their groupand individual-therapy participants improved on the obtained measures of symptomatology (e.g.,
depression, avoidance, and intrusions). Although 96% of the female participants met Diagnostic
and Statistical Manual of Mental Disorder (4th ed., Text Revision; DSM-IV-TR; American
Psychiatric Association [APA], 2000) criterion for PTSD at pretreatment, only 11.6% met full
criteria for PTSD at posttreatment. The number of individuals who met criterion for depression
also decreased from 60% at pretreatment to 11% at the 6-month follow-up. Therefore, although
a substantial number of rape survivors evidenced posttrauma symptoms (e.g., depression and reexperiencing the trauma) at intake, the majority of CPT completers evidenced marked improvements in functioning (e.g., feeling more hopeful about the future) and a reduction in symptomatology
(e.g., re-experiencing the trauma and depression).

Therapists as Trauma Survivors

Mental health professionals are vulnerable to the same traumatic experiences their clients often
face. For example, Schauben and Frazier (1995) found that 70% of female psychologists and

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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.g., attempted rape and sexual harassment). Although
McCann and Pearlman (1990) introduced the concept of vicarious traumatization, which acknowledges that therapists may experience posttrauma-like symptoms when working with trauma survivors, the effects of mental health professionals own victimization are often ignored.
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, 2009). These changes may occur in areas such as identity, worldview, and spirituality
as well as how one understands world events (Pearlman & Saakvitne, 1995). Furthermore, these
changes can persist for months or years (McCann & Pearlman, 1990). It has been suggested that
these distressing effects may be further complicated or exaggerated by characteristics of the therapist, such as trauma histories (McCann & Pearlman, 1990; Williams & Sommer, 1995) and level
of experience (OMalley Reyntjens & Rubin, n.d.).
Previous research suggests that therapists may be at greater risk of vicarious traumatization
when they have a personal history of trauma (McCann & Pearlman, 1990; Williams & Sommer,
1995). For example, 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. However, 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, 2003; Rudolph, Stamm, & Stamm, 1997). For example, Follette, Polusney, and Milbeck
(1994) found that law enforcement personnel who work with trauma survivors reported greater
levels of distress than trauma mental health professionals. This difference was attributed to the
greater number of mental health staff who sought personal therapy (59.1%) than law enforcement staff (15.6%).
It is the authors hope that the current article will draw attention to the importance of selfcare for mental health professionals, which includes acknowledging their own mental health
needs and indicators of distress. The current case study illustrates CPT for Rape Victims (Resick
& Schnicke, 1992, 1993), 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.

2 Case Presentation
Mary is an unmarried White woman in her mid-20s, who was self-referred to the clinic for
mild symptoms of depression and a lack of motivation. Furthermore, approximately 4 years
before referral, Mary was sexually assaulted by a male acquaintance in the presence of several
friends. This traumatic event significantly affected her interpersonal relationships immediately
following the assault and continues to affect her sexual relationships, trust of herself and others,
and sense of control over situations. At the time of intake, Mary was pursuing a doctoral degree
in counseling and lived with her longtime boyfriend. 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.

3 Presenting Complaints
Mary presented to treatment with complaints of emotional numbness, a lack of interest in most
activities (e.g., sexual intercourse and hobbies), low motivation (e.g., schoolwork), anger, and

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irritability. She reported that she had been experiencing those feelings for approximately 1 year
before contacting the clinic. Mary indicated that she had decided to come to therapy because
those around her, such as her boyfriend and professors, had begun to comment on her anger, irritability, and depressed mood. 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. As such,
Mary had become frustrated that despite her psychological knowledge and clinical training and
experience, she had been unable to facilitate any improvement in her current functioning. Furthermore, she had begun to question her abilities as a counselor and was unsure whether she wished
to continue pursuing a degree in counseling.
During the initial interview, it was revealed that Mary had been sexually assaulted by a male
acquaintance approximately 4 years back. She also reported being sexually abused when she was
a child by another female child, who was an acquaintance. In addition to sexual victimization,
Mary reported observing her stepfather inflict physical and emotional abuse on her mother during her childhood. Although Marys presenting complaints did not specifically mention the sexual assault, by the third session she had begun to acknowledge that the traumatic experience
negatively skewed her views of sexual intercourse, romantic and interpersonal relationships, and
trust of others. In addition, Marys 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.
Consequently, Marys current symptoms and complaints had interfered with her daily life and
had led to substantial distress.

