Trauma of Sexual Assault

The patient “Suzy” in this case study is a sexual assault victim, aged 28, married and female. She has 5 years of military service. Because of her military service, she was trained and disciplined in a culture renowned for praising strength and abhorring weakness. In the military, the code also centers on unity and spirit of mission. Soldiers who “betray” their fellow soldiers are seen as untrustworthy and can be ostracized and marginalized. Because Suzy was sexually assaulted while serving in the military, she did not report the assault, fearing that it would lead to her being labeled a bad soldier by the others. Instead, she attempted to cope with the assault and the trauma it caused her. In attempting to cope on her own, however, Suzy encountered depression, a loss of self-esteem and self-confidence; she developed a problem with substance abuse as well as with anxiety. She has stated that she has no real support network now that she is out of the military. She is not close with her family and her old friends all have families and jobs and do not offer much assistance. She has come seeking treatment both for her trauma as a sexual assault victim and for help with her substance abuse. She is a chain smoker (something she says she was not prior to her assault) and she has difficulty sitting still for more than a few seconds at a time.
As Ward (1988) notes, the psychological impact of sexual assault is such that it can deeply scar an individual. Ward categorizes the impact in three ways: psychological, behavioral and interpersonal: psychological maladjustment issues include “anxiety, withdrawal, restlessness, tension, insecurity and emotional instability,” while behavioral issues include lying, substance abuse, inability to hold a job, and interpersonal issues include “ambivalence toward family members and fear of men” (p. 619). Of these three, Suzy demonstrates no fear of men but rather a strong disgust towards any man who tries to show intimacy towards her; she has not tried to hold a job following her release from service and she is not inclined to do so; she has engaged in substance abuse and does demonstrate anxiety, restlessness, tension and depression. All of these signs indicate a strong psychological impact stemming from her assault. Suzy has no medical history of depression, anxiety, or substance abuse. Prior to her assault she says that she did not struggle with any of these issues.
Current treatment plans include cognitive behavioral therapy. Goals regarding looking for work and building out her social network have been identified and Suzy is currently trying to develop more of a support system by going to a local church for Sunday Services and getting to know the people there. However, she is reluctant to befriend many of them there and feels that they would not accept her if they knew about her assault. Billette, Guay and Marchand (2008) recommend that sexual assault survivors get spouses involved if possible to help increase the efficacy of the CBT—but Suzy has no spouse and is not interested in having one. She displays a sign of being unwilling to forgive herself for being a victim. She believes that she something did something wrong in being in a position where she was assaulted and she lives with this shame. It is evident that she needs to process her assault more deeply and trauma-informed care could be effective here in helping her (Elliott et al., 2005).
One theoretical explanation for this case is that Suzy’s emotional, social and esteem needs have to be re-addressed and met, according to Maslow’s theory of the hierarchy of needs and human motivation. She apparently went from being a self-actualizing individual to one who is stymied and now stuck at a lower level of motivation. She does not want to work, does not want to get to know others or allow others to get to know her, and is forever accusing herself and not demonstrating any willingness to accept herself.
To meet her needs and enable her to regain the level of self-actualization that she once possessed, trauma-informed care could be used to help her process her sexual assault, own it, and move on from it. Part of trauma-informed care focuses on the need of the counselor to empathize and show understanding to the patient so that the patient can see how the trauma from this incident has affected her outlook, her behavior, and her mind. By accepting the trauma and engaging with it, the processing of it can take place and the patient can begin to be unburdened by it. From there, CBT could be used more effectively.
The treatment plan I would recommend is to start with trauma-informed therapy and work with Suzy to a point where she is able to process the assault, forgive herself, accept it as part of her personal history and stop trying to hide it or hide from it. By accepting it, she can begin to relax and feel more at ease with her place in the world. Some contextual cues from her religion could be helpful in enabling her to process this assault, showing her that being a victim of a sexual assault does not make her a bad or immoral person. Once this trauma has been addressed in this way, the CBT could begin again with a new set of behavioral goals identified that will allow Suzy to avoid triggers or to address them in a positive manner that will prevent her from turning to the abuse of substances or falling into a pit of depression or a trap of anxiety. Suzy should also work on building out her support network by opening up to friends at church and allowing herself to discuss her past and her place in life.
References
Billette, V., Guay, S., & Marchand, A. (2008). Posttraumatic stress disorder and social support in female victims of sexual assault: The impact of spousal involvement on the efficacy of cognitive-behavioral therapy. Behavior modification, 32(6), 876-896.
Elliott, D. E., Bjelajac, P., Fallot, R. D., Markoff, L. S., & Reed, B. G. (2005). Trauma?informed or trauma?denied: principles and implementation of trauma?informed services for women. Journal of community psychology, 33(4), 461-477.
Ward, C. (1988). The psychological impact of sexual assault: case studies of adolescent victims. Singapore medical journal, 29(6), 619-623.