Sexual trauma therapy

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Sexual trauma therapy is medical and psychological interventions provided to survivors of sexual violence aiming to treat their physical injuries and cope with mental trauma caused by the event. Examples of sexual violence include any acts of unwanted sexual actions like sexual harassment, groping, rape, and circulation of sexual content without consent. [1]

Contents

Different forms of sexual trauma therapy can be applied throughout the healing process. Immediate medical treatment is given to survivors to treat injuries, collect evidence, and prevent sexually transmitted infections (STIs) and pregnancy. [1] Additionally, psychological treatment methods are applied to individuals who have mental illnesses as well as those suffering from emotional aftermath resulting from traumatic events. [2] Psychological treatments include psychodynamic psychotherapy, [3] trauma-focused cognitive behavioral therapy (TF-CBT), [3] eye movement desensitization and reprocessing therapy (EMDR), [3] play therapy, [4] and sex therapy. [5]

Medical Treatment

Treating physical injuries

General body and genital-anal injuries are common in sexual violence survivors; medical attention is required if one sustained any form of medical injury. [6] Depending on the severity of the condition, the affected person would be treated accordingly. Genital-anal injuries are sustained as a result of sexual penetration, where injuries typically include redness, abrasions and tearing. However, there is a varying prevalence of the type and location of physical trauma presented in survivors. This information can be provided through a thorough examination. Many survivors of sexual violence also seek medical attention as a way to collect forensic evidence. [7]

Sexual assault medical forensic exam

After the assault, survivors may opt to receive a sexual assault medical forensic exam. During the process, the survivor can stop, pause or skip steps whenever necessary. [8] These exams collect physical evidence such as photographs, DNA samples through internal examination, swabbing of the outer body surface area, blood, urine and hair samples. Internal examinations consist of inspecting the mouth, genitals and anus. [6] [8]

The forensic examination kit, also known as a "rape kit" or sexual assault evidence kit (SAEK) contain instructions, documents and containers for specimens collected and stored, by the medical personnel. The content of the kit varies by geographical regions. [8]

Choosing to receive a sexual assault medical forensic exam can potentially increase the likelihood of prosecution since DNA evidence takes prominence in court. A report of the sexual violence incident can be filed if the survivor wishes to. [6] [8]

Testing and treating sexually transmitted infections

Emergency contraceptive pill. Emergency contraceptive (cropped).jpg
Emergency contraceptive pill.

STIs such as chlamydia, gonorrhoea, human immunodeficiency virus infection (HIV) and human papillomavirus infection (HPV) are other possible repercussions of penetrative sexual violence. If the disease is left untreated, the survivor may be burdened with long term complications which include: pelvic inflammatory disease, infertility, and some types of cancers. [6] [9]

Immediate and selective testing is recommended for individuals who opt to receive a medical examination after the event to allow for early management and treatment. [9]

Treatment of STIs varies between individuals and the type of infections. The physician would consider the medical history and methods to prevent re-traumatising the survivor. Some forms of recommended treatments include antibiotics for bacterial infections and emergency contraception for HIV, HPV and hepatitis B. [9]

Prevention or assistance for pregnancy

A copper intrauterine device (IUD). IUD with scale.jpg
A copper intrauterine device (IUD).

Individuals can use emergency contraception to help prevent pregnancy after penetrative sexual violence. This may include taking emergency contraceptive pills or inserting an emergency copper intrauterine device (IUD). They are effective up to five days after the event. [10] To validate the outcome, pregnancy tests can be taken ten days or more, after the event. [11]

If one does become pregnant due to sexual violence, they can decide to terminate the pregnancy or carry it to full term. [6] If the individual proceeds with the pregnancy, they can decide whether to place the child up for adoption or raise the child and undertake follow-up care. [6] The decided course of action largely depends on the abortion laws and adoption laws of the geographical location of which the individual resides. [12]

Medication for mental health treatment

Following sexual violence, survivors may experience various negative mental health consequences, including but not limited to: [13]

Medication can be used along with psychological therapy to help the individual on a short-term basis, with psychotherapeutic treatment being the main form of mental health recovery. [14]