4 History
Family
Mary was raised by her biological parents in the northeastern United States from birth until age
3. At this time, Marys parents divorced. Eventually, both her parents remarried and her stepparents were involved in rearing her. Marys mother divorced her second husband when Mary
was an adolescent. Throughout the years, Mary described her home life as hostile and confusing. She indicated that her childhood was difficult because her stepfather was verbally and
physically aggressive toward her mother. Consequently, her mother was often sad and stressed,
which resulted in a troubled home life for Mary, including emotional neglect and an emotionally
tumultuous environment.

Educational and Social

During college, Mary described herself as an overachiever and hard worker. She was a successful student and obtained a bachelors degree in psychology. Although Mary experienced
depression for approximately 6 months at the beginning of her undergraduate career, she indicated it was due to adjusting to college life. She reportedly had many friends; however, she
distanced herself from and was ridiculed by many of her friends following the sexual assault. For
example, 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.
Mary continued her education and obtained a masters degree in clinical psychology. During this
time, Mary was dedicated to her work and was a successful student. At the time of intake, she
was pursuing a doctoral degree in counseling; however, she found herself questioning whether
she still wished to pursue counseling. Also at intake, Mary was living with her boyfriend, whom she
had been dating for approximately 3 years. Despite considering herself a sociable young woman,

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Mary reported that several of her close relationships (e.g., classmates and boyfriend) had become
strained in recent months.

Medical, Mental Health, and Substance Use

Mary neither reported significant medical history nor any major concerns about her physical
health. She described being in good health. However, Mary did report experiencing tension
headaches, fluctuations in her weight, and mild sleep disturbance. As previously mentioned,
Mary sought brief counseling for mild depression in the past. She endorsed using marijuana
when she was an adolescent. At the time she sought treatment, Mary indicated that she did not
use drugs and rarely consumed alcohol. In addition, she reported no significant alcohol or drug
history in her family. She indicated that several members of her family have experienced anxiety
and depression symptoms.

5 Assessment
A thorough pretreatment assessment, including the Beck Depression InventoryII (BDI-II; Beck,
Steer, & Brown, 1996), Impact of Events ScaleRevised (IES-R; Weiss & Marmar, 1997), Symptom Checklist-90Revised (SCL-90-R; Derogatis, 1997), and Anxiety Disorder Interview
ScheduleIV (ADIS-IV; Brown, DiNardo, & Barlow, 2004), was conducted during the intake sessions to assess Marys current level of functioning.

BDI-II
The BDI-II (Beck et al., 1996) is a 21-item self-report instrument used to assess the severity of
depressive symptomatology during the most recent 2 weeks. Clients are asked to respond to an
array of domains, such as hopelessness, sadness, and sleep patterns, using a multiple choice format that provides a list of increasingly severe responses. Responses, which range from 0 to 3, are
then summed to obtain an overall score. Total scores of 0 to 13 are considered in the minimal
range, 14 to 19 are considered in the mild range, 20 to 28 are in the moderate range, and 29 to 63
are in the severe symptomatology range. The BDI-II has demonstrated high convergent validity
(e.g., r = .71 with the Hamilton Psychiatric Rating Scale for Depression) and high internal consistency (e.g., .91 among clinical patients and .93 among college students; Beck et al., 1996).
Marys intake BDI-II score of 18, as seen in Figure 1, was in the mild range of severity.

IES-R
The IES-R (Weiss & Marmar, 1997) is a 22-item self-report measure designed to measure
distress following a traumatic event. Clients are asked to rate how distressing each IES item
was during the previous 7 days using a scale from 0 to 4 (i.e., not at all, a little bit, moderately,
quite a bit, and extremely). The responses are then used to obtain Avoidance, Intrusion, and
Hyperarousal subscale scores. Previous studies have demonstrated Cronbachs alphas ranging from .87 to .94 for the Intrusion subscale, .84 to .87 for the Avoidance subscale, and .79 to
.91 for the Hyperarousal subscale (Creamer, Bell, & Failla, 2003; Weiss & Marmar, 1997).
The testretest reliability across a 6-month period ranged from .89 to .94 (Weiss & Marmar,
1997). At intake, Marys responses revealed an Intrusion IES subscale of 14, Avoidance subscale of 28, and Hyperarousal subscale of 0. Furthermore, her total score of 42 indicated a
moderate level of posttrauma-related distress.

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Figure 1. Treatment outcome assessment: BDI-II scores

Note: BDI-II = Beck Depression InventoryII.

