CBT Case Conceptualization for Childhood Sexual Abuse and PTSD

Introduction and Presenting Concerns

The client is a 26-year-old economics student who has been plagued for many years by feelings of guilt, sadness, and anxiety that he relates to a history of sexual abuse he suffered at the hands of an adult worker on his father's plantation beginning when he was six years old. At the time of this case conceptualization it is not known how long the abuse lasted, but the client has indicated that it was ongoing for some unspecified length of time.

The client is the oldest child in a sibship of three (one younger brother and one younger sister). He has never confided in his family about his childhood experiences of abuse. He reports that his father was an alcoholic and that he could not confide in him because of this. The client has experienced feelings of low self-esteem, depression, guilt, poor motivation, and confusion regarding his childhood traumatic sexual abuse. He still has significant anxiety regarding these experiences and cannot confide in others. He is unsure as to where his life should go and in what direction he should head, even though he is an honor student. The client seeks treatment in order to more effectively deal with this past abuse, increase his feelings of self-worth, be able to identify and relate with others, and get on with his life.

Case Conceptualization and Diagnostic Considerations

In a sport like archery or target shooting, it is virtually impossible to reach the goal of hitting the target — let alone the bull's-eye — unless one can actually see the target. Likewise, it is difficult to treat an individual in counseling without a diagnosis. A solid diagnosis is like having a target in that it allows the clinician to map out an effective treatment program for the individual. Without a solid diagnosis, a counselor can fall into the trap of treating symptoms instead of a syndrome. Symptom management is part of the treatment but is much more effective when the management of symptoms is conceptualized as a syndrome, or a diagnosis of symptoms that hang together (Resick & Miller, 2009). The client has experienced a significant trauma early in his development, and it is with this trauma that the counselor should begin to conceptualize his case.

This is a complex case consisting of a number of potential diagnostic considerations. The most obvious would be a diagnosis of Posttraumatic Stress Disorder (PTSD). Given the client's history and presenting symptoms, this is also the most useful diagnostic consideration. The symptoms of the case are not yet well-defined, and there are several things one would need to consider before making a formal PTSD diagnosis. The major facets of the clinical presentation of PTSD include four broad criteria: (a) the witnessing or experience of a stressful event; (b) painful re-experiences of the event (dreams, recollections, flashbacks, etc.); (c) patterns of avoidance and emotional numbing; and (d) nearly constant hyperarousal (American Psychiatric Association [APA], 2000). One of the defining features of clinically significant PTSD is the intrusive re-experience of the trauma or traumatic event. These re-experiences are more than just memories; they are often experienced as distressing and invasive because the person has no control over when, how, or where they will occur (e.g., flashbacks, dreams, etc.). The intrusive re-experiences also elicit strong negative reactions associated with the initial trauma (Horowitz, 2001). It would be important to determine whether the client is indeed experiencing these symptoms and would meet diagnostic criteria for PTSD. It is estimated that well over 50% of children who are sexually abused will meet the criteria for a PTSD diagnosis, and upwards of 80% of these children continue to experience PTSD-like symptoms into adulthood even if they do not meet the full diagnostic criteria (Merikangas et al., 2010; Sadock & Sadock, 2007). Therefore, the effects of the client's trauma can be treated in a similar manner to the treatment for PTSD clients even if he does not meet every diagnostic criterion. However, if he does have PTSD, the specific flashback experiences would also be a focus of treatment.

There is also the issue of the client's relationship with his father, who he reports is — or was — an alcoholic. Other than this, the client does not supply much information about that relationship; however, there may be some type of abusive dynamic with his father as well. This is something that will need to be explored as his treatment continues. It is notable that the client stated he could not confide in his father due to his father's alcoholism. Substance dependence alone is not a typical reason for a child to feel unsafe in confiding in a parent — and, in fact, a six-year-old son would most likely not label his father as an "alcoholic." Moreover, why did he feel unsafe confiding in his mother? There are probably several other complicated issues regarding the client's relationship with his parents that would need to be explored and uncovered in therapy.

Finally, the client appears to have developed a negative view of himself, the world, and the future — the classic cognitive triad of negative beliefs identified by cognitive theorists (Beck, Rush, Shaw, & Emery, 1979). Counseling should address these negative beliefs and attitudes and have the client test them through discussions in sessions and the use of homework assignments. Once the counselor identifies these beliefs, the client can be helped to concentrate on more rational and realistic beliefs about himself, other people, and his future.

PTSD: Conditioning, Family Variables, and Treatment Context

PTSD is a disorder typically conceptualized in terms of both classical conditioning and operant conditioning mechanisms working in unison (Keane et al., 1985). There are also identified family variables and personality variables that appear to function as risk factors for PTSD (Koenen, Stellman, Stellman, & Sommer, 2003; Nugent, Tyrka, Carpenter, & Price, 2011; Yehuda et al., 2010). In addition, family therapy has been shown to be useful in treating PTSD patients (Cloitre, 2009). In this case it would be best to discuss how the client wishes to include or not include his family in the therapeutic process. The therapist would need to fully explain the benefits and disadvantages of including them in treatment. Family therapy has been demonstrated to be effective in treating PTSD and the effects of trauma, and it would be important to offer the client this option even if he does not initially wish to involve his family. Given his history of not confiding in his father, the current case conceptualization is constructed under the assumption that he does not want to pursue family counseling initially, though this option will remain open to him.

Currently the client is isolated, avoidant, and perhaps experiences hyperarousal — especially regarding relationships with others. It is unclear at this time whether he is experiencing any type of flashback or recurrent dream regarding his experiences. However, the client does exhibit some symptoms of PTSD. Therefore, it would be useful to conceptualize this case as one of PTSD-like symptoms related to the experience of early sexual abuse. These presenting symptoms include the aforementioned concerns as well as issues with self-esteem, depressive symptoms, anxiety regarding his past and in developing relationships, amotivation, and difficulties with trust. The symptoms of depression and anxiety are most likely associated symptoms of his trauma-related issues. It has long been understood that anxiety and depression are symptoms associated with nearly every psychiatric disorder (Hoch, 1972); therefore, these symptoms can be treated in concert with an overall treatment plan aimed at helping the client deal with his trauma, his dysfunctional thoughts, and the low self-esteem associated with his past trauma and adjustment.

Other issues of concern are the client's use of alcohol or drugs (if any), his ability to develop intimate relationships with others, and his overall self-image. It is important for the client to understand that he will never totally forget his past traumatic experiences, but he can change the way he views himself and the way he thinks about these experiences going forward. The event cannot be erased from his memory or personality, but he can learn how to forgive, understand his reactions to these experiences, and view those reactions in a different light.

Conclusion

The client is a young man experiencing distress as a result of sexual abuse he underwent as a child. The choice of a cognitive behavioral approach to treat the symptoms of trauma and/or PTSD is the preferred approach (e.g., APA, 2000; Cloitre, 2009; Resick et al., 2008; Sadock & Sadock, 2007). It is hoped that the client will be able to accept the past, forgive the perpetrator and his family, and learn to identify and alter the dysfunctional and negative cognitions that he automatically engages in as a result of his reaction to his childhood experiences. The cognitive behavioral approach will result in a corrective emotional experience, and he will be able to move forward in a more positive manner — identifying positive goals and no longer being burdened by memories of this experience.