Trina Young Greer, Psy.D., LCP
Learning Objectives
1. The participant will explore examples and best
practice treatment models for counseling clients
who have suffered sexual and emotional abuse.
2. The learner will be able to develop effective
treatment plans for counseling survivors of sexual
abuse, both children and adults.
3. Attendees will discover models for ethically and
effectively integrating the faith of the counselee into
the therapy process as a valuable resource for
healing and hope.
Outline
• Rationale
• Treating Child Survivors
• Treating Adult Survivors
The Need for Care
Abuse Statistics:
• 1 in 3 women and 1 in 5 men are sexually abused prior to
age 18 by someone they are supposed to trust; and many
of these abuses are chronic.
• 1 in 4 women in America experience rape in their
lifetime.
• 50% of sexual assault victims will eventually seek
counseling
• For child sexual abuse 1/3 offenders are parents and ½
are relatives (Courtois, 2010)
Neurobiological Posttraumatic
Stress Symptoms …
• Alter ations in emotional r egulation
• Alter ations in attention and consciousness
• Alter ations in self-per ception
• Alter ations in r elationships with other s
• Somatization/Medical issues
• Alter ations in systems of meaning
(Er ic Scalise, 2014; Chr istine Cour tois, 2009)
Treating Child
Survivors
• Trauma-Focused Cognitive Behavioral
Therapy (TF-CBT)
• Expressive Therapies (Play Therapy)
• Parent-Child Interaction Therapy (PCIT)
TREATING CHILD SURVIVORS
TF-CBT
• Theories
Cognitive-behavioral, attachment,
developmental, family, empowerment,
and humanistic
• Flexible application based on the needs of
the client
• Addresses cognitions, behaviors,
relationships, performance, emotion
regulation and other important factors
(Cohen, Mannarino, Deblinger, 2006)
TF-CBT Cont’d.
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P
P
R
A
C
T
I
C
E
sychoeducation
arenting
elaxation
ffective Expression and Modulation
ognitive Coping and Processing I
rauma Narrative
n-Vivo Desensitization
ognitive Coping and Processing II
nhancing Safety and Future Development
Case Study: Tasha
10 year old, African American girl
• Birth to Age 5: Chaotic household (mother was a polysubstance abuser); many people coming in and out of
household; Tasha was abused
• Age 5: Her biological mother lost parental rights due to
neglect and abuse
• Ages 5 to 7: foster homes
• Age 7 to current: Current guardian received full custody of
Tasha and her brother
Posttraumatic Symptoms at Intake
• Very low self-esteem
• Inappropriate behaviors to include sexual talk and
masturbation
• High levels of distractibility, dissociative signs
• Enuresis, with Encopresis at night
• Inability to socialize well with peers her own age
• Sadness, fears
• Recent episodes of carrying soiled undergarments in
plastic bags from home to school/church in her book bag
• Skin-picking
• Hypervigilance
Spiritual Influences
• Theistic Worldview: Tasha voiced belief in a
benevolent, loving God
• Foster placement: occasionally taken to church
• Tasha’s current guardian regularly took the
children to church, including age-appropriate
“Sunday School” classes at a predominantly
African-American Pentecostal church
• Strong social support system at the church
Psychoeducation
• Provide education on diagnosis
Tasha: PTSD, enuresis, encopresis, skin-picking,
anxiety, ADHD
• Provide overview of treatment (child and parent)
• Normalize the experience
Tasha and Guardian: Statistics on abuse,
“Normal reaction to abnormal events”
Parenting Skills
• Positive Reinforcement
• Differential Reinforcement
• Time-Out
Relaxation
• Deep “belly” breathing, Positive Imagery
• Progressive muscle relaxation
• Meditation to alleviate stress reactions caused by trauma
• Tasha: paired Bible passages and prayer with
relaxation training
• Tasha: meditation helpful in combatting aggression
______________________________________________________________________________________________________________________________
“Thought stopping, positive imagery, and coping self-talk
could all be potentially more powerful if stories, songs, or
passages from the Bible were incorporated into
treatment.” Don Walker, Ph.D., Trauma Research Team, Regent University
Affective Expression and
Modulation
• Feeling identification
• Thought interruption for intrusive and
aggressive thoughts
• Positive imagery
Cognitive Coping and
Processing I
• Teach Self-Talk
• Teach Cognitive
Triangle
Trauma Narrative
After coping skills were taught and
practiced, the trauma narrative work
began.
