Clinical Intervention Paper: Military Sexual Trauma
The purpose of this paper is to discuss and apply prolonged exposure therapy to the case of Harriet. Prolonged exposure therapy, which is a form of cognitive behavior therapy, is designed to treat posttraumatic stress disorder through two primary treatments, imaginal exposure and in vivo exposure. Cognitive behavior therapy and prolonged exposure therapy are both noted to be effective treatment for posttraumatic stress disorder. This paper highlights some of the research supporting the effectiveness of prolonged exposure therapy for military sexual trauma. In addition, several studies have noted positive outcomes of prolonged exposure therapy. Harriet is an Army with veteran diagnosed with posttraumatic stress disorder as a result of military sexual trauma. Although Harriet did not fully engage in treatment, she reported a decrease in some of her trauma-related symptoms. A review of Harriet’s treatment plan is discussed with an emphasizes on the treatment implementation. Lastly, clinical and professional barriers to treatment and Harriet’s cultural considerations are reviewed.
Keywords: military, cognitive behavioral therapy, posttraumatic stress disorder, military sexual trauma, prolonged exposure therapy, female
Clinical Intervention Paper: Military Sexual Trauma
Military sexual trauma (MST) is defined as “sexual assault or repeated, threatening sexual harassment that happened while a Veteran was in the military” (U.S. Department of Veterans Affairs [VA], 2018). The VA’s definition, which derives from Federal law (Title 38 U.S. Code 1720D), states that MST “is psychological trauma, which in the judgment of a VA mental health professional, resulted from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment which occurred while the Veteran was serving on active duty, active duty for training, or inactive duty training” (VA, 2018).
Harriet is a 60-year-old, biracial, African-American and Caucasian, female with approximately 16 years of formal education. She has a 100% service-connected disability for posttraumatic stress disorder (PTSD) and is also diagnosed with depression. Harriet lives alone in rural Pennsylvania and was unemployed at the start of treatment. Harriet’s income reduced by nearly 70% and she depleted her 401 (k) savings, which left her with insufficient funds to engage in her usual activities (i.e., travel). Harriet is presenting for treatment of MST to help reduce stress and anxiety related to her traumatic experience.
Harriet grew-up in a two-parent home with her mother, step-father, and two younger brothers; however, she spent majority of her time with her parental step-grandmother. Harriet never felt loved by her parents, believes she was “pawned” off to her grandmother, and believes her parents used her to care for her younger brothers. During time spent with her grandmother, Harriet developed characteristics such as strength, fortitude, and resilience. Harriet often states, “I learned how to be a strong Black woman from my grandmother.” Harriet considers herself strong, independent, and reliable and does not disclose certain personal details to family and close friends because she does not want to be perceived as a weak and vulnerable individual. She provides emotional and financial support to many of her family and friends, rarely seeks assistance from others, and considered herself the breadwinner of her family.
Harriet has one daughter, one son-in-law, and four grandchildren. Harriet and her daughter have a great relationship and an open line of communication; however, Harriet has not disclosed her MST to her daughter. Although Harriet and her son-in-law do not have a good relationship, they have learned to co-exist. Harriet is divorced, but remains cordial with her ex-husband. Harriet is in a relationship with her boyfriend, of 10 years, and is happy with her current relationship.
Harriet joined the United States Army in 1976, around the age of 19. Harriet served on Active Duty four years, post-Vietnam and was stationed in Alabama, Atlanta, and Korea. Upon completion of her military service, Harriet obtained her bachelor’s degree and most recently worked for Group 360 for 14-years.
During her time at basic training, Harriet was sexually assaulted by her drill sergeant. Harriet’s drill sergeant inappropriately touched Harriet while she slept and ordered Harriet to his office to perform sexual acts. Harriet did not disclose the assaults because her drill sergeant threatened to make her military career “a living hell.” Later in her military career, Harriet disclosed her MST to a commander, who informed Harriet “to strongly think about opening an investigation because it may ruin the life and military career of a good sergeant.” Harriet successfully finished basic training, remained in the military, and completed her military obligation.