The use of medication must be prescribed and monitored carefully by a medical professional to prevent dependence and overuse of psychotropic drugs. [15]

Psychotherapeutic Treatment

Psychotherapy, which is often referred to as "talk therapy", is an intervention to address psychological and behavioral changes as well as mental problems in individuals. [2] Survivors of sexual trauma are also subjected to victimisation, especially adolescents, which increases their likelihood of developing psychological issues. [16]

Psychodynamic Psychotherapy

The psychodynamic psychotherapy approach utilizes the role played by the survivor's unconscious mind to alleviate their symptoms. Psychodynamic psychotherapy allows individuals to confront their trauma, understand what it means to have gone through sexual violence, acknowledge the aftereffects, and how it results in their current behavior and thoughts. [16]

When treating a survivor of sexual trauma, psychodynamic psychotherapy focuses on several features. They are: [3]

Trauma-focused Cognitive Behavioral Therapy

TF-CBT is a treatment approach under cognitive behavioral therapy (CBT) that targets children and adolescents with trauma experiences, including sexual trauma. It aims to reduce trauma symptoms [17] and re-condition negative thought patterns of the survivor. [18] As this technique is commonly used on children and adolescents, alongside focusing on the survivor, the treatment also helps non-offending caregivers, parents, and guardians. The therapeutic focus on caregivers is placed on assisting them in apprehending and processing the trauma, working through their emotional distress, and how to support the survivor. [18]

TF-CBT is a short-term treatment model used at mental health facilities or in-home, hospital, community environments. Each session could be held individually with the survivor and caregiver or jointly with both parties. In the individual sessions, the aim is to work on skills to address the sexual trauma and then practice the skills in joint sessions. [18] During individual sessions with the survivor, a technique that is often applied is trauma narrative. This technique encourages survivors to open up to the trauma's detail and to confront the sexual trauma. [3]    

This therapy approach may not be suitable if survivors are experiencing suicidal temptations or actively abuses substances. The confrontation of their past sexual trauma may trigger impulses and worsen current symptoms. [18]

Efficacy

In a systematic review, CBT has been reported to be a practical therapeutic approach to PTSD from a range of trauma, including sexual abuse. In the same systematic review, two studies made a direct comparison between psychodynamic psychotherapy and TF-CBT. This comparison indicated psychodynamic psychotherapy to be equally or even moderately more effective than TF-CBT. While other direct comparisons suggested TF-CBT was more effective, specific cases reported signs of increased anxiety and distress. The effectiveness was measured by the presence and severity of PTSD symptoms. [16] Overall, the use of this approach exhibited improvement in patients, however, the role of TF-CBT as a preferred treatment should be monitored. [16] [19]

An example of a sand play therapy set up. AdultPsychotherapySandPlay.jpg
An example of a sand play therapy set up.

Play therapy

Play therapy targets survivors of a younger age as they are yet to have the proper cognitive skills to understand their sexual trauma experience. [4] [20] The individual engages in play activities such as sand play, toys, games or puppets while establishing trust and better communication with the therapist. Play activities allow young survivors to express emotions through a familiar self-expression mechanism while learning to understand and work through sexual trauma. [4]

Play therapy can be utilized in an individual or group setting. In a group setting, it includes an added dimension of interaction with other young survivors while participating in play activities. Group play therapy allows children to feel comfortable and establish trust with other children. The structure of group play therapy can be either directive or non-directive. Directive sessions are guided by the therapist, using different play activities to set specific objectives and goals for the session. In non-directive sessions, it takes on a less structured approach where the therapist provides space and safety for sexually abused children to talk through the sexual trauma when ready. Group play therapy can help work through negative behavior exhibited by sexually abused children due to sexual trauma. Common behavioral symptoms include: [20]

Non-offending parents can also be invited to participate in play therapy. The parent's role is to establish a sense of safety for the child during the session. It would also be a chance to improve and work on any relationship strains between the two parties due to the sexual trauma. While this approach is practiced, it may pose a potential breach of patient confidentiality. [21]