____________________________________________________
“We view the role of the psychotherapist as one who bears
witness to the client’s spiritual struggles related to meaning,
purpose of the trauma, and suffering.”
Don Walker, Ph.D., Trauma Research Team, Regent University
Trauma Narrative Themes
• Memory of sexual molestation by male stranger
when she lived within her biological mother’s
home
• Tasha remembered trying to get away from him,
but feared her mother’s anger if she cried out
• Fear, sadness, embarrassment, and terror
• She acted out the story by using stuffed animals
• She noted, “He [the abuser] was a bad, mean man
and God hated how he hurt me.”
• Truth statement: “I don’t ever want to go back
there and God will make sure I don’t.”
Several years later…
Tasha stated,
“My earthly fathers were jerks…
very broken guys who made awful
choices. But that has made me even
more aware of how wonderful and
perfect a Father that God really is to
me… Without God, I wouldn’t have
made it.”
Other Resources
• Family Therapy (e.g., Parent-Child Interaction Therapy , McNiel &
Hembree-Kiggin, 2011)
• Rebuild attachment
• Manage externalizing behaviors
• Adopted children who were abused
• Non-Directive and Expressive Approaches (Daniel Sweeney, 2014;
Gil, 2006)
• Story-telling approaches
• Sand tray
• Puppets
• Art therapy
• Play genograms
Cognitive Processing Therapy
Bibliotherapy/Workbooks
What is Cognitive Processing
Therapy (CPT)?
• Empirically validated cognitive-behavioral therapy for PTSD
and related conditions; manualized/protocol treatment
approach (Monson et al, 2006; Resick et al, 2002; Resick & Schnicke, 1992, 1993)
• CPT focused on rape victims originally, but now expanded
successfully to a range of other traumatic events
• Approximately 12 weekly therapy sessions (individual or
group settings)
• Focus: identifying how traumatic experiences changed
thoughts and beliefs, and how thoughts influence current
feelings and behaviors; “accommodating” new information
• Addresses mental “stuck points”
Goals of CPT
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Improve understanding of PTSD
Reduce the distress about memories of the trauma
Decrease emotional numbing and avoidance
Reduce feelings of being tense or “on edge”
Decrease depression, anxiety, guilt/shame
Improve day-to-day living
CPT: Theory
• CPT is based on a social cognitive theory of PTSD and
information processing theory
• CPT construes PTSD as a disorder of “non-recovery”:
symptoms are attributed to an inhibition, or “stalling out,” in
the natural process of recovery which prevents individuals
from completely working through trauma-related thoughts
• CPT utilizes trauma-specific cognitive techniques to help
patients move past these “stuck points” and progress
toward recovery
The 4 Primary Parts of CPT
1.
2.
3.
4.
Learning About PTSD Symptoms
Becoming Aware of Thoughts and Feelings
Learning Skills
Understanding Changes in Beliefs
Overview of 12 Sessions
• Session 1: Introduction and Education Phase
• Session 2: The Meaning of the Trauma (or Traumatic Bereavement Session,
if applicable)
• Session 3: Identification of Thoughts and Feelings
• Session 4: Remembering the Trauma
• Session 5: Identification of Stuck Points
• Session 6: Challenging Questions
• Session 7: Patterns of Problematic Thinking
• Session 8: Safety Issues
• Session 9: Trust Issues
• Session 10: Power/Control Issues
• Session 11: Esteem Issues
• Session 12: Intimacy Issues and Meaning of the Trauma
General Trauma Treatment
Goals/Interventions:
• Self-care/Self-awareness: traumatized clients are
great at knowing what others are feeling/ thinking,
but not as self-aware of internal feelings
• Install Affirming Tape (e.g., scriptural truths)
• Containment Strategies
• Scaling (0-10) and Pacing
• Reframe Flashbacks
Case Study: Tim
• 24 year old, Caucasian male
Background Information
• Recently completed his BA degree at a highly competitive
college
• No family in area
• “Engulfed” himself in studies until graduation, then entered an
“emotional tailspin”
• Very depressed for several months, with thoughts of suicide
• Recent psychiatric hospital stay for 3 days
