Running head: SHORTENED VERSION OF TITLE

Special Topics Paper: PTSD / Treatment for Survivor of Sexual Assault

Brian Mann
Wake Forest University

Special Topics Paper: PTSD

Introduction
According to a survey conducted by the US Department of Justice involving national
crime victimization statistics, in 2006 in the United States, a total of 260,940 rape/sexual assault
victimizations were reported to the police, of which males accounted for an estimated 26.2% or
68,366 of the victims (Willis, p454). However, it is thought that male rape is under-reported.
Men who have been raped may believe that it attacks the very essence of what it is to be
masculine and male. They may also feel that a survivor who cannot fight back may be seen to be
homosexual or less of a man by others, including helping resources. There is evidence to show
that this is a valid concern for the victim to be further traumatized in environments in which he
should feel safe, such as emergency departments, police stations, or at home. Reports on this
phenomenon have emanated from the experiences of survivors who received negative responses
from people to whom they turned for help, such as the police, doctors, nurses, counselors,
friends, and family members. As a result, many may not seek help unless they perceive a need
for immediate attention, such as physical trauma requiring medical assistance (Ellis, p34-5).
The existing research about male sexual assault survivors suggests that they experience
many distressing psychological aftereffects: fear, helplessness and powerlessness, anger and
irritability, anxiety and posttraumatic stress symptoms such as flashbacks and intrusive thoughts,
self-blame and shame, guilt, interpersonal relational problems, social isolation/withdrawal,
substance abuse, suicide ideation and self-harm, depression, sexual identity/sexual orientation
confusion, and sexual dysfunction (Willis, p458). Although this crime is likely under reported,
the impact it leaves on victims is apparent. In the United States, projected lifetime risk for PTSD
is 8.7%, with twelve-month prevalence among U.S. adults being about 3.5%. Highest rates are

Special Topics Paper: PTSD

found among survivors of rape and military combat (American Psychiatric Association, p276).
This paper explores the current literature on treating PTSD as a result of male on male sexual
assault, and provides a case study of a fictitious client and the treatment plan created for him.
Review of literature
Many studies have documented the efficacy of pharmacotherapy and psychotherapy for
posttraumatic stress disorder (PTSD). A meta-analysis of pharmacotherapy for PTSD showed
that more patients responded to medication (59.1%) compared to placebo (38.5%). However, the
best evidence and treatment guidelines suggest trauma focused psychotherapy is more effective
and should be considered a first line treatment for PTSD (Powers et al., p636).
Recent meta-analyses were focused on the efficacy of specific psychological treatments
for PTSD. Seidler and Wagner (2006) compared seven studies of trauma-focused cognitive
behavioral therapy (CBT) to EMDR. The results showed that both treatments were effective with
no significant differences between treatments. In an analysis of 33 studies, Bisson and Andrew
(2007) demonstrated that trauma-focused CBT, EMDR, stress management and group
trauma-focused CBT were more effective than non-trauma focused treatments at reducing
PTSD symptoms. In a similar study, Bisson et al. (2007) analyzed 38 studies on traumafocused CBT, EMDR, stress management, and group CBT. Results indicated that traumafocused CBT and EMDR were more efficacious than waitlist/control on most outcome
measures; however, the evidence for EMDR was not as strong. (Powers et al., p 636)
Benish et al. remarks that in their recent analysis, Bisson et al. (2007) noted that many
psychotherapies (viz., TFCBT, EMDR, stress management, and group CBT) were consistently
superior to wait list or usual care controls, except for other therapies which did not differ from

Special Topics Paper: PTSD

controls. Bisson et al. concluded that other therapies, which consisted of an assortment of
treatments including hypnotherapy, psychodynamic therapies, supportive therapies, and nondirective counseling, were the least efficacious of the treatment categories and that EMDR and
TFCBT were the most efficacious. Importantly, Bisson et al. (2007) urged caution interpreting
the conclusion because of the considerable unexplained heterogeneity observed in these
comparisons (Benish et al., p747-8).
Substantial evidence supports efficacy of several specific psychological treatments of
PTSD, including prolonged exposure (PE), eye movement desensitization reprocessing (EMDR),
stress inoculation therapy, trauma management therapy, cognitive therapy, and others (Bisson &
Andrew, 2005; Bisson et al., 2007; Bradley, Greene, Russ, Dutra, & Westen, 2005; Van Etten &
Taylor, 1998), but consensus does not exist with regard to the relative efficacy of these
treatments (Benish et al., p747).
In summary, there is ample evidence to show that psychological treatments of PTSD are
effective. However, due to the complex nature of this disorder and how the many studies vary
with regard to participants, outcome measures employed, treatment standardization, treatment
length, severity of disorder, and multiple unmeasured variables, it is unclear exactly which
treatment approach stands as the most effective. The meta-data suggests that trauma focused
treatments are among the most effective.
Case study: Paul
Paul is a 34 year old white male. He was raised in a rural area of North Carolina,
and is employed as a maintenance mechanic for a utilities company. He is married to Martha, his
wife of 4 years. They have no children, but hope to have some in the future. Paul grew up poor

