My field placement is with the Office for Violence Prevention and Victim Assistance (VPVA) on the Rutgers University College Avenue campus. VPVA serves students seeking advocacy and counseling for sexual assault or harassment, domestic violence, stalking and childhood sexual abuse. VPVA clients are often dealing with the response to trauma in a way that negatively impacts their academic and social functioning.
I will refer to the client described here as Anna. Anna is a female identified, 21-year-old, Caucasian Rutgers senior who was sexually assaulted by a camp counselor at the age of 14. She came to VPVA on the suggestion of a friend following the Joe Biden rally. The rally, where sexual assault was the topic, was a trigger for Anna. In the days following the rally, she experienced a downward spiral that culminated in cutting behaviors. She hadn’t relied on cutting behaviors for several years, and as a result she went to Counseling and Psychological Services in crisis. While they were able to admit her into a 30-day program at Early Intervention Support Services (EISS), she felt the services were less trauma-informed than she needed.
Anna was adopted by her mother as an infant. She is Russian in heritage but has lived in the United States her entire life. She has not shared anything with me regarding the circumstances of her biological family. Her adoptive mother lives in New Jersey. She has a difficult relationship with her mother, but they do talk and see each other regularly. Anna does not have an adoptive father. Her mother has diagnosed with an illnesses that at one point required Anna to live at home to assist her with day-to-day living. Anna has some resentment towards her mother for that lost time, but also credits it for the break she needed between her hospitalization and the transfer of academic work to Rutgers. Anna’s environment and socio-economic status provided her all the basics she needed to thrive. She does make reference to the fact that she lacks a warm, nurturing relationship with her mother, however, which I see as a potential contributing factor to her struggles. Anna is in a relationship with a man and he knows of the sexual assault, although not in detail. She is afraid to share it with him for concern he will not understand why it impacts her so deeply. Several of her friends know of the incident and her diagnoses and have been supportive.
Anna cites her first traumatic experience of significance as the sexual assault that occurred at sleep-away camp. While it may not be appropriate to consider adoption trauma, I suspect that there is some unresolved pain associated with that experience and her subsequent development. In long-term therapy it would be appropriate to dive into that topic, however I will be focusing on the traumatic incident that brought her to VPVA and Anna’s current goals. Anna does not have any additional developmental history factors or experiences that she has cited as contributing to her functioning issues. In fact, she cites the sexual assault as a turning point that shifted her outlook and ability to trust others. She doesn’t recall a time when she was cynical or negative prior to the assault, or that she felt particularly distrusting of others prior to that time. That shift has resulted in a general lack of hope about the future, a sense that others do not want to engage with her, that she is a burden when she shares her feelings or needs to talk, and that she is not managing life well generally.
Anna managed her depression and anxiety until the end of her sophomore year of college when she was hospitalized for suicidal ideation. She was then formally diagnosed with major depressive disorder, severe, and generalized anxiety disorder. Anna reports that Xanax was the only of many medications prescribed that were effective in the management of her anxiety and depression. She stopped taking them prior to transferring to Rutgers and hasn’t felt a need for medicinal intervention until now. At EISS, she was prescribed a mood stabilizer for bi-polar/manic episodes, but not formally diagnosed as such, and Lexapro. Anna reports the most effective self-soothing techniques she engages in are cutting behaviors and food restriction.
Anna was diagnosed with Major Depressive Disorder Severe and Generalized Anxiety (American Psychiatric Association, 2013) at the age of 19 following hospitalization due to cutting behaviors and suicidality. According to the American Psychiatric Association (2013), the symptoms of Major Depressive Disorder Severe include depressed mood that is a clear difference from regular mood, for more than two weeks; impaired social, educational or occupational functioning; and at least five of the following occurring every day: depressed mood most of the day every day, decreasing interest in activities, weight and/or appetite changes, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness, diminished ability to concentrate on tasks, and suicidality. At the time of diagnosis, Anna was exhibiting all the symptoms, therefore meeting the criteria for a diagnosis of severe. In terms of Generalized Anxiety Disorder, Anna meets the criteria of excessive anxiety and worry that is difficult, if not impossible, to control more often than not for six months, a feeling of being on edge, fatigue, inability to concentrate, irritability, tension in the body, and inability to sleep that is severely distressing and interrupts social and occupational functioning (American Psychiatric Association, 2013).
