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Journal of Child Sexual Abuse
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A Case Study of Social Cognitive
Treatment of PTSD in a South African
Rape Survivor: The Central Role of Case
Formulation
Anita Padmanabhanunnia & David Edwardsb
a University of the Western Cape, Bellville, Cape Town, South Africa
b Rhodes University, Grahamstown, South Africa
Published online: 06 Mar 2015.
To cite this article: Anita Padmanabhanunni & David Edwards (2015) A Case Study of Social Cognitive
Treatment of PTSD in a South African Rape Survivor: The Central Role of Case Formulation, Journal of
Child Sexual Abuse, 24:2, 174-194, DOI: 10.1080/10538712.2015.997412
To link to this article: http://dx.doi.org/10.1080/10538712.2015.997412
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Journal of Child Sexual Abuse, 24:174–194, 2015
Copyright © Taylor & Francis Group, LLC
ISSN: 1053-8712 print/1547-0679 online
DOI: 10.1080/10538712.2015.997412
A Case Study of Social Cognitive Treatment of
PTSD in a South African Rape Survivor: The
Central Role of Case Formulation
ANITA PADMANABHANUNNI
University of the Western Cape, Bellville, Cape Town, South Africa
DAVID EDWARDS
Rhodes University, Grahamstown, South Africa
This is a systematic case study of the psychological assessment
and treatment of Zinhle (19), a Black South African student
with posttraumatic stress disorder, following a rape at age 10.
Treatment was based on Ehlers and Clark’s (2000) cognitive ther-
apy, a flexible formulation driven model. The study documented
the secondary trauma experienced by families following child sex-
ual abuse and showed how treatment not only needed to target the
trauma memory but also the ruptured relationships within and out-
side the family. This was done within the framework of Tarrier and
Humphreys’s (2004) social cognitive model. At the end of treatment
Zinhle no longer met criteria for PTSD, and the narrative supports
Ehlers and Clark’s model as well as the social cognitive model.
KEYWORDS childhood sexual abuse, cognitive therapy,
posttraumatic stress disorder, social support, systematic case
study, South Africa
This is a systematic case study of the psychological assessment and treat-
ment of Zinhle (19), an isiZulu speaking Black South African survivor of a
single episode of rape that occurred when she was 10 years old. The study
illustrates the secondary trauma experienced by families as they confront
Received 9 September 2013; revised 8 September 2014; accepted 11 September 2014.
Address correspondence to Anita Padmanabhanunni, Department of Psychology,
University of the Western Cape, Private Bag X17, Bellville, Cape Town, 7535, South Africa.
E-mail: apadmana@uwc.ac.za
174
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Social Cognitive Treatment of PTSD in Rape Survivor 175
child sexual abuse (CSA) and highlights the importance of case formula-
tion in planning treatment of posttraumatic stress disorder (PTSD) and the
significance of enhancing social support in promoting recovery.
In South Africa a wide range of legislative commitments to chil-
dren’s rights and well-being were made by the postapartheid government
(Proudlock & Jamieson, 2007). Legislation related to CSA is currently cov-
ered in the Criminal Law Sexual Offences and Related Matters Amendment
Act (32). In terms of the act, reporting of CSA is mandatory, and CSA is
defined as any sexual act that results in the exploitation of a child. It includes
noncontact CSA, including exposure to pornography, suggestive behavior,
or sexual comments directed at the child and contact child abuse, including
genital penetration, oral sex, or encouraging the child to perform sexual acts
on the perpetrator.
Despite legislative commitments to protecting children, the country is
still characterized by high rates of CSA. Estimating the actual prevalence of
CSA in South Africa is complicated by high rates of underreporting. Only 1 in
9 of all rapes are reported to the police. According to South African Police
Statistics (SAPS), the ratio of reported rape is 144 per 100,000 of the popula-
tion. One in 6 of all reported rapes involve girls below the age of 12 (Seedat,
Van Niekerk, Jewkes, Suffla, & Ratele, 2009). The majority of rapes against
children are perpetrated by someone known to the victim, with a minority
of assaults perpetrated by a family member (Smith, Bryant-Davis, Tillman,
&Marks,2010). For children, disclosing rape to parents or the police can
lead to further harm, particularly in situations where the perpetrator lives
in close vicinity to the victim. Children are often revictimized by the per-
petrator as punishment for having reported the abuse (Van Niekerk, 2004).
In some cases, the perpetrator might be the primary breadwinner, and the
threat of the removal of financial support can deter disclosure. Furthermore,
children and their families who report sexual assault experience ostracism
within their communities, and fears around being shunned or disgracing
their families can deter reporting (Richter & Dawes, 2008). Self-blame and
related feelings of guilt and shame represent another obstacle to disclosure.