• Entered intensive outpatient treatment immediately after
hospitalization
• Sexually abused from ages 5 to 7 by great uncle
Symptoms of Concern
• Depression
• Anxiety
• Sleep Disturbance: insomnia and nightmares
• Feeling “psychologically fragile”
• Intrusive disturbing thoughts of earlier sexual abuse
• Repression of abuse memories (until recently)
• Self-disgust and shame related to unwanted feelings of “anger
toward God” and sexual identity confusion
• Anguish
Tim’s Self-Stated Treatment
Plan:
• “I want to deal with my past demons”
• “I want true peace and redemption in the
Biblical sense”
• “I never want to be hospitalized again”
(symptom reduction)
Therapy Progression
• Increase healthy coping: relaxation training, breathing
exercises, scaling technique, maintain
sleep/nutrition/exercise/healthy socialization balance
(Sessions 1-3)
• Deeper work related to re-processing the abuse
narratives (Sessions 4-8)
• Growth: internal and relational (Sessions 9-12)
• Maintenance of Treatment Gains
Themes Addressed in
Therapy
• Self-discovery: guilt feelings related to abuse were preventing him
from pursuing his earlier goal of becoming an ordained minister
“The abuse has robbed me of my calling”
“[I’ve been held] emotionally and spiritually hostage for years”
• Anger toward his great uncle, grandmother, mother, and ultimately
God
Therapeutic Interventions and
Results
Therapeutic Technique: God image questionnaire
Result: Tim realized the disparity between what he objectively
believed about God and what he emotionally felt about God
Therapeutic Technique: Written Account of Abuse, “Empty Chair”
with scaling technique
Result: Read letter re: abuse, portion written to his abuser, and a
final portion written to God; Tim expressed his confusion
regarding why God allowed his abuse, told God he experienced
God as distant and uncaring when distressed re: sexual trauma,
and Tim asked God for help to understand this.
Therapeutic Interventions and
Results
• Bibliotherapy: Hinds Feet on High Places (from spiritual battle
to peace)
• Trauma Narrative: Tim ended his narrative with a redemptive
theme, stating, “What happened in my past, only drives me
closer to God.”
Posttraumatic Growth
Tim’s Goal: Forgiveness
• 5 Step Forgiveness Intervention Pioneered by Everett
Worthington, Jr. (e.g., Worthington, 2006)
• REACH
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Recall the hurt
Empathize with the one who hurt you
Offer the altruistic gift of forgiveness
Commit to forgive
Hold on to the forgiveness
One year later…
• Tim reported he was “holding on to forgiveness”
• No panic attacks or depression
• Attending seminary
• Dating a young woman (whom he later married)
Questions?
Presentation
www.GenesisAssist.com/2014MF
References
•
AACC’s Stress and Trauma Care training program. (2009). Forest, VA: American Association of Christian
Counselors.
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Allender, Dan (1995). The Wounded Heart: Hope for Adult Victims of Childhood Sexual Abuse. Colorado Springs,
CO: NavPress.
•
Borja, S. E., Callahan, J. L., Long, P. J. (2006). Positive and negative adjustment and social support for sexual assault
survivors. Journal of Traumatic Stress, 19 (6), 905-914.
•
Chard, K.M. (2005). An evaluation of cognitive processing therapy for the treatment of posttraumatic stress
disorder related to childhood sexual abuse. Journal of Consulting and Clinical Psychology, 73, 965–971.
•
Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating traumatic grief in children and adolescents. New
York, New York: The Guilford Press.
•
Courtois, C. A. (2010). Healing the incest wound: Adult survivors in therapy 2nd ed. New York; W.W.
Norton.
•
Courtois, C.A. and Ford, J.D. (2009). Treating Complex Traumatic Stress Disorders: An Evidence-based
Guide. New York, NY: The Guilford Press.
•
Foa, E. B., Keane, T. M. and Friedman (2000). Effective Treatments for PTSD: Practice Guidelines from the
International Society for Traumatic Stress Studies. New York, NY: Guilford Press.
•
Gil, E. (2006). Helping abused and traumatized children: Integrating directive and non-directive approaches. New
York, NY: Guilford Press.