Her most current diagnosis, chronic Posttraumatic Stress Syndrome (PTSD) with delayed onset, is a result of having been exposed to a traumatic experience, avoidance of anything related to the trauma, and at least three of the following that cause impairment in various levels of functioning for over a month: avoidance of the trauma in discussion, feelings or thoughts, activities, places, people or things; inability to piece together a narrative or recall important aspects of the event; lack of interest in activities; detached feelings; inability to feel full range of emotions; loss of hope; interrupted sleep behaviors; anger or irritability; inability to concentrate; hyperarousal; and startled responses when unnecessary (American Psychiatric Association, 2013). In addition to the symptoms that correlate with her diagnoses, Anna has a general negative outlook that functions as a defense mechanism, difficulty getting close with people, feeling like a burden but craving social connection, and difficulties with sexual intimacy.
Anna is very intelligent. She is bright and engaging when she is feeling well, and has a great sense of humor. Anna has manifested resilience throughout their life. She managed to graduate high school and attend her first year of university even after experiencing a sexual assault that she never sought help to deal with at the age of 14. Following her hospitalization and subsequent suspension from her previous university, she helped her mother navigate an illness that left her homebound. During that time, Anna applied for and was admitted to Rutgers University after having failed two semesters. She is now in her final year and has done well academically. Anna holds an important position with an organization related to her career path on campus and a part-time job. She has been in a relationship for two years and has a core group of supportive friends. Finally, despite her negative experiences in therapy, Anna sought out help from more than one organization. She clearly has courage and is determined to find a way to make improvements in her life.
Anna’s adoption and lack of a nurturing relationship with her adoptive mother has come up several times in session. She laments the lack of support by her mother. She also indicates that several of her mother’s behaviors contribute to her own anxiety level, and she often makes decisions based on how she believes her mother will react. Anna has not told her mother about the assault, mainly because she fears her response will be blaming. Although she hasn’t reported experiencing overt abuse, Anna does report parental hostility and is exhibiting what Teyber and McClure (2017) describe as a fearful attachment style. Anna’s attachment issues likely contribute to her fear of sharing intimate information with others or asking for support, as she has been shown that doing so tends to result in dismissal. In an analysis of 46 studies, Woodhouse, Ayers and Field (2015) found that for survivors of trauma, attachment styles determine the intensity of posttraumatic stress disorder (PTSD) symptoms. They found that high anxiety attachment, such as fearful attachment styles, are strongly correlated to persistent PTSD symptoms (Woodhouse, Ayers & Field, 2015).
The sexual trauma has caused Anna to further lose trust that she can be safe with or obtain support from others. What’s more, Anna believes she is to blame for the assault and therefore cannot trust herself. Self-blame can function as a way to feel some control in a situation where there is none, however it fuels feelings of shame and vulnerability (Miller, Handley, Markman & Miller, 2010). The feelings associated with self-blame also tend to increase social withdrawal (Miller, Handley, Markman & Miller, 2010). In the past, Anna’s social withdrawal has led to increased distress and hospitalization. She believes that she has no control over her distress, and that failure is therefore inevitable. The vicious cycle feeds itself and diminishes any hope for relief.
The main treatment goal for my work with Anna is to help her to curb cutting and food restriction as a coping mechanism. The second treatment goal formulated with Anna is to address her self-blame for the sexual assault.
Interpersonal interactions during session are touch-and-go. Anna doesn’t talk a lot, but has complained that other clinicians don’t engage her and just sit and stare. I try to find a balance between giving her space to think and respond, and continuing the discussion so we can address all her concerns and pressing issues each week. She tends to shoot down all discussion of alternative coping skills in the moment, only to come back several sessions later with a more open mind. She does get easily triggered, and when that happens she completely disassociates. These interactions indicate that she may be difficult to engage and negative around friends and family, which I imagine is frustrating for them and they may give up trying to reach out or help her, leaving Anna with a sense of abandonment and burden.
The therapeutic relationship has been difficult to build but we have made progress. In our first session, and without even knowing it, I provided Anna with a corrective emotional experience (Teyber & McClure, 2017) as she detailed her cutting behaviors. I asked her how it made her feel, what purpose it served and mirrored back those responses. Anna informed me that the psychologist she saw earlier that week at EISS told her to promise she was going to go home and throw away her cutting kit. There was no discussion of what might replace that coping mechanism, only what Anna perceived as a judgmental command. In the past therapists told her cutting is a maladaptive tool that keeps her from having closeness with others. Providing validation and an empathetic response, I was able to show Anna that not all therapy experiences are negative.