Another barrier in estimating the prevalence of rape is related to poor
management of rape cases by the SAPS. In a study conducted in the Western
Cape Province, Richter and Dawes (2008) found that in 82% of cases of
rape recorded by the police, the age of the victim was not noted in the
case docket. In addition, very few large scale or systematic studies have
been conducted on the prevalence of CSA, with the majority relying on the
recollection of young adults (Smith et al., 2010). Owing to differences in the
definition of rape, it is not possible to provide a comparative analysis of
prevalence rates, and such an analysis is beyond the scope of this paper.
CSA in South Africa is typically opportunistic, and girls who are
neglected or live in circumstances characterized by high levels of poverty
are often the most vulnerable (Padmanabhanunni & Edwards, 2013). Smith
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176 A. Padmanabhanunni and D. Edwards
and colleagues (2010) point out that in community settings parents typically
must travel long distances to work and children are often left at home with
limited supervision. In many cases, children are cared for by a social, rather
than a biological, mother, such as a neighbor, relative, or friend of the par-
ent, and this represents a significant factor influencing vulnerability to harm.
High rates of unemployment and associated feelings of helplessness and
frustration can lead to punitive behavior toward children, including abuse.
Overcrowded living conditions and shared sleeping quarters can mean that
children are exposed to adult sexual activity. In such conditions, co-sleeping
of children and adults or with older children may create circumstances for
abuse. Richter and Dawes (2008) point to the problems caused by alcohol
and substance abuse in disadvantaged settings and how this can hinder a
parent’s ability to identify when abuse is occurring or engage in protective
behavior.
CSA frequently gives rise to PTSD (Kaminer, Grimsrud, Myer, Stein, &
Williams, 2008; Walker, Carey, Mohr, Stein, & Seedat, 2004). PTSD is a debili-
tating condition in which memories of the trauma intrude into consciousness
uninvited producing marked distress. These flashbacks often represent “hot
spots”—parts of the traumatic event that elicit the most distress on recall and
that are associated with salient cognitive themes (i.e., problematic appraisals
of the traumatic event and/or its sequelae). This term has been widely used
in the literature on the treatment of PTSD in the United Kingdom (e.g., Ehlers
& Clark, 2000; Grey, Young & Holmes, 2002; Ehlers et al., 2010). If unad-
dressed, such PTSD symptoms can persist into adulthood and compromise
the survivors’ daily functioning and their capacity to sustain meaningful
relationships (Kaminer et al., 2008).
The quality of social support available to children posttrauma influences
their vulnerability to PTSD (Ford & Courtois, 2009). Lack of social support
for traumatized children is widespread in South Africa, owing to adverse
social circumstances including poverty, substance abuse, and community
violence (Kaminer & Eagle, 2010). Often, children who are abused grow
up in dysfunctional family environments in which significant others may be
perpetrators or simply ineffectual as support providers due to their own
experiences of trauma (Vranceanu, Hobfoll, & Johnson, 2007). Even where
social support is available posttrauma, problematic trauma-related appraisals
of both the child survivor and her or his significant others can create an
interpersonal climate that impedes recovery (Tarrier & Humphreys, 2004).
Sexually abused children often believe that they are unworthy of protection
and care and feel guilty and ashamed about the abuse. This inhibits them
from disclosing or conversing about the traumatic experience. Parents, too,
may experience feelings of shame, guilt, anger, and powerlessness (Grosz,
Kempe, & Kelly, 2000) and may doubt their competence as caregivers, attri-
butions that affect the quality of support they actually provide their child
(Salmon & Bryant, 2002).
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Social Cognitive Treatment of PTSD in Rape Survivor 177
Several of these factors were prominent in the case of Zinhle who had
been raped at a neighbor’s house at the age of 10. Although her parents had
confronted the perpetrator and laid a charge against him, Zinhle believed
they blamed her for the rape. Several subsequent events exacerbated these
feelings, and, in addition to suffering from PTSD, she became depressed.
Despite this, Zinhle did well at school and in her final year won a bursary
to study at university and relocated to another province. However, hearing
about the violent death of the rapist precipitated an intensification of her
PTSD, prompting her decision to seek treatment.