SCL-90-R
The SCL-90-R (Derogatis, 1997) is a 90-item self-report instrument that assesses a wide range
of symptomatology. Clients are asked to rate on a 5-point scale (0 = not at all, 4 = extremely) how
frequently each symptom had occurred in the past week. 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. Marys scores on the nine domains of the SCL-90-R were as follows:
Somatization = 35, Obsessive-Compulsive = 58, Interpersonal Sensitivity = 53, Depression = 60,
Anxiety = 50, Hostility = 54, Phobic Anxiety = 44, Paranoid Ideation = 54, and Psychoticism = 58.
Her scores on the three global index scores were as follows: General Severity Index = 56, Positive Symptom Index = 58, and Positive Symptom Distress Index = 53. Scores above 70 on any
given subscale indicates clinical-level symptomatology. Thus, Marys score of 60 on the Depression subscale was slightly elevated. Research has demonstrated alpha coefficients for the subscales ranging from .70 to. 90 and testretest coefficients ranging from .68 to .93 (Horowitz,
Rosenberg, Baer, Ureno, & Villasenor, 1988; Simonds, Handel, & Archer, 2008).

ADIS-IV
The ADIS-IV (Brown et al., 2004) is a structured interview based on the DSM-IV-TR (APA,
2000) that assesses for the necessary information to make differential diagnosis among anxiety,
mood, and somatoform disorders. The interview uses a branching format that starts with
screening questions to determine whether symptom-specific questions are relevant. The ADISIV has demonstrated moderate to high interrater reliability (i.e., .67-.86; DiLillo, Hayes, &
Hope, 2006). Notably, during the PTSD/Acute Stress module, Mary endorsed experiencing an

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avoidance of thoughts/feelings and activities/situations as well as loss of interest in significant

activities, feelings of detachment from others, restricted range of emotions, and a sense of foreshortened future. In addition, she endorsed intrusive recollections of the sexual assault, dreams
of the event, and emotional distress and physical response to reminders of the trauma. Mary also
reported difficulties in falling or staying asleep, irritability or outbursts of anger, and difficulty
in concentrating. Moreover, she indicated that these symptoms had onset since the sexual assault,
significantly interfered with her life, and led to severe distress. During the major depression
module, Mary endorsed significant weight change, psychomotor agitation, and feelings of worthlessness and guilt. Furthermore, these symptoms had also resulted in interference with her daily
life and substantial distress.

6 Case Conceptualization
On the basis of the intake interview and assessment measures, it was revealed that Mary had been
experiencing pessimism, guilt, self-criticalness, a loss of interest in significant activities, irritability, concentration difficulty, sleep disturbance, fluctuations in weight, and a loss of interest in
sex. Furthermore, she had experienced at least one prior episode of depression, and her current
depression symptoms, although clinically significant, were mild in nature. Therefore, DSM-IVTR criteria for recurrent, mild major depressive disorder (APA, 2000) were met. Also, Mary
endorsed evidence of intrusions (e.g., nightmares), avoidance (e.g., lack of interest in sex), and
hyperarousal (e.g., psychomotor agitation) symptomatology following the sexual assault 4 years
earlier. Thus, a chronic PTSD diagnosis was made.
Marys presenting schema, degree of distress, and symptomotology made her an excellent
candidate for CPT. Marys previous schema regarding rape was consistent with those of many
women who have been attacked. Specifically, she viewed rape as an event that happens to women
who are not careful, is committed by bad men that do not know the women they attack, and
occurs in a dark alley with no witnesses. Subsequently, Mary experienced great distress when
attempting to understand this event because it contradicted her preexisting schema. To integrate
the rape into her schema, she believed that it was her fault. It is possible that the majority of her
symptoms (e.g., guilt, loss of interest in sex, and sleep disturbance) resulted from her attempts to
integrate the traumatic event into her existing schema.
Furthermore, Marys distress was beginning to affect her ability to function as a graduate student
and counseling trainee. The onset of these symptoms coincided with the beginning of her training in
the doctoral counseling program, which included working with clients. Many of the problems she
was experiencing, such as difficulties in trusting others, and feelings of incompetency and emotional distress, were related to changes in her cognitive schema and were affecting her ability to perform adequately as a therapist. Likely she was also experiencing vicarious traumatization.