To build trust, I began the process of academic advocacy. I contacted Anna’s professors to request excuses for recent and future absences and extensions without penalty on assignments and tests. This process showed Anna that I believed her trauma was real and impactful, that I was willing to do everything I could to help, and that she could trust me to follow through. At one point, we had a frank interaction that I believe was the turning point in our relationship. She said that all her options for moving forward academically, therapeutically, in terms of personal relationships, all suck. In a moment of what I felt as frustration, I replied “yes, all of these options suck, but what is the least sucky option?” This made her open up to me in ways she hadn’t before. She felt validated in that moment, and I realized I was only just now succeeding in building the necessary foundation and the validation needed to move forward.
At one point in our work I suggested Anna write a letter to the perpetrator, not to mail to him, but to express her anger in a way she hadn’t before and turn those feelings out towards him and away from herself. She decided it would help her more to write a letter to the camp where the assault occurred. She did, and decided to mail the letter in hopes of making a difference for a camper that might be experiencing what she did. We discussed the ways that mailing the letter might impact her, and ultimately, she followed through. When the camp responded with a very serious email, she had an anxiety attack. What I thought might be an exercise that could provide her some relief and a perspective shift turned out to be harmful to her progress. This rupture in our alliance, while not entirely my doing, felt like a failure to me. I discussed it with her bluntly, letting her know that I felt I had made that suggestion too soon in the process and that I hope we can work through to the other side of this bout of anxiety by moving at a slower pace.
Recently we have begun to incorporate aspects of Dialectical Behavioral Therapy (DBT) and Cognitive Behavior Therapy (TF-CBT) into session. I informed Anna that we would discuss the activities involved prior to attempting them and she could provide feedback about her experience or general interest in the activity. I requested her honesty about where she is mentally in session, and what she feels she is capable of doing outside of session.
CBT and DBT are shown to be effective treatment modalities for Anna’s diagnoses of major depression, generalized anxiety and posttraumatic stress syndrome and her specific goals (Bohus et al., 2012; Beck, 2011). Considering the little time I have to work with her, and my lack of training, I see the process of building a strong therapeutic alliance as the most impactful aspect of both methods.
Created by Marsha Linehan, Dialectical behavior therapy (DBT) was devised as a treatment for border line personality disorder (BPD), a biological disorder that manifests in invalidating environments and results in an inability to regulate emotions, and suicidality (Linehan, 1998). Linehan describes BPD as (Linehan, 1998). DBT is a form of cognitive-behavioral therapy that integrates acceptance of where the client is at emotionally and cognitively (Linehan, 1998). DBT is unique from CBT in its approach because it does not simply focus on changing the client and their way of thinking, but incorporates acceptance with the push for change through teaching new skills and increasing motivation to use those skills to create balance (Chapman, 2006). Validation of emotions and thoughts, particularly with survivors of trauma, is an important component in building the therapeutic alliance and facilitating healing (Chapman, 2006). Support and guidance in the process of change is equally important, but one cannot be effective without the other (Chapman, 2006). DBT has also been shown to help those engaging in maladaptive coping behaviors, such as cutting behaviors and food restriction, by replacing those coping mechanisms with adaptive skills that ultimately become second nature (Bohus et al., 2012; Chapman, 2006; Linehan, Bohus & Lynch, 2007). Like all other methods of therapy, the steps of DBT begin with creating a safe space and strong therapeutic alliance (Chapman, 2006).
Because I am not trained in the employment of DBT, and my client is not ready to address the trauma verbally, I use applicable components of DBT including mindfulness and acceptance-oriented interventions. There are several worksheets in the Marsha Linehan DBT Skills Training Manual (2015), shared with me by a co-worker, that are applicable in session with Anna. For instance, exploring alternatives to cutting and food restriction as coping mechanisms is done with the use of the distress tolerance worksheets that facilitate crisis survival skills, such as the five senses activity to self-soothe, and the TIP skill to change the body chemistry (Linehan, 2015). In our second session we started with the five senses activity to ground her and alleviate anxiety. Anna closed her eyes and I asked her to think of what living her best life will look like. I asked her to visualize it, describe her surroundings to herself, the physical feeling, the smell and any tastes she associates with the vision. This worked well in that session, and I asked that she try that in the future when she feels the triggers that lead her to overwhelming anxiety. She reported later that she was able to use this in class when discussing a novel that triggered anxiety.
The TIP skill was something we discussed specifically to address the cutting. Anna sees the cutting behaviors as the most powerfully effective coping mechanism for her anxiety. She describes a building up of anxiety, that leads to thoughts of cutting, and culminates in the behavior. The temperature portion of the TIP skill, using cold water, facilitates what Linehan (2015) describes as a dive response, which slows the heart and redirects blood to the brain, allowing for the regulation of emotions.