METHODOLOGY
This is one of a series of systematic case studies that examined the transporta-
bility of Ehlers and Clark’s (2000) cognitive therapy (CT) for PTSD to South
African conditions (Edwards, 2010,2013). Systematic case study research is
a mixed-methods approach in which qualitative data documenting the pro-
cess of assessment and treatment are supplemented by data gathered from
the repeated administration of self-report measures. Fishman (2005) sets out
principles for writing what he calls a pragmatic case study, which has formed
the basis of case studies in the online journal Pragmatic Case Studies in
Psychotherapy. Bare reporting of facts and numbers can defeat the ends of
clinical research in that findings are not communicated to practitioners in
a manner that gets the message across. The pragmatic case study format is
a way of addressing this communication problem while remaining rigorous
and systematic.
McLeod (2010) recommends that the case narrative in such a study
should be written in “a way that allows the reader to enter into the lived
experience of the therapy” (p. 103). It should, therefore, “contain enough
unique detail to allow the reader ... to gain as reasonably comprehen-
sive appreciation of how this particular therapy helped this particular client”
(p. 100). There should be an emphasis on drawing out the nature and char-
acteristics of the therapeutic relationship, and this should include “author
reflexivity” (p. 112), which means presenting aspects of the author’s experi-
ence at particular moments in the therapy. Information should be included
about the client’s experience of the therapy and perspective on its helpful-
ness. There should also be “sufficient discussion of the theoretical, clinical,
and research background ...to allow the reader to decide about the general-
izability to other, similar clients and about the wider implications of the case
(p. 100). At the data reduction phase, the aim is to generate a phenomenolog-
ically trustworthy narrative account of the assessment and treatment process.
To do this, the researcher engages with the session recordings and transcripts
not from a purely objective stance but from one of “empathic hermeneutics”
(Smith & Osborn, 2003,p.51).
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178 A. Padmanabhanunni and D. Edwards
Narratives are constructed to include information that is typically lost
in attempts to be objective without going beyond what a listener with a
“psychological attitude” (Giorgi & Giorgi, 2003, p. 49) would hear in the
recordings. The aim is to achieve “thick descriptions that include the detail,
complexity, context, subjectivity, and multifaceted nature” (Fishman, 2013,
p. 406) of the experiences being presented. These are intended to com-
municate to readers in a manner that is “compelling” and that “discloses,
transforms and inspires” (Finlay, 2011). The narrative is supplemented by
self-report measures that track changes in symptomatic reactions across
sessions, evaluate the impact of specific interventions, and provide an addi-
tional source of data relevant to assessing treatment effectiveness (Young &
Edwards, 2012). In line with the principles of phenomenology, this was not
just a bare description but one that explicated the ongoing experience of the
client (and to some extent the therapist) without going beyond what would
be obvious to a psychologically minded observer (Finlay, 2011).
Participants
Participants were sought through advertising, which included posters in pub-
lic places and through clinical services at Rhodes University. Respondents
were screened by interview to determine suitability: inclusion criteria (age
>14, meet DSM-IV-TR [American Psychiatric Association, 2000] criteria for
PTSD related to the rape, and understand English) and exclusion criteria
(suffering from psychosis). Ten women responded to the advertisement, and
seven were selected based on the criteria.
Zinhle was referred by the latter, and the referral suggested she met
criteria for inclusion in this branch of the study (diagnosis of PTSD following
rape). Zinhle was educated in English and was fluent in the language. She
signed written consent to participate in the project in terms of ethical proce-
dures approved by Rhodes University. She was assessed and treated by the
first author under the supervision of the second author.
Intervention Model
Treatment was based on Ehlers and Clark’s (2000) CT, which has been shown
to be efficacious in treating PTSD (Ehlers, Clark, Hackmann, McManus, &
Fennell, 2005). It is a flexible, formulation-driven treatment model, manual-
ized at the level of principles but not on a session-by-session basis (Ehlers,
Hackmann, & Michael, 2004). In an assessment phase, the clinician works
with the client to gather information about: (a) the nature of the trauma
memory and the extent to which it is fragmented or coherent, (b) emo-
tionally charged hot spots, and (c) problematic cognitive-behavioral coping
strategies that are contributing to the maintenance of symptoms. The clinician
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Social Cognitive Treatment of PTSD in Rape Survivor 179
also provides psychoeducation about PTSD and the mechanisms underlying
the disorder as well as a rationale for treatment.