Efficacy

A meta-analysis found that a combination of play therapy with other psychotherapies (TF-CBT, supportive therapy, psychodynamic therapy) presented lower levels of sexualized behavior, anxiety, depression, and behavior problems upon therapy. Play therapy alone did not achieve statistically significant outcomes. [22]  Another systematic review also concluded that play therapy did not have sufficient evidence to prove its effectiveness on reducing PTSD symptoms following a traumatic event in children. [23]

Eye movement desensitization and reprocessing therapy

EMDR can help restructure memories associated with the sexual trauma experience of the survivor. The exact mechanism of how EMDR achieves this remains unknown. The original understanding hypothesizes the involvement of the adaptive information processing (AIP) area within the brain to alter negative thoughts into more positive thoughts. The therapist can encourage the activation of the survivor's AIP through triggering bilateral brain stimulation. [24] In EMDR, bilateral brain stimulation can be achieved with the therapist placing their fingers before the survivor's face, producing finger movements for the survivor's eyes to follow. The source of the movement does not matter. As the survivor focuses on the movement, the therapist will begin asking questions to prompt any recollection of the sexual trauma event allowing for the brain's bilateral stimulation. [3]

EMDR for sexual trauma consists of six different components; one of them is bilateral stimulation. The five others include: [24]

  1. Target image - establishing the survivor's key image related to the sexual trauma incident that occurred.
  2. Negative Cognitions - understanding and identifying any negative self-perpetuated thoughts that stemmed from the trauma.
  3. Positive Cognitions - identifying positive affirmations of the survivor that will be utilized to replace their negative cognitions.
  4. Level of Emotional Disturbance - recognizing negative emotions associated with the trauma.
  5. Body sensations - identifying physical sensations that coexist with the negative emotions felt by the survivor.

A typical EMDR treatment approach would begin with assessing the suitability of the survivor to undergo EMDR. This would include collecting information about attempted treatment plans. EMDR may prompt adverse side effects that are specific to the survivor's overall condition and day-to-day practices; therefore, suitability varies. Once EMDR is considered appropriate, the therapist will familiarize and allow the survivor to feel comfortable. The six components stated will then be used to assess the survivor's situation and restructure the memory of the target image to reinforce positive cognitions. Progress may require multiple sessions and is reviewed frequently. [24]

Efficacy

In a systematic review on psychotherapies targeting PTSD, authors concluded that both TF-CBT and EMDR showed greater improvement compared to recommended treatment. An additional systematic review also found EMDR to reduce PTSD symptoms. However, supplementary studies are required to obtain more conclusive and reliable evidence. [25] [26]

Sex therapy

Sexually traumatized individuals may experience PTSD expressed in the form of sexual dysfunction, fear of sexual activity and intimacy within relationships. [27] This can be treated through sex therapy. Sex therapy can be conducted individually or with a partner. [5] [28]

Sex therapy integrates building on skills within the cognitive and behavioral areas for both parties in therapy. For cognitive areas, the survivor works to recondition negative self-perception and come to terms with the incident without blaming oneself. The partner can support the survivor's progress by understanding how their past sexual trauma caused PTSD symptoms. Building skills for the behavioral areas by implementing a series of verbal and stimulation activities can help the couple work towards becoming sexually comfortable again. [5]

Related Research Articles

<span class="mw-page-title-main">Cognitive behavioral therapy</span> Therapy to improve mental health

Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. CBT focuses on challenging and changing cognitive distortions and their associated behaviors to improve emotional regulation and develop personal coping strategies that target solving current problems. Though it was originally designed to treat depression, its uses have been expanded to include the treatment of many mental health conditions, including anxiety, substance use disorders, marital problems, and eating disorders. CBT includes a number of cognitive or behavioral psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.

Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life. Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the fight-or-flight response. These symptoms last for more than a month after the event. Young children are less likely to show distress but instead may express their memories through play. A person with PTSD is at a higher risk of suicide and intentional self-harm.