Harriet has a history of diabetes mellitus type-2, hypertension, asthma, hypothyroidism, congestive heart failure, microscopic hematuria, and polyp colon. She is currently prescribed acetaminophen, albuterol, aluminum/magnesium supplement, levothyroxine, lorazepam, metformin, atorvastatin, diphenhydramine, haloperidol, and pantoprazole. Outside of the listed medical conditions, Harriet does not have any additional health concerns. Harriet denies alcohol and substance abuse, but socially drinks wine. Harriet denies suicidal and homicidal ideations.
Conceptualization and Summary of Anxiety Disorder/Symptoms
The theoretical model of choice for Harriet is cognitive behavior therapy (CBT). Cognitive behavior therapy, as defined by the Beck Institute for Cognitive Behavior Therapy, “is a time-sensitive, structured, present-oriented psychotherapy directed toward solving current problems and teaching clients skills to modify dysfunctional thinking and behavior” (Beck Institute, n.d.). Furthermore, CBT is structured and direct and uses direct and specific agendas, techniques, and concepts that assist clients in obtaining their goals (National Association of Cognitive-Behavioral Therapists [NACBT], 2016).
Prolonged exposure therapy (PE), which is a form of CBT, seeks to treat PTSD through two primary treatments, imaginal exposure and in vivo exposure (Foa, Hembree, & Rothbaum, 2007). Imaginal exposure, which typically occurs in session, allows the client to revisit the traumatic event in present tense, audibly recounting the trauma (Foa et al., 2007). Furthermore, repeated recall of the traumatic event decreases symptoms and helps to develop a new perspective of the trauma (Foa et al., 2007). In vivo exposure is conducted in-between sessions and is aimed to treat the fear and avoidance of places and people directly related to the traumatic event (Foa et al., 2007). Overall, PE is an effective treatment that has been proven to successfully treat PTSD (Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010).
Three weeks prior to her initial session, Harriet admitted herself to the in-patient psychiatric ward at the VA. Harriet’s voluntary admittance resulted from her behaviors during her recent surgical procedure. Harriet was scheduled to have her surgical mesh removed and was given a combination of anesthesia. Harriet reports that she became delirious, extremely agitated and combative; tried to scratch her eyes; and began to talk about “monsters requiring restraints.” Harriet believes she was “set-off” because her body “did not tolerate the medications.” After 72-hours in the psychiatric ward, Harriet signed herself out as she “did not feel comfortable being on a locked unit.”
Harriet typically describes her mood has anxious, overwhelmed, and stressed. She is fully-oriented and presents with full-range and congruent affect. Harriet exhibits social skills and is able to maintain eye contact, but displays a decrease in positive emotions and has cognitive, behavioral, emotional, and physiological symptoms. Harriet’s intellectual functioning is considered to be average, her insight is fair, and she has good judgement.
Harriet experiences anxiety attacks, approximately two to three times a day and endorses difficulty concentrating, withdrawal from others, and sleep trouble. Harriet’s emotional symptoms include decreased mood, guilt, shame, hopelessness, and numbness. Harriet is unable to participate in hobbies and has difficulty allowing her 1-year-old granddaughter to physically touch (i.e., hug) her without “feeling dirty.”
Harriet was directly exposed to an actual sexual violence; moreover, she experiences physical sensations and upsetting dreams and avoids triggering stimuli to include memory of her traumatic event. Harriet endorses a negative self-evaluation, difficulty concentration, and sleep complications (American Psychiatric Association [APA], 2013). She also avoids memories and conversations related to her sexual trauma, that address her emotions and her core beliefs, and engages in self-blame.
Harriet is angry with herself, believes she allowed the assault to occur, and thinks she should have been stronger. Harriet’s fear of speaking about her MST is closely related to her thoughts that speaking about her trauma will lead to acceptance and acceptance means she is a failure. Harriet’s strong sense of disappointment stems from her belief that she let herself down. Her thoughts include “how could I fail myself” and “I should have been stronger.” Harriet’s feeling of guilt originates from her grandmother’s teachings, “to never allow anyone to take advantage of you and to always be strong.” Although Harriet has not verbalized details of her MST, she wants to move past her trauma and live a fulfilling life. Based on the important presented, Harriet is diagnosed with Posttraumatic Stress Disorder (F43.10) and Major Depressive Disorder, Recurrent, Mild (F33.0) (APA, 2013). For in-depth criteria for the above-mentioned disorders, refer to the DSM-5 (APA, 2013).