In the treatment phase, the aims are to help clients discriminate triggers
that elicit reexperiencing, to reduce reexperiencing through further elabora-
tion of the trauma memory, to modify excessive negative appraisals of the
trauma, and to help the client drop dysfunctional coping strategies, especially
those that result in avoidance of triggering of the trauma memory. A central
feature of treatment is promoting the client’s vivid experiential engagement
with the trauma memory in imagination. This is referred to as “reliving”
(Ehlers & Clark, 2000; Ehlers et al., 2005; Ehlers et al., 2004; Ehlers et al.,
2010) and serves to identify problematic peritraumatic appraisals (appraisals
made during the trauma). These can be addressed through cognitive restruc-
turing and imagery rescripting within reliving (Arntz, Tiesema, & Kindt, 2007;
Grey et al., 2002). Once the trauma memory has been reprocessed in this
way, the client no longer experiences flashbacks and hyperarousal and does
not resort to avoidant coping.
Data Collection and Reduction
Zinhle attended nine sessions. The first four (60 minutes each) constituted
the assessment phase (A1–A4) as they predominantly focused on gathering
information. The remaining five (60–90 minutes each) were treatment ses-
sions (T1–T5). The four assessment sessions took place over a two week
period, and the following data was collected.
SESSION RECORDS
During each session of assessment and treatment, the clinician took notes,
which she summarized afterward. These included information relevant to
the process of assessment and treatment planning, observations of her
experience of the session, and observations of the client’s process.
AUDIO RECORDINGS AND TRANSCRIPTS
Voice recordings were made of all sessions, which were transcribed verbatim.
One transcript, randomly selected by an independent assessor, was evaluated
against the audiorecording. No distortions or omissions were reported.
SELF-REPORT SCALES
The following self-report scales were administered repeatedly during the
assessment and treatment process: the Posttraumatic Diagnostic Scale (PDS)
Part 3 (Foa, Cashman, Jaycox, & Perry, 1997), which comprises 17 items
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180 A. Padmanabhanunni and D. Edwards
assessing the nature and severity of PTSD symptoms; the Beck Depression
Inventory (BDI-II: Beck, Steer, & Brown, 1996), which is a 21-item measure
of clinical symptoms of depression and anxiety respectively; and the Beck
Anxiety Inventory (BAI; Beck & Steer, 1993), which is a 21-item measure of
clinical anxiety. All of these have been widely used with English-speaking
people in many parts of the world and found to be clinically valuable with
English speakers of all ethnic groups in South Africa (Young & Edwards,
2012).
SUPERVISION NOTES
The clinician took notes on issues discussed and suggestions made during
regular case supervision. These data sources were used to generate the fol-
lowing data reductions: An assessment summary (step 1), including case
history and diagnosis. These served as a basis for a case formulation and
treatment plan (step 2). The treatment itself (step 3) formed the basis for
a comprehensive treatment narrative, written as a first person account by
the therapist, based on the principles set out for pragmatic case studies.
Finally, at step 4, scores on the self-report scales were presented graphically
(see Figures 1–3). These reductions, presented in detail in Padmanabhanunni
(2010), have been abbreviated for the present article.
24
12
6
0
0
10
20
30
A2 T2 T3 T5
PDS
FIGURE 1 Zinhle’s PDS scores. Symptom scores: 1–10 =mild; 11–20 =moderate; 21–35 =
moderate/severe; 36–51 =severe; assessment sessions (A); treatment sessions (T).
0
5
10
15
20
A2 T2 T3 T5
BDI-II
FIGURE 2 Zinhle’s BDI scores. Symptom scores: 0–7 =normal; 8–15 =mild; 16–25 =
moderate; 26–63 =severe; assessment sessions (A); treatment sessions (T).
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Social Cognitive Treatment of PTSD in Rape Survivor 181
21
19
00
0
5
10
15
20
25
A2 T2 T3 T5
BAI
FIGURE 3 Zinhle’s BAI scores. Symptom scores: 1–13 =minimal; 14–19 =mild; 20–28 =
moderate; 29–63 =severe; assessment sessions (A); treatment sessions (T).
THE ASSESSMENT
Assessment Sessions A1–A2: Building a Narrative of the Trauma
Initially, Zinhle was anxious and ambivalent about sharing her story. To reas-
sure her, I offered psychoeducation around the process of psychotherapy
and explained that I mostly worked with survivors of rape and knew it was
painful to share such distressing memories. I also emphasized that I wanted
to help her cope with what had happened. With a sigh of relief, Zinhle said
she had been “waiting for someone to say that [to her] for a very long time”
and began to tell me what had happened in detail.
At the age of 10, one evening after school, Zinhle visited her neighbor’s
home on an errand for her mother, and just as she was about to return home,
the neighbor’s son (age 25) indicated he wanted to share some news and
led her to the backyard. He then violently pulled her into a stationary van
and started pulling off her clothes. Frightened and confused, Zinhle tried
to escape but the doors were locked. The perpetrator then reached for a
plastic bag, which he used as condom, before raping her. Zinhle screamed
and banged on the doors of the van. Mandla (8), her brother, eventually
heard her screams and ran to her. Although he could not grasp what was
happening, he went to the neighbor’s house, demanding the van be opened.