7 Course of Treatment and Assessment of Progress

After Mary presented for therapy, five sessions were spent collecting the aforementioned intake
and assessment information, building rapport and establishing a therapeutic relationship, and
discussing Marys expectations for therapy. These initial sessions were followed by a 12-session
treatment phase, as outlined by Resick and Schnicke (1993). Treatment was delivered in 1-hr
weekly individual sessions over a span of 12 weeks. 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. At the time of treatment, she had already obtained a masters degree and had
completed an adult psychopathology course that covered CPT with trauma clients. In addition,
she received weekly supervision from a licensed clinical psychologist who is a trauma specialist.

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As part of this supervision, the specific aspects of CPT with trauma survivors were discussed and
reviewed. In addition, the supervisor reviewed detailed documentation and viewed videotaped
portions of each session to ensure the treatment was appropriately administered.

Treatment Session 1: Introduction and Education

The treatment phase commenced with an introduction to the planned course of treatment, a general explanation of rape reactions based on the cognitive information processing theory and
education of symptoms of PTSD and depression. Mary was also given a worksheet on and introduced to the term stuck points, which are conflicting beliefs that create unpleasant feelings
(e.g., anxiety) and maladaptive behaviors (e.g., avoidance). The therapist then emphasized the
importance of session attendance and completion of homework assignments because avoidance
is a very common reaction. At the conclusion, Mary was given the first homework assignment,
which involved writing about what it meant to her that she was raped. The areas she was asked
to consider when completing the homework included what effects the rape had on her thoughts
about herself, others, and the world in relation to perceived safety, trust, power/control, esteem,
and intimacy.

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. Mary then read her homework assignment aloud. Specifically, Mary indicated recognizing that she was not invulnerable, and this acknowledgment
made her feel weak and pathetic. In regards to others and the world, Mary believed that other
people could never be trusted, that she was not safe, and that she will never feel intimate with
someone ever again. At this point, 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 she felt vulnerable, dirty, and common when she wrote down her thoughts
and shared them in session. Mary indicated that although she was angry at herself, the perpetrator, and the witnesses for standing by while the event occurred, she felt better once the therapist
validated her feelings. Examples of stuck points that were identified included you cannot be
raped by a friend, so therefore I was not raped and I should be able to protect myself, so I must
be an accessory to the crime. These distressing beliefs had resulted in Mary feeling guilty and
attempting to convince herself that she was not raped. In preparation for the next session, Mary
was asked to complete worksheets examining the links between activating events, her beliefs,
and consequences (i.e., A-B-C sheets).

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. The goal of the exercise was to help Mary understand the connection
between events, her beliefs, and outcomes as well as identify stuck points related to the rape. For
example, she indicated that [her] boyfriend initiating sex was a distressing event for her. When
this occurred, Marys beliefs included I owe him, Lets just get this over with, and I dont
want to do this. The outcome of the situation was that Mary felt frustrated, ashamed and
annoyed with [herself], but [she] had sex with him anyway. After discussing her homework,
Mary realized that she was afraid of having sex because she felt she does not have control over
the situation. Although she trusted and loved her boyfriend, she felt as though she was being
raped again because she was not in total control of the situation. For the next homework

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assignment, Mary was asked to write a full account of the rape and include as many sensory
details as possible.

Treatment Session 4: Remembering the Rape

At the beginning of the fourth session, Mary was asked to read her account of the rape out loud.
While reading the account, Marys voice was monotone and she appeared disengaged. She indicated that she felt dirty and angry while reading the narrative. Although Mary had completed the
assignment, her account lacked many details and appeared emotionless. The therapist reinforced
Marys effort, but asked whether she withheld her emotional reaction. 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. Therefore, another stuck point for Mary involved her belief that
to keep herself from going crazy, she had to abstain from emotionally reacting (e.g., crying) to
the rape. This distorted idea related to Marys belief that because she was in training to become a
therapist, she had to be in control of her emotions at all time. The therapist informed Mary that she
was safe, that it was healthy to express her feelings, and that the therapist was there to assist her if
she became distressed while discussing the rape. Mary appeared relieved by this and began to
discuss the rape in more detail and with more emotion. In doing so, Mary indicated she had
remembered numerous details she had refrained from thinking about since immediately following
the event. For homework, Mary was asked to start over and write a new account of the rape.

