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: mathiga@yahoo.com

 

 

 

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