Once it was open, Zinhle rushed out, ran home, and hid in her room fearing
the rapist would follow her. Later, Zinhle did not respond to her mother’s call
to supper. Her mother found her hiding under her blankets in the bedroom,
and although she asked if something was wrong, Zinhle told her she was
not hungry and was tired and wanted to sleep. Her mother stayed for a few
minutes and Zinhle worried that she could sense something was wrong. The
next morning, she scrubbed herself clean and threw away her blood stained
clothing.
The following day after school, Mandla insisted that she tell their mother
about the incident. Once she had done so, he ran to his room and isolated
himself for the remainder of the day, leaving Zinhle feeling alone. When her
mother angrily admonished her for not disclosing the incident immediately,
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182 A. Padmanabhanunni and D. Edwards
Zinhle felt hurt, ashamed, and confused, believing her mother blamed her
for what had happened. Zinhle’s mother immediately informed her husband.
Her parents confronted the perpetrator’s father who dismissed their story
and told them they would never be able to prove it. Then they accompanied
Zinhle to the hospital for medical attention. They, subsequently, visited the
police station where Zinhle’s parents encouraged her to report the rape.
The perpetrator was arrested but later released on bail. At home, Zinhle’s
parents were cautious around her and avoided speaking about the rape
in her presence. Although she now tentatively believed that they had not
wanted to distress her further, at the time she had felt isolated, desperately
needing comfort and care.
Three months later, the case went to trial, and the perpetrator was
acquitted, and the community accused Zinhle and her parents of having
fabricated the rape to obtain money from their wealthy neighbor. Zinhle’s
parents, subsequently, had her live with a relative in another city for six
months, and she now tentatively believed this may have been to prevent
her from being further distressed. At the time, however, she assumed that
her parents blamed her for the rape, and she felt abandoned. Once Zinhle
returned home, her parents “acted as if nothing had happened,” avoided
any discussion of the CSA, and discouraged her three siblings from broach-
ing the subject. Feeling confused and hurt, she withdrew from her family.
Fearing encounters with the perpetrator, she avoided venturing outside the
home without her parents. At age 12, she tentatively disclosed the CSA to a
female friend who responded with support, a response that surprised Zinhle.
However, she still felt unable to broach the topic with her family, fearing they
would react by admonishing and rejecting her.
As she told me all this, Zinhle became more and more distraught, and I
acknowledged the pain she had suffered, reassured her that the trauma was
over, and thanked her for her willingness to share her story with me. Feeling
calmer, she told me about the guilt and shame she felt because she believed
her parents blamed her for rape. I experienced sadness for Zinhle and her
parents, as it was evident that the rape had devastated their family. I believed
that Zinhle’s parents had responded supportively by believing her and taking
active steps to protect her, but their distress and uncertainty around how to
respond to her had inhibited them from providing the emotional support
she had needed. I explained the impact of CSA on the parents of victims and
how it can be traumatic for them and evoke feelings of shock as well as guilt
and helplessness around not having protected their child. I also suggested
that from the evidence of their behavior it seemed they did not blame her but
were distraught and angry that she had been hurt and wanted to ensure the
perpetrator was held accountable. Zinhle then started crying, saying she had
never considered that her parents might also have been deeply wounded by
her victimization.
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Social Cognitive Treatment of PTSD in Rape Survivor 183
She later shared her confusion around the silence they had maintained
around the abuse. I suggested that it was possible that her parents, like many
other people, did not know how to cope with a traumatic event or how best
to support a child exposed to CSA and might have believed that speak-
ing about the trauma would compound the family’s distress. I expressed
my shock and sadness at the community’s response following the trial and
reflected on the sense of alienation and stigma her parents had also experi-
enced. Zinhle was tearful as she remembered how she and her mother had
often avoided venturing into the community. In tears, she spoke of want-
ing to rebuild her ties with her family and repair some of the damage that
had been done. I offered my encouragement for this, and Zinhle indicated
she would begin by connecting with her two older sisters, as it seemed less
daunting. Both of them had left home when she was 14 to pursue their
careers.