Special Topics Paper: PTSD

and had a very unstable childhood. He and his older brother were exposed to physical abuse at
the hands of several step-fathers and were taught to take it like a man. Now he stands 6 feet
tall, weighing 165 and has a wiry build. He dresses in casual clothes but appears neat and clean.
Paul is courteous and quiet but generally has a friendly demeanor.
Paul was attacked and sexually assaulted while he was in a remote fishing cabin, about 18
months ago. This left him traumatized and feeling disgusting and un-manly. He kept this secret
from everyone until recently. Following the attack he has had diminished sexual interest and has
avoided intimacy with Martha. He did not disclose his sexual assault to Martha until last month.
Martha reacted to this news with sympathy and concern for him, but at the same time it has
fueled dis-trust in him. She now is constantly checking his phone and e-mail accounts for
evidence of cheating. She confided to him that she feels like he will leave her because he is no
longer attracted to her. She is haunted by the similarity between her own marriage and that of her
parents which ended in her fathers cheating and ultimately divorce.
Paul feels like a worthless husband. He has been absent from work often lately and has
little drive to go to work, and he has serious doubts that he and Martha will ever get back to
normal. He has come to counseling for help to resolve his marital problems, and for help getting
his life back on track.
Conceptualization and treatment plan
Paul has internalized the trauma associated with the sexual assault in the same way that
he was taught as a child. This coping strategy is not working for him. Instead, it has created
secondary problems that he is now responding to. Pauls willingness to share this very private

Special Topics Paper: PTSD

event with Martha and to take action by coming in for counseling shows that he is moving from
the contemplation stage to the preparation stage of change readiness.
A Biopsychosocial interview indicates that Paul has symptoms consistent with a
diagnosis of PTSD unspecified. This is supported by the following: He was exposed to actual
traumatic sexual violence; he has had recurrent involuntary and intrusive distressing memories of
the traumatic event; persistently avoids distressing memories and external reminders that arouse
distressing feelings about the event; he has markedly diminished interest in significant activities;
a persistent negative emotional state focused on shame and guilt; inability to feel positive
emotions associated with intimacy and sexuality; problems with concentration; hypervigilance;
these disturbances have existed for more than one month; the disturbance causes clinically
significant distress in social, occupational or other areas of functioning; the disturbance is not
attributable to the physiological effects of a substance or another medical condition.
Objectives of treatment will include short-term, mid-term and long-term goals that he
wants to achieve. These will be determined collaboratively, but will be built on the foundation of
his ability to access and process the trauma, express his feelings; increase his coping
capabilities; reduce cognitive distortions and self-blame and restoring a more positive selfconcept.
Assessment: First priority for this client is to make sure he is in a safe environment,
which he is. He will be assessed for suicide. He will also be assessed using the ClinicianAdministered PTSD Scale (CAPS) and will be assessed in terms of his coping skills and
strengths. Additionally, a recommendation for physical examination will be made to assess
whether any physiological issues exist which may have resulted from the assault.

Special Topics Paper: PTSD

Clinician characteristics: Beyond setting conditions of warmth and positive regard,

empathy and consistency in building Pauls trust, a safe and secure environment must be
established in which Paul can regain a sense of control and empowerment. Providing
psychoeducation about common reactions to trauma and navigating the fine line between his
vulnerability and resilience will be important.
Location: Paul currently lives at home and is in no immediate danger to himself or to
others, so outpatient therapy is appropriate.
Intervention approach: The approach to be used with Paul is Cognitive Processing
Therapy (CPT), which is a combination of exposure based therapy along with cognitive
restructuring.
Emphasis of treatment: An authoritative emphasis will be taken with Paul to as we
structure activities designed to recall the assault and its ensuing trauma, and as we set goals for
change in his behavior. This will be handled delicately so as not to re-traumatize him, but rather
to allow him gradually reduce the anxiety and change its meaning as he recalls the event over
and over. Paul will develop improved coping skill through a therapeutic emphasis on support by
challenging his take it like a man approach and other maladaptive beliefs then replacing them
with healthier ways of dealing with the trauma. For example we will use written recollections of
the event to facilitate the his exploration of his feelings, responses and understanding of what has
happened to him, what strengths he has and how he may be able to restructure his view of the
event in order to regain the quality in his life.
Numbers: The modality recommended for Paul is individual counseling with family
counseling as a support.

Special Topics Paper: PTSD

Timing (frequency, pacing, duration): Paul will be encouraged to attend weekly 50

minute sessions for individual CPT counseling for 12 weeks, then frequency will be re-evaluated.
Family sessions will be bi-weekly for the first month, then monthly.
Medication: Many different medications have been effective in treatment of symptoms
related to PTSD. In Pauls case the role of medication will be discussed, and if requested, he will
be referred to a psychiatrist for a medication consultation.
Adjunct services: Martha in particular seems to be adding to his concern through the way
she is reacting to her own fears of marital failure. Helping Paul and Martha together to process
what has happened; develop effective communication and increased mutual empathy; and to
develop support skills for each other, will be helpful to them both. Couples counseling is
recommended as an adjunct service.
Prognosis: With treatment, Pauls prognosis for recovery is good. He was functioning
positive before his trauma; and he has a strong social support network of friends. These two
factors are associated with successful recovery; however, Paul will need to be informed that
relapses are not uncommon.
Advocacy, multicultural and legal/ethical issues
The widespread prevalence and substantial adverse effects of sexual assault on female
victims have been well documented. Although relatively less attention has been paid to
understanding the male victims of this same crime, a limited but growing body of literature has
begun to provide evidence of the presence and negative consequences of male sexual assault.
(Peterson et al., p2)

Special Topics Paper: PTSD

Studies of MSA have primarily focused on Caucasian males, with limited data available
on men from different ethnic backgrounds. Therefore, we have little idea how someone from a
different ethnic group or culture may respond psychologically to MSA (Campbell & Vearnals,
p284).
In summary, there is a need for further research in the area of male on male sexual assault
in terms of the impact on victims, the efficacy of treatment for PTSD related to sexual assault,
the differences among males of various cultures. In the US, it seems to be treated as a taboo
subject, likely due to the same reasons for it being under reported crime. Bringing light to this
issue, and discovering new, improved ways to facilitate healing for victims is a worthy cause.

Special Topics Paper: PTSD

10
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