<span class="mw-page-title-main">Dialectical behavior therapy</span> Psychotherapy for emotional dysregulation

Dialectical behavior therapy (DBT) is an evidence-based psychotherapy that began with efforts to treat personality disorders and interpersonal conflicts. Evidence suggests that DBT can be useful in treating mood disorders and suicidal ideation, as well as for changing behavioral patterns such as self-harm and substance use. DBT evolved into a process in which the therapist and client work with acceptance and change-oriented strategies, and ultimately balance and synthesize them—comparable to the philosophical dialectical process of thesis and antithesis followed by synthesis.

Psychological trauma, mental trauma or psychotrauma is an emotional response to a distressing event or series of events, such as accidents, rape, or natural disasters. Reactions such as psychological shock and psychological denial are typical. Longer-term reactions include unpredictable emotions, flashbacks, difficulties with interpersonal relationships and sometimes physical symptoms including headaches or nausea.

Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy developed by Francine Shapiro in the 1980s that was originally designed to alleviate the distress associated with traumatic memories such as post-traumatic stress disorder (PTSD). In EMDR, the person being treated recalls distressing experiences whilst doing bilateral stimulation, such as side-to-side eye movement or physical stimulation, such as tapping either side of the body.

<span class="mw-page-title-main">Complex post-traumatic stress disorder</span> Psychological disorder

Complex post-traumatic stress disorder is a psychological disorder that is theorized to develop in response to exposure to a series of traumatic events in a context in which the individual perceives little or no chance of escape, and particularly where the exposure is prolonged or repetitive. It is not yet recognized by the American Psychiatric Association or the DSM-5 as a valid disorder, although was added to the eleventh revision of the International Classification of Diseases (ICD-11). In addition to the symptoms of post-traumatic stress disorder (PTSD), an individual with C-PTSD experiences emotional dysregulation, negative self-beliefs and feelings of shame, guilt or failure regarding the trauma, and interpersonal difficulties. C-PTSD relates to the trauma model of mental disorders and is associated with chronic sexual, psychological, and physical abuse or neglect, or chronic intimate partner violence, bullying, victims of kidnapping and hostage situations, indentured servants, victims of slavery and human trafficking, sweatshop workers, prisoners of war, concentration camp survivors, and prisoners kept in solitary confinement for a long period of time, or defectors from authoritarian religions. Situations involving captivity/entrapment can lead to C-PTSD-like symptoms, which can include prolonged feelings of terror, worthlessness, helplessness, and deformation of one's identity and sense of self. C-PTSD is linked to adverse childhood experiences, especially among survivors of foster care.

Francine Shapiro was an American psychologist and educator who originated and developed eye movement desensitization and reprocessing (EMDR), a form of psychotherapy for resolving the symptoms of traumatic and other disturbing life experiences.

Childhood trauma is often described as serious adverse childhood experiences (ACEs). Children may go through a range of experiences that classify as psychological trauma; these might include neglect, abandonment, sexual abuse, emotional abuse, and physical abuse, witnessing abuse of a sibling or parent, or having a mentally ill parent. These events have profound psychological, physiological, and sociological impacts and can have negative, lasting effects on health and well-being such as unsocial behaviors, attention deficit hyperactivity disorder (ADHD), and sleep disturbances. Similarly, children with mothers who have experienced traumatic or stressful events during pregnancy can increase the child's risk of mental health disorders and other neurodevelopmental disorders. Kaiser Permanente and the Centers for Disease Control and Prevention's 1998 study on adverse childhood experiences determined that traumatic experiences during childhood are a root cause of many social, emotional, and cognitive impairments that lead to increased risk of unhealthy self-destructive behaviors, risk of violence or re-victimization, chronic health conditions, low life potential and premature mortality. As the number of adverse experiences increases, the risk of problems from childhood through adulthood also rises. Nearly 30 years of study following the initial study has confirmed this. Many states, health providers, and other groups now routinely screen parents and children for ACEs.

Prolonged exposure therapy (PE) is a form of behavior therapy and cognitive behavioral therapy designed to treat post-traumatic stress disorder. It is characterized by two main treatment procedures – imaginal and in vivo exposures. Imaginal exposure is repeated 'on-purpose' retelling of the trauma memory. In vivo exposure is gradually confronting situations, places, and things that are reminders of the trauma or feel dangerous. Additional procedures include processing of the trauma memory and breathing retraining.