Assessment Sessions A3–A4: Building Social Support and Further
Psychoeducation
At A3, Zinhle excitedly reported that she had contacted her eldest sister and,
despite feeling anxious, tentatively shared her longing to establish a closer
relationship with her. To her surprise, her sister apologized for not taking
the initiative in connecting with her, and Zinhle felt encouraged to share
her university experiences. I emphasized that here was evidence that her
family cared for her and did not blame her for the abuse. At A4, Zinhle
reported being badly shaken by a nightmare of the rape scene involving
being trapped in the van. She had another dream where the perpetrator
approached her seeking forgiveness, which left her angry and distressed,
because she could not conceive of forgiving him for harming her family.
I provided psychoeducation around triggering and PTSD to normalize her
experience. Although relieved, she expressed concern about whether “it was
possible to ever recover from PTSD.” I explained that PTSD could be treated
and that this would involve processing the trauma memory by visualizing
the traumatic episode and vividly describing what had occurred.
DIAGNOSES, CASE FORMULATION, AND TREATMENT PLANNING
Zinhle met DSM-IV-TR (American Psychiatric Association, 2000) criteria for
chronic PTSD. Her PDS score of 24 is in the moderate to severe range for
PTSD symptoms, and her BAI of 21 represents a moderate level of clinical
anxiety. She had first met criteria in the months following the rape and had
felt intensely frightened by intrusive memories, as she did not understand
what was happening to her. Her intrusions took the form of flashbacks trig-
gered by the sight of vehicles similar to the one in which the rape occurred,
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184 A. Padmanabhanunni and D. Edwards
venturing into the backyard of her house, as it resembled the perpetrator’s
yard, and looking at the perpetrator’s house. She had also found it distress-
ing to travel in the school bus, as the seats were similar to the ones in the
van where the rape occurred. Throughout adolescence, Zinhle experienced
intermittent flashbacks and nightmares and coped by trying to avoid triggers
and distracting herself.
She also met criteria for major depressive disorder (chronic, mild). Her
BDI-II score of 17 is in the mild range. Her first episode occurred after the
rape, and her symptoms were aggravated by the perpetrator having been
acquitted, stigmatizing responses from the community, and her assumption
that her family blamed her. Since the time of the rape, Zinhle had also felt
sad and hurt, believing she was to blame for her family growing apart. After
hearing of the perpetrator’s death, she also started to feel guilty because
she had always wished for him to die and believed that she had somehow
contributed to his murder.
Zinhle was raised in a loving and caring home environment and felt
particularly close to her parents and three siblings. Her rape at age 10 devas-
tated her family, and, not knowing how to cope with the trauma, her parents
responded by avoiding speaking about it, assuming this would protect the
family from further distress. The unexpected backlash from the community
compounded the family’s distress and left them stigmatized and alienated.
Zinhle interpreted her parent’s behavior to mean they blamed her for the
trauma, and she felt hurt and rejected and grew distant from them. She sup-
pressed memories of the rape and assumed that others would reject her
if they knew about the rape. This contributed to her being socially isolated
and lonely. Avoidant coping strategies inhibited the processing of the trauma
memory and maintained her PTSD.
The treatment plan had two main parts. The first was to help her face
and process the memory of the rape, using the standard procedures of CT.
The second, which she had already made a start on, was to support her in
rebuilding her relationships with family members.
THE THERAPY PROCESS
Therapy Session T1: Addressing PTSD
Zinhle wanted to work on processing the trauma, as she now had a better
sense of the mechanisms underlying her intrusions and felt less threatened.
I prepared her by explaining that reliving had the potential to be harrowing
but that her distress would not be indefinite. I then invited Zinhle to draw
a layout of the perpetrator’s house and backyard and then guided her to
imaginally relive the memory. She reported that as the van door was being
pried open by the perpetrator’s brother, the rapist had quickly dressed and
hurriedly left the vehicle on the other side. Once her side of the vehicle was
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Social Cognitive Treatment of PTSD in Rape Survivor 185
open, Zinhle started crying, and Mandla noticed she was not fully clothed
and, assuming she had been involved in some tryst, started mocking her.
Ashamed, she fumbled with her clothing and ran home. The next day Mandla
continued to mock her and later insisted that she disclose the incident to their
mother.
After the reliving, Zinhle reported feeling unnerved but surprised that
she had been able to cope with speaking about the rape in such detail.
I encouraged her, explaining that her ability to relive the trauma was reflec-
tive of her capacity to tolerate her memories. Zinhle reported anger toward
Mandla for having mocked her and later abandoning her when she disclosed
the rape. Upon hearing her narrative, I had felt sad for Mandla, as I surmised
that discovering that his sister had been raped had come as a shock to him.