PTSD Checklist for DSM-5
The PTSD Checklist for DSM-5 (PCL-5) was developed by the National Center for PTSD (Blevins, Weathers, Davis, Witte, & Domino, 2015). The PCL-5, which is a 5-point Likert (0 = not at all; 4 = extremely) self-report measure, was developed to assess the 20 symptoms of PTSD (Weathers et al., 2013). The measure can be used to make a provisional PTSD diagnosis as well as monitor symptoms during and after treatment (Weathers et al., 2013). The items are summed and scores range from 0 – 80, yielding symptom severity for symptom clusters and for the overall disorder (Blevins et al., 2015). The PCL-5 demonstrated strong internal reliability (Cronbach’s = .94), good test-retest reliability (r = .82), and good validity (Blevins et al., 2015). The revised PCL-5 was compared to the original PCL and determined to have comparable psychometrics (Blevins et al., 2015). The PCL-5’s lower scores should be considered when screening or determining cause whereas higher scores can assist with making a provisional diagnosis or to decrease false positives (Weathers et al., 2013).
The assessment takes approximately 5 – 10 minutes to complete and will be given to Harriet prior to, during, and after treatment to assess her symptoms and effectiveness of treatment.
Clinician-Administered PTSD Scale
The Clinician-Administered PTSD Scale (CAPS-5) is a structured clinical interview tool that was developed by the National Center for PTSD (Weathers et al., 2018). The CAPS-5, which is a 30-item questionnaire, that is parallel to the DSM-5 PTSD criteria and takes approximately 45 – 60 minutes to administer (Weathers et al., 2013; Weathers et al., 2018). The CAPS-5 diagnoses current, past month, and lifetime PTSD and assesses symptoms over the past week (Weathers et al., 2013). To arrive at a diagnosis, the frequency and intensity of an item are combined into a single severity rating, followed by the sum of the total symptom severity for the 20 PTSD symptoms; furthermore, the symptom cluster severity scores are summed (Weathers et al., 2013). The CAPS-5 is determined to be a psychometrically sound measure for PTSD demonstrating strong reliability (Cronbach’s = .88, = 78 to 1.00) and good validity (r = .66 to .83) (Weathers et al., 2018). Harriet will be given the PCL-5 as a screening tool, to assess her current symptoms; however, the CAPS-5 will not be administered because Harriet received a PTSD diagnosis by the supervising therapist. Nevertheless, the use of the CAPS-5, in conjunction with the PCL-5 can provide an opportunity to clarify information, ask follow-up questions, and implement clinical judgement.
Supporting Literature for Treatment
Military sexual trauma is a common experience amongst men and women in the military; however, women account for 38.4% of reported MST cases, compared to 13.9% of male cases (Wilson, 2018). An analysis of literature on the prevalence MST revealed that women had significantly higher rates of sexual trauma compared to men (Wilson, 2018). Women were also found to be twice as likely as men to acquire PTSD, even though men experienced more trauma (Resnick, Mallampalli, & Carter, 2012). Therefore, clinicians have a responsibility to use an evidenced-based treatment that is developmentally appropriate with clients to reduce distressing symptoms.
The use of exposure therapy in cognitive behavior therapy has been found to be effective females who have experienced a sexual trauma (Foa et al., 1999). Specifically, PE is a widely-used treatment that rejects negative cognitions and decreasing stressful PTSD-related symptoms (Foa, & Rauch, 2004). In a randomized control trail conducted, by the National Center for PTSD, 284 female veterans were randomly selected to receive PE or presented-centered therapy (Schnurr et al., 2007). The female veterans who received PE displayed lower levels of PTSD symptoms, obtain complete remission, and no longer met criteria for PTSD (Schnurr et al., 2007). In a study of female sexual and nonsexual survivors, PE revealed that a reduction in negative cognitions (i.e., self, the world, and self-blame) were directly associated to a reduction of PTSD-related symptoms (Foa, & Rauch, 2004).
