TITLE: BEST PRACTICES WITH SHORT THERAPIES IN A PSYCHOTRAUMA SETTING:
TRAUMA OF GRIEF AND LOSS FOLLOWING RAPE
THE 8TH ANNUAL PAN –AFRICAN PCAF PSYCHOTRAUMA CONFERENCE
Immacolata M. NyagaCounseling Psychologist
&PhD Candidate, University of Nairobi Nyaga Counseling Services, Adams Arcade
Email: [email protected]
It has been recognized that stressful life events
may cause emotional and behavioral effects. When
a threat to survival is received. Numerous brain
and body systems are activated and uncontrollable
stress is associated with elevated fear and anxiety.
Acute stress disorder resembles Post traumatic
stress disorder but symptoms persist for at least
two days but less than four weeks
INTAKE FORM Patient’s name, B.N Date: 10/6/2014 Source of referral: Social worker Kibera Informant if any: Mother and aunt
GENERAL DATA Age 18yrs Date of Birth: 1996 Sex: female Religion: Christian (SDA)Birth place: Nairobi Education: FORM IV
PRESENTING COMPLAINTS/MAJOR HEALTH
PROBLEMS
The patient presented with chest pain, abdominal pain
accompanied with vaginal discharge, crying, fear of
dying, feeling dizziness, headaches and fear of losing
control. She had disturbed sleep and was screaming due
to night mares, anxious, suspicious and hyper vigilant.
HISTORYOF PRESENTING COMPLAINTS
B.N was well until four weeks before she was attacked by
two men when coming from school. The men raped her
and threatened to kill if she screamed or reported to
anybody. A week later, she feared contracting HIV/AIDS
and developed chest pain that was worsening in the
evenings when family members came home. She had
disturbed sleep, night mares, fear of going to school and
poor concentration in school .
She thought of suicide attempt with an overdose of medicine when
she realized an offensive vaginal discharge but did not do it . On the
morning of 10th June 2014, she started screaming; talking things the
mother could not understand. The mother thought it was an attack of
Malaria and took her to a nearby health facility where she was
referred to Mathari psychiatric hospital but instead of going to
mathari mother and aunt sought psychological intervention.
FAMILY HISTORY:
B.N was from a family of 6 children and she is the 5th born. Three
of her siblings are working and they all related well with the
patient. Mother was 50 years, and a business woman. She related
well with her daughter. Father was 56 years, a driver and related
well with her daughter. Aunt was 40 years, a business woman and
the patient described her as a good friend and the only aunt she
could trust
PERSONAL AND DEVELOPMENTAL HISTORY
Prenatal/postnatal/Infancy; all was normal
Early childhood and adolescent; normal
SCHOOL HISTORY/ SOCIAL HISTORY
She started nursery school at the age of 5years and joined standard one
at the age of 7years then completed standard eight at the age of 13 years
and attained grade C+
She joined form one in 2006
At the time of interview she was in form IV, did her National
examination four months later and attained grade C+. Due to the
rape trauma she went through, she related poorly with parents,
siblings and friends. She was frequently reported crying and
quarreling with siblings and students. She was suspended for two
weeks from school due truancy and she withdrew from most of the
activities she used to enjoy. (Going to church)
Hobbies- she liked playing netball before the illness.
Religious involvement-she was an active member in her church
youth group before the illness
SUBSTANCE ABUSE: None FORENSIC HISTORY:
None
PREMORBID PERSONALITY/.EXTENDED
INFORMATION
She was a shy person. The mother and the aunt reported B.N had
been experiencing some stress which she was not telling the
family members. In exploring what issues in her life could have
made her not reveal the problem, she reported fearing HIV/AIDS
death.
MENTAL STATUS EXAMINATION
Appearance: was clean and kempt. Behavior: she was crying, coiling herself on the chair.She was very suspicious.Speech: fluctuating from low tone to high Pitched tone and not coherent Mood: sad Affect; was mood congruentPerception: had visual perceptual hallucinations (seeing two men following her) Thought process (form): Her thought was illogical and not coherent She had suicidal thoughts and wanted to kill herself by climbing the top of the building when she excused going to the toilet. Delusion- she had a strong belief she was going to die after one month
Cognitive functions:
Consciousness: she was conscious and hyper vigilant
Orientation: oriented in time, place and Person: she was aware the
assessor was a counselor.