I reflected on this and gently explained that Mandla had also been a child
at the time and it was possible that, upon learning about the rape, he had
felt upset, guilty, and ashamed for having mocked her. I explained that, in
shutting himself in his room, he had not intended to hurt her but had not
known how to cope with such a trauma. I empathized with Zinhle as she
tearfully acknowledged that she had not considered this before. To challenge
Zinhle’s appraisal that her ill-wishes had somehow led to the perpetrator’s
death, I used Socratic questioning (a form of gentle questioning to evoke
cognitive dissonance; this is a basic method from Beck’s cognitive therapy
that is incorporated into the Ehlers and Clark model). She was then able to
appreciate that he had been involved in criminal activity and that this came
with certain dangers. At the close of our session, I explained that it was
possible she could be triggered after session and that she could use relaxing
activities to manage any distress.
Therapy Session T2: Further Processing of the Memory and
Addressing Social Isolation
Zinhle reported that after T1 she had experienced intrusive memories of
the rape while she rested on her bed but had not felt overly distressed as
she now understood that these were unprocessed fragments of the trauma
and that the rape had happened in the past and she had survived. As such,
rather than avoiding these memories, she allowed herself to experience each
intrusion and the emotions evoked and found that after a few hours her
flashbacks ceased. She then felt as if a “rock had been removed” and she
was “now free.” I was impressed by her resourcefulness in managing such
painful memories and shared this. Zinhle reported feeling proud that she had
confronted and survived memories that had haunted her since childhood,
and I affirmed this.
I then discussed my concerns that she had not established friendships
since starting at the university and explained that I did not want the harm
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186 A. Padmanabhanunni and D. Edwards
engendered by the trauma to be perpetuated in her continued isolation and
loneliness. After taking a few minutes to absorb this, Zinhle looked sad
and reported that she had nothing positive to share with others about her
life and that, if people learned of the rape, they would blame and reject
her. I realized that the rape had overshadowed her memories of childhood
and adolescence. To encourage Zinhle to reflect on her childhood and
identify memories that evoked feelings of happiness and connectedness
with others, I used guided discovery (which, like Socratic questioning, is
a basic CT technique that uses pointed but gentle questioning). To her
surprise, she was able to identify happy memories, including getting up
to mischief with Mandla, outings with her family, and being babysat by
her sisters. Zinhle then reported feeling sad that she had disregarded these
memories. I acknowledged this and emphasized that she had much to
share with others that was positive about her life. I also highlighted her
friend’s supportive response to her disclosure and emphasized that people
who were genuinely caring would respond in a similar way. In addition,
I used Socratic questioning to help her fully appreciate that members of
her community had been extremely uncaring and irresponsible when they
accused her family of fabricating the rape. Zinhle could now see that it
was absurd to blame a 10-year-old for having been victimized. I actively
encouraged her to spend time with other students in her residence rather
than isolating herself in her room, and, feeling reassured, she agreed to this.
Therapy Sessions T3–T4: Enhancing Social Support
At T3, Zinhle had contacted her other sister who responded with surprise
and excitement. She now believed that her siblings had not blamed her for
the rape and that the rift that had separated her from her family was growing
smaller. She reported that, after T4, she would be returning home for the
university holiday period and wanted to reconnect with her parents, but she
felt afraid and ambivalent. Zinhle disclosed that, in the months following
the rape, she had written letters to her parents telling them she was hurting
and needed their support. However, they had not changed their behavior
toward her, and this still left her feeling confused, hurt, and angry. Through
close questioning, I learned that Zinhle had placed these letters in sealed,
unaddressed envelopes and left them in odd locations around the house,
assuming her parents would find and read them. I acknowledged her des-
peration as a child in wanting to receive comfort and care but also raised the
possibility that her parents may not have been aware that the letters were
meant for them or may not have noticed them since they were unmarked.
Zinhle then started crying, as she saw how much she had wanted to share
her pain with her parents but had not known how.
Zinhle now wanted to reveal to her parents her sense of having been
abandoned by them after the trauma and longing to establish a closer
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Social Cognitive Treatment of PTSD in Rape Survivor 187
relationship with them. I used role-play to prepare her and invited her to
imagine how her parents might respond and to predict the reactions she
feared. She worried that her parents might react by admonishing her for
not approaching them with these concerns earlier, and I reminded her that
she had not been able to reach out to her parents because their silence sur-
rounding the trauma had left her feeling hurt and alone. She decided that she
would explain this to them in the event that they reacted as she predicted.