•
Heegaard, M. (1992). When Something Terrible Happens: Children Can Learn to Cope with Grief . Minneapolis: MN:
Woodland Press.
References
•
Hathaway, W. L. (2003). Clinically significant religious impairment. Mental Health, Religion & Culture, 6(2),
113.
•
Helping Victims of Sexual Assault. Retrieved January 20, 2011, from
http://www.aardvarc.org/rape/about/howhelp.shtml
•
Langberg, Diane (1999). On the Threshold of Hope. Carol Stream, IL: Tyndale House Publishers.
•
Langberg, Diane (2003). Counseling Survivors of Sexual Abuse. Longwood, FL: Xulon Press.
•
McNiel, C. B. & Hembree-Kigin (2011). Parent-child interaction therapy (2nd ed.). New York: Springer
Science+Business Media.
•
Owens, G.P. & Chard, K.M. (2001). Cognitive distortions among women reporting childhood sexual abuse.
Journal of Interpersonal Violence, 16, 178-191.
•
Rape, Abuse and Incest National Network. (2009). Get Info. Retrieved January 20, 2011, from
http://www.rainn.org/get-information
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Resick, P. A., Galovski, T. E., Uhlmansiek, M. O., Scher, C. D., Clum, G. A., & Young-Xu, Y. (2008). A
randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic
stress disorder in female victims of interpersonal violence. Journal of Consulting and Clinical Psychology,
76, 243–258.
References
•
Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., & Feuer, C. A. (2002). A comparison of cognitive processing therapy
with prolonged exposure therapy and a waiting list condition for the treatment of chronic posttraumatic stress disorder
in female rape victims. Journal of Consulting and Clinical Psychology, 70, 867–879.
•
Resick, P. A., & Schnicke, M. K. (1993). Cognitive processing therapy for rape victims: A treatment manual. Newbury Park,
CA: Sage.
•
Scalies, E. (2014). The neurobiology of trauma and traumatic relationships. Christian Counseling Today, Vol. 20/3, 28-32.
•
Schulz, P. M., Resick, P.A., Huber, L.C., Griffin, M.G. (2006). The effectiveness of cognitive processing therapy for PTSD
with refugees in a community setting. Cognitive and Behavioral Practice, 13, 322-331.
•
Sweeney, D. (2014). The Neurobiology of Trauma: Use of Expressive Therapies with Children. Counseltalk Webinar
(aacc.net).
•
Tedeschi, R. G., Calhoun, L. G. (2004). Posttraumatic growth: Conceptual foundations and empirical evidence.
Psychological Inquiry, 15, 1-18.
•
TF-CBT Web . Retrieved from: http://tfcbt.musc.edu/
•
Virginia Sexual and Domestic Violence Action Alliance. (2005). Action Alliance Newsletters. Retrieved from
http://www.vsdvalliance.org/secPublications/newsletters.html
•
Walker, D. F., Reese, J. B., Hughes, J. P., & Troskie, M. J. (2010). Addressing religious and spiritual issues in trauma-focused
cognitive behavior therapy with children and adolescents. Professional Psychology: Research and Practice, 41, 174-180.
•
Walker, D. F., Reid, H. D., O’Neil, T. & Brown, L. (2009). Changes in personal religion/spirituality during and after
childhood abuse: A review and synthesis. Psychological Trauma: Theory, Research, Practice, and Policy, 2(1), 130–145.
Dr. Trina Young Greer
Trina Young Greer, Psy.D., Licensed Clinical Psychologist is the founder and
Executive Director of Genesis Counseling Center. Genesis is an
outpatient counseling group with multiple offices serving eastern
Virginia with comprehensive Christian counseling and psychological
services. She is the co-founder of Genesis Assist, a company dedicated
to assisting mental health providers in outpatient practice. Dr. Young
Greer obtained her Doctorate of Psychology degree from Regent
University and Ed.S. from The College of William and Mary. She is
recognized for her work with individuals struggling to recover from
sexual trauma, grief and loss issues, and anxiety disorders. She has
taught the course Psychology of Trauma at the graduate level. She has
also written a trauma training manual and provided training to first
responders in West Africa and the US.
• www.genesiscounselingcenter.com
• www.genesisassist.com