Attention and concentration was low, she answered only two digits
of serial seven. Memory: Immediate memory: Good -she was asked
to repeat three words after the therapist
Abstract: was good she was able to complete a Kiswahili proverb
“Hapa Na hapa”Judgment: was good -She was asked what she could
do in case of a burning house and she answered correct
Insight: poor
MULTI-AXIAL DSM-TR DIAGNOSIS
Axis I - Acute stress disorder
Differential –Major depressive episode after rape trauma
Axis II -None
Axis III -Sexually transmitted infection (STI)
Axis IV -Environmental slum stress
Axis V -51-61
INDIOGRAPHIC (PERSONALISED) DIAGNOSTIC
FORMULATION:
B.N is an 18 years old female who presented with a 4 weeks history
of chest pain, abdominal pain accompanied with vaginal discharge,
crying, fear of dying, feeling dizziness, headaches and fear of losing
control. She had disturbed sleep and was screaming due to night
mares. Suspicious and hyper vigilant. On MSE the patient had
persecutory hallucinations and delusion, and suicidal attempts. A
diagnosis of acute stress disorder with a differential of major
depressive episode following a rape trauma was ruled out.
Differential diagnosis: Major depressive episode
Etiological possible factors:
(i) Predisposing factors; social circumstances of loss of her
virginity
(ii) Precipitating factors: fear of contracting AIDS and loss of
virginity through rape
(iii)Maintaining factors: loss of social and family dignity
(iv) Protective factors: family support especially from mother and
aunt
Collaborative management/confidentiality
Drug therapy -This was carried by a psychiatric Nurse at the
health facility
Laboratory investigations
Pre-counseling-Voluntary counseling and testing (VCT) was done
then post counseling
Blood for HIV- Non reactive
Investigations done by therapist
More information was gathered from aunt and mother who had a
session with therapist. An assessment by psychometric instrument-
Becks anxiety inventory to measure how the patient had expressed
as common symptoms of anxiety =54 scores that indicate severe
anxiety (severe is from 44+) Impact of events scale-revised, to
asses current subjective distress for any specific life
event=Intrusions 1, 2, 3,6 6,9,19,20= 11 scores
Avoidance 5,7,8,11,12,13,17,22= 13 scores
hyperarousal4,10,14,15,18,19,21=19
total scores=43 scores This indicated moderate range of anxiety
PSYCHOLOGICAL MANAGEMENT
Session 1:10/6/2014
Psycho education was given to the mother and aunt on acute stress
disorder following a traumatic event of rape. The mother was very
worried that her daughter had contracted HIV/AIDS She wanted her
tested for HIV. She was explained that BN would have VCT after she
gained insight.
Ten sessions of trauma focused cognitive behavior therapy (TFCBT)
was planned with the patient.
Relaxation techniques involved
i) Progressive muscle relaxation
Ii) Deep breathing exercises
The patient was explained the importance of the exercises. It was
demonstrated and both patient and therapist did them together.
Social coping skills
Assertiveness was explained to the patient to be able to
communicate and interact positively with her environment
Session 2: 15/6/ 2009:
Cognitive behavior therapy -Gradual exposure
Patient was clean, calm but drowsy.
She reported she was feeling better and she had insight.
On MSE the concentration was fair and her perception was good, no
more of persecutory hallucination and delusions, neither did she have
suicidal thoughts. TFCBT was introduced to the patient.
The theoretical basis was explained on how TFCBT works on
thoughts, feelings, and behavior and how each element influences the
other psychologically. To help the client open up, the therapist started
with a statement:
I know how difficult it is to talk about painful things, especially to
people that you don’t know well but whatever you tell the therapist
will be treated with a lot of confidentiality
Using TFCBT by applying empathetic listening, the client was
able to talk a little about the rape event then she broke down into
tears. Stress inoculation therapy (SIT) through progressive muscle
exercise was done to help her relax and reduce the physiologic
manifestation of stress. Patient thanked and session ended.