Treatment Session 5: Identifying Stuck Points

To begin the fifth session, Mary was asked to read her new account of the rape. While reading
the new version, Mary expressed more emotion and shared more details throughout the recount.
On inquiry, Mary indicated that it was harder to read the second account aloud because it contained more details; however, she felt it was more helpful to do so because it was a more accurate
representation of what happened. In discussing the rape with the therapist, 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, he followed [her] and raped [her]. Therefore,
Mary believed that she would never be safe because bad things happened even when [she] tried
to protect [herself]. However, the therapist pointed out that during her narrative, Mary indicated
that the rape stopped when she fought away from the perpetrator. Thus, Mary had succeeded in
preventing the rape from continuing. Mary indicated that she had never considered that detail
and appeared reassured by the therapists comment. For homework, Mary was asked to explore
two stuck points by completing two challenging questions worksheets. These worksheets
listed a series of questions aimed at helping the client challenge his or her maladaptive beliefs.

Treatment Session 6: Challenging Questions

As soon as the sixth session began, Mary shared that the therapists comment during the previous
session, in regard to Mary stopping the rape, had alleviated a lot of the self-blame she had been
experiencing. The therapist reinforced Marys hard work and pointed out that it was Marys
detailed account that had in fact revealed her successful stop to the rape. Mary then read the
challenging questions worksheets she had been asked to complete as homework. 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. After completing
the homework, 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. The therapist then

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introduced the concept of faulty thinking patterns and Mary was asked to complete a faulty
thinking patterns worksheet for homework. Specifically, Mary was asked to generate examples
of faulty thinking patterns relating to her stuck points.

Treatment Session 7: Faulty Thinking Patterns

The session began with a discussion of the faulty thinking patterns worksheet that Mary had
completed for homework. For example, Mary realized she had disregarded important aspects of
the situation (e.g., she said no to the perpetrator) and had been overgeneralizing from the single
rape event (e.g., sexual intercourse is bad). Mary indicated that the worksheet had helped her
examine many aspects of the rape she had not considered since it occurred. 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. The therapist reinforced her application of the
homework to everyday situations and encouraged her to continue to do so.

Treatment Sessions 8 to 12: Five Relevant Topics

During the last five sessions, five areas (i.e., safety, trust, power and control, esteem, and intimacy) of psychological and interpersonal functioning that may be affected by rape were explored.
To do so, Mary was given a handout during each session that detailed the topic for that given day.
In preparation for each session, Mary was also asked to complete a challenging beliefs worksheet
that combined the A-B-C, challenging thoughts, and faulty thinking patterns worksheets from previous assignments. Mary found that the relevant topic sessions were very helpful
because she had experienced stuck points related to all five topics. For example, Mary believed
that she should have control of [herself] at all times or bad things will happen. Therefore, when
anything bad happened, she assumed it was her fault. Her control issues were also problematic
because to remain in control, Mary felt that it was too risky to express emotions. After discussing the control handout and completing the homework, Mary realized her ideas of control
had become distorted, extreme, and unhealthy. In preparation for the last session, 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.

Assessment of Progress
Outcome measures, which included the BDI-II and IES-R, were obtained during each therapy
phase to assess progress as well as 3 and 6 months post therapy. Not all the pretreatment measures were administered at posttreatment because the initial battery of measures was more comprehensive to elucidate her presenting complaints. Once intake was complete and the appropriate
diagnoses were identified, then more specific and appropriate measures were used to monitor
progress and outcome.
The BDI-II was administered on a weekly basis at the beginning of the session and during
3- and 6-month follow-up assessments. As seen in Figure 1, Marys BDI-II scores evidenced a
steady decline in severity across the 12-week therapy phase, with the exception of a slight spike
during the 4th week. However, because Mary had been asked to write a full account of the rape
event in preparation for the fourth session, it is not unexpected that she would demonstrate a
minor elevation in depression symptomatology.
Mary was also administered the IES-R during the intake phase, at the conclusion of therapy, and at 3 and 6 months post therapy (see Figure 2). At intake, Marys responses revealed
an Intrusion IES subscale of 14, Avoidance subscale of 28, and Hyperarousal subscale of 0.
However, at the conclusion of therapy, Marys scores revealed an Intrusion IES subscale of 1,

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Figure 2. Treatment outcome assessment: IES-R scores

Note: IES-R = Impact of Events ScaleRevised.

Avoidance subscale of 3, and Hyperarousal subscale of 0, reflecting a substantial decrease in

PTSD symptomatology. The decreases in her symptomatology, as measured by both the BDI
and IES-R, were maintained at 3 and 6 months post therapy.

