Introduction

According to the Rape, Abuse, & Incest National Network, sexual

assault occurs every two minutes in the United States, with one in six women

sexually assaulted during their lifetime. It is estimated that 60% of sexual

assaults are unreported to the police. This indicates that the prevalence of

sexual assault may be far higher than the official numbers suggest.

This is alarming, considering the impact of this type on crime on the

survivor. Results of one study indicate suggest that PTSD occurring as a
result of sexual assault may be associated with higher symptom severity,
and that post traumatic stress disorder resulting from sexual assault may
have its own distinctive pattern symptomatology within the PTSD framework
(Eakin et al. 2009). Davis and Russell, (2007) also report that rape survivors
appear to suffer more negative psychological outcomes when compared to
other crime victims.
It appears that those who have been sexually assaulted are at an
increased risk for serious mental health issues as well, with 31% of rape
victims developing PTSD in their lifetime and 30% experiencing at least one
major depressive episode in their lifetime. Survivors of rape also are 4.1
times more likely to contemplate suicide than those who have never been
victims of a crime, with their percentage being 33%. ( Rape, Abuse, & Incest
National Network)
The evidence of adverse psychological consequences and the
prevalence of rape indicate a high need for effective treatment (Margolin &
Vickerman, 2009).
This paper will describe two cognitive behavioral interventions and
their effectiveness in treating sexual assault survivors suffering from post
traumatic stress disorder, as well as possible future directions in therapy
with this population.
Cognitive Processing Therapy

Development

Cognitive processing therapy was originally developed for use with

sexual assault survivors (Resick & Schnicke, 1992). The rationale of cognitive

processing therapy rests firmly on the shoulders of information processing

theory.

According to Hollon and Garber, (as cited in Resick & Schnicke, 1992)
when one is exposed to information that directly contradicts a prior schema
(such as a rape) the usual response consists of either assimilation or
accommodation. In assimilation, a rape survivor would perhaps modify their
view of the situation or even draw negative conclusions about themselves.
For example, if a rape survivor holds the schema that good women do not
get raped, she will draw the conclusion that she must be must have done
something wrong to deserve what happened.
In contrast, accommodation involves the modification of the schema
itself. As opposed to believing being the victim of rape meant one deserved
it, the survivor would perhaps draw the conclusion that “Sometimes bad
things happen to good people.” (as cited in Resick & Schnicke, 1992)
However, without good social support or the guidance of a therapist
overaccomodation may result. Resick & Schnicke (1992) report observances
of overaccommodation in rape victims. Overaccommodation occurs when the
accommodation is maladaptive or extreme such as, “I am never safe
anywhere.”
Resick and Shnicke (1992) asserted that these cognitive processes are
directly responsible for the symptoms of PTSD.
Components of Cognitive Processing Therapy

Three elements are involved in Cognitive Processing Therapy. The first

is education. Clients are educated about information processing theory and

the symptoms of PTSD. (Resick & Schnicke, 1992)

The second element results from a modification of Foa and Kozack's

(as cited in Resick and Schnicke, 1992) recommendation for prolonged
exposure therapy. They asserted that for the reduction of fear to occur, the
fear needed to be activated and incompatible with the new information
presented. This combination would result in a new memory, thus achieving
the goal of fear reduction.
In Cognitive Processing Therapy, clients participate in an exposure
exercise which involves writing a detailed account of their trauma and
reading it aloud. (Resick & Schnicke, 1992)
However, Resick and Schnicke (1992) pointed out that while exposure
may address the symptom of fear, there may not be any change in other
emotional domains besides fear, such as shame, anger, or disgust. They
proposed that exposure may be more effective if it is followed by direct
confrontation of conflicts, misattributions, and expectations. This led to the
development of the last element of CPT, cognitive therapy.
The cognitive therapy piece consists of cognitive restructuring
worksheets, Socratic questioning, and discussion, the purpose of which is to
challenge maladaptive beliefs, and train clients to identify thoughts and
affect. These modules were based on the research of McCann, Sakheim, and
Abrahamson (as cited in Resick & Schnicke, 1992) which identified five
specific schemas involving both the self and others were affected by
victimization: safety, trust, power, esteem, and intimacy. (Resick & Schnicke,
1992)
Effectiveness

A comprehensive literature review (Margolin & Vickerman, 2009)

examined three studies involving a total of 89 women. Findings of all three

studies indicated that CPT generated significant improvement in PTSD,

depression, guilty, hopelessness, self-blame, social adjustment and all

Symptom Checklist-90 Revised subscales, regardless of whether the women

were treated individually or in a group format.

`Another study examined the effect of cognitive processing therapy on

cognitions related to negative assimilation and overaccomodation. The

authors hypothesized a reduction in PTSD symptoms as well as on these

types of cognitions. They suspected that the reduction of negative

cognitions would be significantly related to the reduction of PTSD symptoms.