Avoidance of thoughts, memories, feelings, and reminders of the trauma commonly occurs with PTSD (APA, 2013). Although avoidance is an unhealthy coping strategy that is typically used to provide relief from negative symptoms, avoidance can maintain or exacerbate negative emotions related to trauma such as increase anxiety and negative thoughts. In a study, comparing the differences of PE on PTSD symptom clusters and individual symptoms, research suggested that PE is not only effective for PTSD, but can also be beneficial for avoidance and numbness (Schnurr & Lunney, 2015). Avoidance reduction has been considered to be important to PTSD treatment and a vital function of PTSD recovery (Foa et al., 2007; Suvak, Treanor, Mitchell, Sloan, & Resick, 2012). With the use of PE to directly address avoidance, female veterans can learn how to tolerate anxiety-provoking situations and learn avoided situations, place, and people are actually safe.
Female veterans who have experienced MST often experience a change in their emotions, sleep disturbances, difficulties with memory and concertation, and difficulty maintaining relationships, (VA, 2015). Subsequently, the use of a highly practical and evidenced-based treatment that is also accepted by the U. S. Department of Veteran Affairs is important for effective treatment.
Harriet will receive PE. The treatment plan will first establish safety and will include assessing for PTSD; identifying triggers; identifying avoidance behaviors; restructuring her cognitions and perception of trauma; and breathing exercise. The treatment plan should provide Harriet with the necessary tools to decrease distressing symptoms related to her trauma, increase coping skills, and facilitate growth. Although PE is conducted with a minimal of ten sessions, Harriet was seen for a total of six sessions. Harriet also briefly identify some anxiety-provoking situations and avoidance behaviors (Appendix A).
What Should Have Occurred
The CAPS-5 will be conducted prior to the start of treatment. Session one of PE is dedicated to providing a rationale, explaining treatment procedures, and collecting relevant data about the trauma, to include the client’s reactions and experiences prior to trauma (Foa et al., 2007). Lastly, breathing training will be introduced and homework will be assigned (i.e., review of rationale and audio tape and practice of breathing) (Foa et al., 2007). Session two includes the presentation of an agenda, review of homework, and exploration of common reactions to the trauma (Foa et al., 2007). Followed by the rationale of in vivo exposure and development of a hierarchal list related to common avoidance (Foa et al., 2007). Session two is concluded by assigning in vivo homework (Foa et al., 2007). Breathing retraining and review of hierarchal list and audiotape is also assigned as homework (Foa et al., 2007). Session three begins with creation of an agenda and review of homework assignments and concludes with the rationale and engagement of imaginal exposure and processing of thoughts and feelings in regard to the exposure (Foa et al., 2007). Review of imaginal exposure recording and continuation of in vivo exposures will be assigned as homework (Foa et al., 2007). Sessions four to nine continues with review of homework; in-session imaginal exposures, with an emphasizes on hot spot; discussion of cognitions and emotions related to the exposure; and in-depth review of in vivo exposures (Foa et al., 2007). The final session will consist of homework review, an abbreviated imaginal exposure, exploration of the exposure, and discussion of practices and possible relapse posttreatment (Foa et al., 2007).
What Actually Occurred
Session one consisted of the administration of the PCL-5 and discussion of the rationale of PE. While Harriet had already conducted her own research, she engaged in the discussion and provided her thoughts about treatment. Harriet provided background information pertaining to her MST and medical procedure. She also discussed some of her trauma-related symptoms (i.e., anxiety attacks and negative cognitions). Therapist introduction deep breathing and assigned as homework. During session two Harriet discussed her “bad dreams” that typically involve her MST and overall military experience. She also explored her fear of engaging in PE, automatic thoughts, and acceptance of her MST. Harriet stated the first step of her acceptance is reading the details of her assault, which she wrote in her journal. Homework assignments included MST journal reading and deep breathing. Therapist also asked Harriet to bring journal to next session. After a check-in and while setting the agenda, in session three, Harriet stated she did not want to talk about anything and she “give a damn.” The therapist explored Harriet’s feelings which led to discussion of Harriet’s childhood and family history. Harriet also mentioned that she continued to have anxiety attacks and nightmares. Lastly, Harriet discussed why she did not complete her homework assignment. Throughout the session, therapist supported Harriet as she discussed her family history and connected Harriet’s family history and trauma to her fears and automatic thoughts about her MST. Therapist validated Harriet’s feelings and reminded Harriet of the positive effects of PE. Homework assignment included deep breathing along with reading and bringing MST journal entries to session four.