Memory and trauma is the deleterious effects that physical or psychological trauma has on memory.

Cognitive processing therapy (CPT) is a manualized therapy used by clinicians to help people recover from posttraumatic stress disorder (PTSD) and related conditions. It includes elements of cognitive behavioral therapy (CBT) treatments, one of the most widely used evidence-based therapies. A typical 12-session run of CPT has proven effective in treating PTSD across a variety of populations, including combat veterans, sexual assault victims, and refugees. CPT can be provided in individual and group treatment formats.

PTSD or post-traumatic stress disorder, is a psychiatric disorder characterised by intrusive thoughts and memories, dreams or flashbacks of the event; avoidance of people, places and activities that remind the individual of the event; ongoing negative beliefs about oneself or the world, mood changes and persistent feelings of anger, guilt or fear; alterations in arousal such as increased irritability, angry outbursts, being hypervigilant, or having difficulty with concentration and sleep.

Transgenerational trauma is the psychological and physiological effects that the trauma experienced by people has on subsequent generations in that group. The primary modes of transmission are the uterine environment during pregnancy causing epigenetic changes in the developing embryo, and the shared family environment of the infant causing psychological, behavioral and social changes in the individual. The term intergenerational transmission refers to instances whereby the traumatic effects are passed down from the directly traumatized generation [F0] to their offspring [F1], and transgenerational transmission is when the offspring [F1] then pass the effects down to descendants who have not been exposed to the initial traumatic event - at least the grandchildren [F2] of the original sufferer for males, and their great-grandchildren [F3] for females.

Trauma focused cognitive behavioral therapy (TF-CBT) is an evidence-based psychotherapy or counselling that aims at addressing the needs of children and adolescents with post traumatic stress disorder (PTSD) and other difficulties related to traumatic life events. This treatment was developed and proposed by Drs. Anthony Mannarino, Judith Cohen, and Esther Deblinger in 2006. The goal of TF-CBT is to provide psychoeducation to both the child and non-offending caregivers, then help them identify, cope, and re-regulate maladaptive emotions, thoughts, and behaviors. Research has shown TF-CBT to be effective in treating childhood PTSD and with children who have experienced or witnessed traumatic events, including but not limited to physical or sexual victimization, child maltreatment, domestic violence, community violence, accidents, natural disasters, and war.

Ricky Greenwald is a clinical psychologist and an expert on eye movement desensitization and reprocessing (EMDR). He is also the creator of progressive counting (PC), both psychotherapy methods for resolving traumatic memories and associated symptoms. He founded the Trauma Institute & Child Trauma Institute, a non-profit organization, and is currently its executive director and chair of the faculty.

<span class="mw-page-title-main">Trauma and first responders</span> Trauma experienced by first responders

Trauma in first responders refers to the psychological trauma experienced by first responders, such as police officers, firefighters, and paramedics, often as a result of events experienced in their line of work. The nature of a first responder's occupation continuously puts them in harm's way and regularly exposes them to traumatic situations, such as people who have been harmed, injured, or killed.

<span class="mw-page-title-main">Internet-based treatments for trauma survivors</span>

Internet-based treatments for trauma survivors is a growing class of online treatments that allow for an individual who has experienced trauma to seek and receive treatment without needing to attend psychotherapy in person. The progressive movement to online resources and the need for more accessible mental health services has given rise to the creation of online-based interventions aimed to help those who have experienced traumatic events. Cognitive behavioral therapy (CBT) has shown to be particularly effective in the treatment of trauma-related disorders and adapting CBT to an online format has been shown to be as effective as in-person CBT in the treatment of trauma. Due to its positive outcomes, CBT-based internet treatment options for trauma survivors has been an expanding field in both research and clinical settings.

In psychology, Trauma-informed feminist therapy is a model of trauma for both men and women that incorporates the client's sociopolitical context.