Two other aspects of DBT that have been helpful with this client are the pros and cons skill and the check the facts skill (Linehan, 2015). At one point, Anna was feeling so overwhelmed and stuck that she felt she couldn’t face anything. We worked through ways to take a break, and made a pros and cons list that outlined how taking a break from classes, work and family would positively and negatively impact her. This process, while seemingly straight forward, was surprising helpful and ultimately encouraged her to take a break that allowed her to make some important decisions. She kept the list, and indicated that she will modify it as needed for future decisions. I often use the check the facts skill (Linehan, 2015) with Anna in session when it comes to immediate stressors, like deciding to apply to graduate school even with some semesters of low grades. We have also used that skill when discussing the future in general in an attempt to build hope for the future of her relationships and career.
Cognitive Behavior Therapy (CBT) is a brief therapy that focuses on how thoughts are the root cause of feelings and behaviors, and that by modifying thoughts, clients can feel better and behave more productively (Beck, 2011). Anna and I have used CBT in session to focus on her goal of shifting the blame for the sexual assault away from herself. For instance, because Anna identified her enjoyment of writing early on in our work, I provided her with a copy of the thought journal handout from McKay, Davis and Fanning (2011) to use when she starts to spiral due to self-blame. Anna was hesitant at first, but ultimately used the worksheet when she took a trip with her boyfriend’s family. She admitted she felt worried about not having the option of cutting during the trip, and when she felt the urge she started writing. The journal allowed us to pinpoint some of the situations that cause her to spiral, the most prevalent being the anxiety of sitting with her thoughts without distraction.
Anna reports that when she thinks about the assault, she tends to feel anger at herself for having “put herself in that position” and spirals into destructive feelings of low self-worth and stupidity. She believes that at 14 years old she should have been stronger, smarter, less easily influenced, and that because she was not that she is never going to reach her goals. Using the thoughts journal, we began to test core beliefs about the assault, her worth and her potential. She is convinced that she will never have her ideal life because she “messed up” before, therefore she has no faith in her ability to handle things in the present or future. We are currently working through this process, but there have been shifts in the way she talks about her future goals.
Professional Use of Self
Performance anxiety, something common in new practitioners (Teyber & McClure, 2017), has impacted my work with Anna. I find myself anxious, unsure of how her mood might dictate the way the session goes. I often worry that I will contribute to her lengthy negative history with therapy, and diminish any remaining hope she has that she can find relief from her symptoms.
Anna is not talkative, and tends to turn inward and get quiet when she is anxious. This happened a lot more in our first sessions than it has recently, but it made getting to know her and understand her concerns very difficult. I led the discussion far too much in those early sessions, and have since learned how to give her space and time to open up. Rather than forcing the conversation, I often respond to her movements or facial reactions during those moments. That has served the process in that she sees I am not just looking past her and waiting, but really understanding who she is through those visceral reactions.
An issue of countertransference I have experienced with Anna is that she reminds me of my brother. Her cynical sense of humor and general negative outlook is similar to his, and I find myself wanting to save her from herself much like I want to help my brother. I have had a strained relationship with my brother in the past, and interacting with Anna has made me recognize similar feelings in anticipation of our meeting to those I have when I have interacted with my brother. I have recently mended the relationship, which was an important step in leaving those feelings behind and out of the therapy room. I must remind myself that I am aligned with Anna in progress towards her goals, not saving her from herself.
A challenge I have run into is my own frustration at Anna’s generally negative perception of the world. At times her cynical view is understandable, her dark humor funny, but for the most part it is a defense mechanism that is nearly impenetrable, making treatment and progress difficult. The connections and progress we make in a session is largely determined by her mood that day, how open she is to discussion and suggestions, and whether something triggers her in session. The triggers also change. In some sessions she invites discussion about issues or topics, while in others she has an immediate physical reaction to that same topic. It has made my work with her challenging, but I reaffirm that she is in charge of the process and we will only go to places she is ready to go, and focus on the goals we have set. I have started to ask her “What would you like to process or discuss today?” after doing a quick mood check and update from our last interaction. Thus far this has helped the process go more smoothly, as she feels comfortable telling me how she is feeling and what is most bothersome to her in that moment.
My work with Anna has been challenging, but there has been measurable progress. DBT has aided her in adopting new ways to cope that do not harm her body or put her at risk for hospitalization. She has lingering doubts about her role in the sexual assault and a continued diminished ability to trust others, and depending on the circumstances in her life she may have continued intermittent anxiety and depression. However, Anna is now able to identify when she starts to fall down the hole of self-blame. She may never fully trust others again, but continued therapy will be helpful in transforming some of her negative thinking and provide her with the validation and support she seeks.