8 Complicating Factors
Throughout treatment, Marys educational background as a counselor was both helpful and
problematic. She evidenced marked insight, and an exceptional knowledge base of cognitive
processing theory and therapy procedures. Therefore, she easily grasped the concepts that were
presented in session. She was also compliant and dedicated to treatment because she was aware
that treatment outcome is often associated with attendance and treatment compliance. However,
she became very frustrated at times when she was unable to express her feelings or label her
emotions. She frequently appeared embarrassed because she was seeking help despite her educational background. Marys acquired skills of examining distorted cognitions were helpful when
challenging some of her own maladaptive cognitions (e.g., I dont need help because I am a
counselor). Thus, many of the techniques Mary learned were then used to address her difficulties related to her position as a clinician-in-training.
In addition, during the last week of the 12-week treatment phase, Mary began experiencing
relationship difficulties with her longtime boyfriend. Thus, at the conclusion of the treatment
phase, Mary and the therapist agreed it was appropriate to continue therapy; however, the focus
was shifted from the rape to difficulties with her boyfriend. The therapist believes that because
Mary had effectively processed the rape through the CPT protocol and adjusted her distorted
beliefs, she was better able to explore other difficulties she was experiencing.

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. In addition, more recent studies support

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the efficacy of the treatment by demonstrating significant decreases in distress at posttreatment as

well as 3- and 9-month follow-ups (Resick, Nishith, Weaver, Astin, & Feuer, 2002).

10 Follow-Up
The overall reduction in depression and posttraumatic symptoms, as measured by the BDI-II and
IES-R, was maintained 3 and 6 months following the completion of CPT (see Figures 1 and 2).

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. First, the current case study provides further support for
the efficacy of CPT for Rape Victims (Resick & Schnicke, 1993) when working with adult
female sexual assault survivors. Because of the high prevalence of sexual assault and the welldemonstrated link to psychological consequences, it is encouraging that such a successful treatment protocol has been established. Therefore, it is imperative that researchers and counselors
continue to expand on this efficacious treatment and explore its effectiveness in a more diverse
population (e.g., male survivors of rape).
Second, the current case study provides support for the use of CPT for Rape Victims (Resick
& Schnicke, 1993) in assisting a counselor-in-training with confronting her own trauma history.
The client had been experiencing symptoms that are indicative of vicarious traumatization, such
as sleep difficulty and helplessness (McCann & Pearlman, 1990). Therefore, it is likely that as
Mary progressed through her clinical training and practicum hours, the effects of her own victimization became more apparent. Ultimately, she began to question her abilities as a counselor.
However, through therapy, 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. To address these issues, the therapist encouraged her to apply the skills she had learned
to challenge her cognitions related to her abilities as a therapist. Thus, the current case study
expands on previous research that emphasizes the importance of personal therapy for therapists
with trauma histories, which is an aspect of self-care (McCann & Pearlman, 1990).
A third implication is the flexibility, versatility, and effectiveness of CPT for Rape Victims
(Resick & Schnicke, 1993), especially because the acting therapist in the current case study was
a counselor-in-training. However, it is important to note that she received weekly supervision,
had been oriented to CPT, and had already obtained a masters degree. The manual was an excellent resource for the therapist, and it was easy-to-follow and sufficient for preparing the therapist
for each session. In addition, the current case confirmed that the treatment protocol can be completed in a brief period of time (i.e., 12 weeks). Thus, a noteworthy advantage of CPT for Rape
Victims (Resick & Schnicke, 1993) is its clear procedures and efficient treatment format.

12 Recommendations to Clinicians and Students

The findings of the current case study support at least two important recommendations for clinicians. First, 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. As referenced earlier, Follette et al. (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. Following treatment, Mary evidenced a reduction in both depression and PTSD symptomatology, as well as
cognitive distortions related to her ability to perform as a counselor. Therefore, by seeking

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

Funding
The author(s) received no financial support for the research and/or authorship of this article.

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Bios
Laura C. Wilson is a doctoral candidate in the clinical psychology program at Virginia Tech. Her research
interests include the developmental consequences of child abuse, parental incarceration, and other traumatic experiences and the impact of psychophysiological mechanisms and psychosocial factors on aggression and violence in terms of perpetration and victimization.
Russell T. Jones is a professor of psychology at Virginia Tech and a clinical psychologist who specializes
in clinical child psychology and trauma psychology. His research targets the topic of child and adult stress
and coping. Coping with common stressful life events, as well as major traumas (i.e., natural, technological
and mass violence), is also examined.

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