Being exposed to traumatic events such as war, violence, disasters, loss, injury or illness can cause trauma. Additionally, the most common diagnostic instruments such as the ICD-11 and the DSM-5 expand on this definition of trauma to include perceived threat to death, injury, or sexual violence to self or a loved one. Even after the situation has passed, the experience can bring up a sense of vulnerability, hopelessness, anger and fear.

Imagery Rescripting is an experiential therapeutic technique that uses imagery and imagination to intervene in traumatic memories. The process is guided by a therapist who works with the client to define ways to work with particular traumatic memories, images, or nightmares.

References

  1. 1 2 Garcia-Moreno, Claudia; Guedes, Alessandra; Knerr, Wendy (2012). "Sexual violence". WHO. WHO. Retrieved 31 March 2021.{{cite web}}: CS1 maint: url-status (link)
  2. 1 2 American Psychiatric Association (2019). "What is Psychotherapy?". www.psychiatry.org. Retrieved 2021-03-31.{{cite web}}: CS1 maint: url-status (link)
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  7. ↑ Jina, Ruxana; Jewkes, Rachel; Vetten, Lisa; Christofides, Nicola; Sigsworth, Romi; Loots, Lizle (2015). "Genito-anal injury patterns and associated factors in rape survivors in an urban province of South Africa: a cross-sectional study". BMC Women's Health. 15: 29. doi: 10.1186/s12905-015-0187-0 . PMC   4396864 . PMID   25887051.
  8. 1 2 3 4 "What Is a Sexual Assault Forensic Exam?". RAINN. Retrieved 31 March 2021.
  9. 1 2 3 Sachs, Carolyn J.; Ladd, Megan; Thomas, Brooke (Jan 2021). "Sexual Assault Infectious Disease Prophylaxis". StatPearls. StatPearls Publishing. Retrieved 31 March 2021.
  10. ↑ Massachusetts Department of Public Health (2014). "Emergency Contraception after Sexual Assault: Five Key Facts for Survivors". Massachusetts Department of Public Health. Retrieved 31 March 2021.{{cite web}}: CS1 maint: url-status (link)
  11. ↑ Cleveland Clinic (2017). "Pregnancy Test Information". Cleveland Clinic. Retrieved 2021-03-31.{{cite web}}: CS1 maint: url-status (link)
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  15. ↑ Josse, Evelyne (2010). "'They came with two guns': the consequences of sexual violence for the mental health of women in armed conflicts". International Review of the Red Cross. 92 (877): 177–195. doi:10.1017/S1816383110000251. ISSN   1816-3831. S2CID   54816091.
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  19. ↑ de Arellano, Michael A. Ramirez; Lyman, D. Russell; Jobe-Shields, Lisa; George, Preethy; Dougherty, Richard H.; Daniels, Allen S.; Ghose, Sushmita Shoma; Huang, Larke; Delphin-Rittmon, Miriam E. (May 2014). "Trauma-Focused Cognitive-Behavioral Therapy for Children and Adolescents: Assessing the Evidence". Psychiatric Services. 65 (5): 591–602. doi:10.1176/appi.ps.201300255. ISSN   1075-2730. PMC   4396183 . PMID   24638076.
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  21. ↑ Hill, Andrew (2006). "Play therapy with sexually abused children: Including parents in therapeutic play". Child Family Social Work. 11 (4): 316–324. doi:10.1111/j.1365-2206.2006.00411.x. ISSN   1356-7500.
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  27. ↑ O'Driscoll, Ciarán; Flanagan, Esther (September 2016). "Sexual problems and post-traumatic stress disorder following sexual trauma: A meta-analytic review". Psychology and Psychotherapy: Theory, Research and Practice. 89 (3): 351–367. doi:10.1111/papt.12077. PMID   26449962.
  28. ↑ Almås, Elsa; Benestad, Esben Esther Pirelli (2021-03-16). "Treatment of Traumatised Sexuality". Frontiers in Psychology. 12: 610619. doi: 10.3389/fpsyg.2021.610619 . ISSN   1664-1078. PMC   8008146 . PMID   33796043.
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