(Rabalais, Resick, & Sobel, 2009)

To test their hypothesis, authors administered the PTSD scale to 37

participants both before and after cognitive processing therapy. They were
also asked to write an impact statement about the meaning of their rape
after their first cognitive processing therapy session and again just before
their last cognitive processing therapy session. (Rabalais et al. 2009)
The impact statements were evaluated according to a coding manual
developed to detect accommodated, assimilated, and overaccomodated
thoughts. (Rabalais, Resick, & Sobel, 2009)
The study results demonstrated a significant decrease in
overaccomodated and assimilated cognitions while accommodated
cognitions increased. Additionally, support was generated for the authors'
hypothesis that increases in accommodation and decreases in assimilation
and overaccomodation would be related to reduction of PTSD symptoms.
(Rabalais, Resick, & Sobel, 2009)
Prolonged Exposure

Prolonged exposure therapy was developed by Edna Foa and

colleagues (as cited in Eftekhari, 2006). Like CPT, prolonged exposure rests

on the concept of assimilation, accommodation, and overaccomodation.

Prolonged exposure consists of 9-12 individual sessions with additional

sessions added as necessary(Eftekhari, 2006). Each session lasts anywhere

from 90 – 120 minutes(Eftekhari, 2006). The components of prolonged

exposure are as follows: psychoeducation regarding treatment rationale and

common reactions to trauma, breathing retraining, (a form of relaxation),

and in vivo and imaginal exposure (Eftekhari, 2006).

In in vivo exposure, the client is to approach those situations which

they have been avoiding as a result of their trauma (Eftekhari, 2006). For
example, if a sexual assault survivor avoids going to any parties because her
assault occurred at a party, in vivo exposure would involve going to a party
(Eftekhari, 2006). In imaginal exposure, a client repeatedly tells the story of
her assault in a systematic fashion involving both thoughts and feelings at
the time of the rape (Eftekhari, 2006). The purpose of both exercises is to
reduce fear in regard to both related stimulus and the actual memory of the
trauma (Eftekhari, 2006). The imaginal exposure piece also serves to assist
the client in processing the memory (Eftekhari, 2006).
Effectiveness of Prolonged Exposure

Margolin and Vickerman (2009) examined the effectiveness of

prolonged exposure therapy in their literature review regarding rape

treatment outcome. According to their findings, prolonged exposure

provides significant pre-post improvements in PTSD, depression, guilt,

anxiety, rape-related fears, and rape narrative organization. Due to support

for its effectiveness, prolonged exposure is considered the treatment of

choice for PTSD (Kramer, 2009).

In another study, Cahill, Feeny, Hembree, Raunch,Riggs, & Yadin

(2005) compared prolonged exposure therapy to prolonged exposure
therapy with cognitive restructuring to a wait list conditions. There were no
significant differences between prolonged exposure therapy and prolonged
exposure with cognitive restructuring. However, both treatments showed
significant improvement over the wait list condition in PTSD symptoms and
depression. Additionally, there were significant improvements in social
functioning and work. These improvements were maintained at 3, 6, and 12
month follow up.
Cahill, Foa, Hembree, Grunfield, Raunch, and Yadin (2009) studied the
effects of prolonged exposure therapy on social function and physical health
symptoms. These authors concluded that prolonged exposure therapy
resulted in a significant decrease in the frequency of reported health
difficulties and in social functioning improvement.
Study comparison of Cognitive Processing Therapy and Prolonged Exposure

A study performed by Bruce, Galovski, Monson, and Resick (2009)

compared the differential effects of these two therapies on sleep and health

within a sample of 108 female rape suvivors suffering from PTSD.

Participants were assessed before their first session of either treatment, and

at both two weeks after the last session and 9 months after the last session.

In both conditions, there was a total of 13 hours of treatment over 6 weeks.

While there was significant improvement concerning sleep in both treatment

conditions, there was no significant difference in improvement between the

two conditions. In contrast, there was significant improvement pertaining to

health concerns, with more improvement demonstrated using cognitive

processing therapy..

Future Directions/Creativity in Sexual Assault Treatments

Taking Charge

Cotton, Simpson, and David (2006) examined a rather interesting

approach to the treatment of post traumatic stress disorder resulting from

sexual assault. In their study, they employed the use of self defense training

as an exposure method.