Harriet made great progress in session four; although she did not bring her journal, she discussed her trauma and recalled forgotten details. Harriet also explored the negative feelings and thoughts she has towards her drill sergeant. Harriet stopped talking halfway through the exposure and stated, “I shared too much information with you.” Subsequently, Harriet and the therapist processed the exposure and explored her emotions. They also discussed Homework assignment included reading and bringing MST journal entries to session five.
Sessions six and seven were abbreviated due to Harriet being late. However, Harriet continued to explore emotions surrounding the trauma. Therapist assigned homework for each session. After session seven, Harriet obtained employment and stopped coming to treatment. She unexpectedly returned one month later. During the follow-up session, Harriet
Barriers to Treatment
Based on common knowledge, barriers are obstacles that hinder both the patient and therapist from progressing forward in treatment. Harriet’s most prominent barriers to treatment include insight and avoidance. Harriet conducted research and is knowledgeable of the rationale, purpose, and the positive effects of exposure therapy. However, Harriet’s fear of how the therapist would perceive her hindered Harriet from fully engaging in treatment. Subsequently, Harriet discussed the meaning of acceptance and explored her emotions. Although Harriet knew the therapist would not view her as being weak or vulnerable, Harriet’s value of always being a strong woman also became a barrier to treatment. Harriet often stated, “I know that discussing what happened to me is the only way to move forward, I am just not ready to accept it.”
As with all barriers that develop in therapy, I obtained clinical supervision. Clinical supervision allowed me to regularly conceptualize Harriet’s case as well as discuss her progress and my clinical skills. Clinical supervision also offered an alternative perspective allowing me to recognize and develop a reasonable line between accepting Harriet’s avoidance and conducting exposure therapy. There were several occasions when I took a step back and allowed Harriet to direct the session. In this, I realized that conducting therapy at a VA hospital is different than conducting therapy at an disorder-focused center. Unlike clients who seek specific treatment, veterans typically pursue therapy with the intent to receive supportive and talk therapy.
During my time with Harriet, I recognized my frustration and consciously made a decision to not allow my emotions to be a barrier in treatment. Perhaps, my frustration emanated from Harriet’s insight and self-awareness, but unwillingness to fully engage in treatment. Work with Harriet allowed me to recognize that no matter how much a therapist engages and tries to move the client beyond their comfort zone, the therapist should meet the client where they are, instead of working against the client. I offered Harriet empathy and explored her perspective to ensure she felt heard and understood and not judged. Meeting Harriet at her level of functioning removed barriers and allowed Harriet to openly discuss her feelings related to her trauma. I now have an improved understanding of patience and empathy for working with female veterans diagnosed with PTSD.
Cultural factors, background, personal relationships, moral and value systems, socioeconomic status, and religion should all be considered when providing treatment. Furthermore, as the therapist, I must be aware of my background, attitudes, values, and biases as each may influence my ability to conduct treatment. Additionally, I must educate myself to ensure I have a basic level of understanding for each client’s diverse background. The recognition and exploration of cultural differences are important and can increase clients’ awareness of how their cultural considerations impact their mental health and treatment out.
As I considered Harriet’s cultural background, which consisted of mostly African-American women, I was reminded that Harriet’s resistance to treatment may have originated from the stigma of African-Americans seeking mental health treatment. Harriet was raised by her grandmother to be a strong Black woman and to always protect herself. Additionally, Harriet was taught to pray and read her Bible to deal with stressful situations. Cultural considerations such as mental health stigma and judgement in the African-American community were explored in treatment. Additionally, Harriet provided her definition of a weak woman and discussed her meaning of being a strong Black woman. I provided Harriet with empathy and psychoeducation, reviewing some of the positive effects of treatment in the African-American community. I also obtained supervision and discussed the appropriateness of addressing culture from personal and professional perspectives to build rapport.
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