Session: 3 30/6/2014
Gradual exposure continued
MSE Patient was good. She had insight of her problem and wanted
help. She reported improvement and feeling better. She wanted to go
back to school but was explained that she had to go through a few
sessions until the symptoms subsided and recommended fit to go to
school. Gradual exposure was introduced and the patient was able to
come out with a short narrative of the rape without crying. She was
encouraged to try and talk about it many times. The mother reported
the patient was requesting to be bathed by her
The request was challenged by confronting the mother to prevent
dependency. The patient was given home work that involved putting
down in a paper about all the types of negative thoughts she would
experience within the two weeks duration for the next session. The
session ended with a deep breathing exercise
4th session7/7/2014
Setting goals
The previous session was reviewed and the thoughts she came out
with were discussed (I feel ashamed I could have screamed for
help) This was challenged by helping the patient understand that
she is able to work diligently and practice changing herself defeating
beliefs by examining them and engaging in behavior that allows her
to confront her fears. A 2nd Home work was given to the patient to
write a narrative of the rape event in a kind of a letter. She was
helped to set four goals towards her healing process.
(i) Her first goal was to go back to school and concentrate
with her studies
ii) To be courageous to Test for HIV and be ready to face the
consequence of the results
(iii) To pass through the road where she was attacked every
day she comes from school but in the company of others
(iv) To identify all the feelings and name them to enhance
safety
Voluntary counseling and testing:
This was done by VCT counselor
She was counseled and tested for HIV and was comfortable to
reveal the results to the therapist without being requested. It was
repeated after three months and was negative
5th Session 12/8/2014
Thought processing continued
The patient appeared very low. She was crying. she verbalized feeling sad.
In exploring the feelings on what lead her to cry. She reported
to have thought people knew about her rape event. Thought
stopping was done through stress inoculation technique to
short circuit the vicious cycle which typically occurs in
traumatized rape survivors that leads to cognitive distortions.
She was helped to learn to make constructive self-statements
by learning to observe her own behavior then replace the
negative thoughts with positive ones like “I am still myself
and I must move on with my life. “Yes I can” She was taught
to blow a balloon as a technique of thought stopping any
time she had an intrusive thought. She reported this
technique to have helped her.
6th Session 1/9/2014
Rape narrative exposure
B.N came alone that day. She appeared calm and clean. On
MSE nothing abnormal was noted. She had gathered courage to
walk alone. Her mother had requested to be notified when she
arrived at the clinic, which was done. A review of the previous
session was done.
In exploring on the fears, she was able to narrate verbally about
the rape event and promised to write it down like a story. This
was very encouraging.
Patient was helped to continue on thought processing by
making more constructive self-statement done by taking a
particular situation that was problematic for her and pay
particular attention to the automatic thought then do an
internal dialogue. The session ended with a deep muscle
relaxation exercise.
Session 7:15/9/2014
TFCBT narrative Continued
A review of the previous session on cognitive processing for the
patient to completely dismantle in-accurate and unhelpful thoughts
was done .She gave out a written narrative of the rape ordeal, she felt
relieved after she wrote the narrative.
She was encouraged to use coping skills that she had learnt in therapy
to focus on what is positive instead of the negative aspects of any
given event. A letter recommending her back to school was issued and
she was informed of a near future termination.( Narrative in the
patients file).
Session 8:24 /11/2014
The patient was dressed in a smart dress
She reported a great improvement and had started her form IV
national examination. On MSE nothing abnormal was noted. She
reported the use of progressive muscle exercises before starting the
examinations and any time she felt a symptom of anxiety and it
worked well. A review was done on the following before she was
prepared for termination.
Rape: was discussed and she was allowed to ask questions
Rape trauma and the survivor, HIV related distress, guilt and
shame
Safety measures: behavior seeking help. The client’s feelings
and thoughts were explored. She reported she would talk about
rape to many girls if requested to.
Termination was discussed and entered to, but there was room to
see the therapist in case of need but with a prior arrangement.
The mother and patient were thanked for the efforts they made to
therapy and the aunt for the support she gave to the client
Session9:31/1/201
Supportive therapy
Three months after termination the mother and the patient rang
the therapist. They sounded very excited
The mother requested to give thanks to the therapist because the
daughter had passed her national examination with a grade of
C+. The therapist was so motivated by her client.
END