Prior research indicates that self defense training can provide women
with the skills necessary to cope with the threat of violence by supplying a
sense of control over their own safety. Based on these findings, the authors
wondered if perhaps self defense training could also serve to function as
enhanced exposure therapy because of the repeated exposure to assault
scenarios involved in exposure therapy. Additionally, these scenarios would
also double as opportunities for teaching proactive cognitive and behavioral
responses to feared stimuli. (Cotton et al. 2006)
The purpose of this intervention was to provide training in
assertiveness, boundary setting, prevention skills, and physical techniques to
prevent assault. The group met for a total of 36 hours: 12 three hour
sessions. Sessions consisted of sexual assault psychoeducation, roleplay
involving assertive communication and boundary setting, physical self
defense training, and extensive group debriefing. (Cotton et al. 2006)
Participants in this study completed assessments a month before the
first session, immediately before the first session, at the end of the final
session, three months after the conclusion of the intervention, and six
months after the conclusion of the intervention. The instruments used
included (portions of) the Self-Defense Scale, the Aggression Questionnaire,
the PCL-C, the Beck Depression Inventory, and the General Self Efficacy
Scale. The Self Defense Scale was used to assess self efficacy involving
ability to perceive risk, ability to navigate potentially dangerous situations,
and ability to engage in various community activities. The Aggression
Questionnaire was used to gauge how likely an individual is to engage in
physical and verbal aggression, as well as to feel anger and hostility. The
PCL-C was utilized to discover the level of discomfort caused by each
symptom of PTSD. The Beck Depression Inventory was used to assess
current depression. Lastly, the General Self Efficacy Scale was used, as the
name implies, to assess self efficacy across a variety of situations. (Cotton et
al. 2006)
Results indicated significant improvement in several areas.
Participants reported “a heightened ability to discern risky situations, a
decrease in obsessive fear and worry about assault without believing
themselves to be invulnerable; an increased sense of personal safety and
increased confidence in their self-defense skills, improved confidence in their
ability to be assertive and to set appropriate interpersonal boundaries,
decreased depression, decreased PTSD avoidance and hyperarousal
symptoms, increased willingness to participate in community
activities(Cotton et al. 2006 p. 562).”
Animal-Assisted Prolonged Exposure

Bleiberg, Debiak, Lefkowitz, Paharia, and Prout (2005) proposed a new

model of prolonged exposure which involves the use of animals. They report

that the dropout rate for prolonged exposure therapy, an empirically

supported intervention for PTSD suffering sexual assault survivors, is as high

as 26%, and many refuse to engage in these treatments in the first place.

With these facts as their basis, the authors asserted that prolonged exposure

can be intimidating to survivors and that any method of improving the

accessibility of prolonged exposure therapy should be seriously considered.

They outlined several possible benefits of involving animals in

prolonged exposure therapy. A calm animal can indicate to the client that
they are in a safe environment with a safe person, which would be important
for the survivor as they relieve a terrifying experience in the presence of a
virtual stranger. The authors also theorized based on prior research that the
presence of an animal during in vivo and imaginal exposure exercises could
assist in attaining habitation at a faster rate. They noted however, that the
therapist would to have to be careful not to introduce the animal in exposure
exercises before maximum anxiety had been reached―to do so could
possible interfere with the effectiveness of the exercise. (Bleiberg et al 2005)
Another benefit included prior research noting a relationship between
increased compliance in psychotherapy and the presence of a therapeutic
animal. (Bleiberg et al 2005)
The authors also discussed some situations in which a therapeutic

animal could be detrimental, including medical reasons, such as allergies,

and fatigue and burnout of the animal. In the case of burnout, the authors

suggested scheduled breaks to attempt in preventing it. (Bleiberg et al 2005)

Lastly, the authors outlined a session by session specific model for

animal-assisted prolonged exposure. After ascertaining the client’s
receptiveness (willingness to work with an animal and lack of medical
conditions prohibiting work with a therapeutic animal) to a therapeutic
animal, session #1 would involve the client interacting with the dog for
about 15 minutes for the purpose of introductions and the building of
familiarity. The therapist then explains the rationale for the combination of
prolonged exposure and animal assistance. Rules will be set regarding
appropriate treatment of the dog. Finally, the therapist will teach breathing
retraining at the end of the session. With regard to the remaing sessions,
the protocol appears quite typical of prolonged exposure therapy, with the
exception of opportunities to interact with the animal. (Bleiberg et al 2005)
Conclusion

In their meta-analysis, Russell and Davis (2007) recommended that

rape crisis centers and social workers examine exposure and cognitive

behavioral interventions as a viable option when working with rape survivors

because of the strong evidentiary support.

Indeed, it does appear that cognitive behavioral methods may be the

best treatment available for this population. In reviewing for this literature, I
noticed an overwhelming amount of support in both the forms of quasi-
experimental peer reviewed studies, in literature reviews, and in one meta-
analysis.
The new applications and possible future directions of these types of
therapies in their use with sexual assault survivors were fascinating to
review. I suspect it will be even more interesting in the coming years.
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