Therapy Session 5: Concluding Treatment
Upon her return, five weeks later, Zinhle reported that while at home she
had felt confident about her ability to cope with the trauma memory and had
ventured into the backyard of her home. She had looked at the perpetrator’s
house and had not felt anxious or experienced intrusions. In addition, she
had not been perturbed by the sight of the vans parked in the backyard of her
neighbor’s house. I remarked on her courage in confronting the situations
that evoked her memories and explained that the absence of triggering meant
that the trauma memory had been put to rest. Zinhle disclosed that during the
holiday period she had felt that she first needed to reconnect with her parents
before she could feel safe enough to broach the CSA. She had initiated this
process by being less withdrawn and actively sharing some of the challenges
she experienced in adjusting to being away from home. Her family had
been attentive and caring, and Zinhle had felt very loved and supported. She
reported that she was also developing closer relationships with some of her
peers and was feeling less alone. I reflected on the progress she had made in
repairing some of the harm caused by the rape, and Zinhle remarked that, in
confronting the trauma memory and reconnecting with her family, she had
achieved her goals for therapy and now felt able to take the next steps on
her own. At this point I was not surprised, as I knew her to be resourceful,
and so I wished her well for the future and invited her to remain in touch and
return if she felt she needed to. Five months later, Zinhle called me to say
she was no longer going to let the rape shadow her life and the relationships
she cherished and so had decided to pursue her studies at a university in her
home city so she could be closer to her family.
SELF-REPORT SCORES
Her scores on the self-report scales, which were administered four times,
are presented in Figures 1–3. They show the clinical levels of depression,
anxiety, and specific PTSD symptoms that were apparent at A2. Her depres-
sion, anxiety, and PTSD symptoms were all markedly improved before she
went home for the vacation after T4, and this progress had been further
consolidated when she presented at the final session.
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188 A. Padmanabhanunni and D. Edwards
DISCUSSION AND CONCLUSIONS
A single systematic case study like this can provide evidence relevant to the
evaluation or refinement of existing theories (McLeod, 2010). Debates about
the treatment of PTSD center around the importance of “exposure” in relation
to other interventions and just how much exposure is needed for treat-
ment to be effective (Olatunji, Deacon, & Abramowitz, 2009). Randomized,
controlled trials provide a means of evaluating the efficaciousness of inter-
ventions, but the considerable diversity in how clients present and how they
respond to what therapists offer means that such multivariate research meth-
ods can tell us little or nothing about the factors that contribute to change in
psychotherapy (Dattilio et al., 2010; McLeod, 2010). They are, therefore, of
little value in determining the factors that contribute to the maintenance of
chronic PTSD.
In contrast to the strategy of prescribing repeated exposure to the trauma
memory, Ehlers and Clark (2000; Ehlers et al., 2005) recommend an approach
based on individual case formulation within which specific factors (e.g.,
hot spots in the trauma memory, dysfunctional coping) are identified and
targeted. This case study demonstrates the practical value of making case
formulation a central feature in treatment planning. The clinician developed
a detailed understanding of the idiosyncratic psychological processes under-
lying Zinhle’s symptoms and used that understanding to tailor interventions
responsively (Edwards, 2013). In Zinhle’s case, this meant a twin focus on
repairing lost social support particularly in the family and on helping her
deal with negative emotions and associated beliefs in the trauma memory.
This emerged early on in the assessment process, so much so that behavioral
experiments to address the ruptured relationships in her family were initiated
during the assessment process.
Although Zinhle’s parents had responded to her disclosure with tangible
support (Hyman, Gold, & Cott, 2003) (confronting the perpetrator, ensuring
she received medical care and seeking legal recourse), their belief that speak-
ing about the trauma would heighten Zinhle’s distress inhibited them from
initiating any discussion with her. Zinhle’s appraisal that this meant they
blamed her left her hurt and ashamed, and she withdrew and concealed
her distress from her parents. Such responses from children result in parents
underestimating the impact of the trauma on the child (Hafstad, Gil-Rivas,
Kilmer, & Raeder, 2010). In such situations, children are unable to use the
parent–child relationship as a context for processing the meaning of the
trauma, with the result that problematic appraisals remain unresolved and
children have to regulate their distress alone (Charuvastra & Cloitre, 2008;
Stovall-McClough & Cloitre, 2006). In Zinhle’s case, this was exacerbated
by the hostile response from the community at large, which compounded
the family’s sense of helplessness. Such negative community responses are
not uncommon in South Africa, where, owing to the considerable stigma
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Social Cognitive Treatment of PTSD in Rape Survivor 189
associated with CSA, families are often shunned if they accuse a respected
person of perpetrating abuse, leaving them devastated and isolated (Kaminer
&Eagle,2010; Lee, 2006). Tragically, for Zinhle, this led to her living with
chronic PTSD for almost a decade.
Once Zinhle began treatment, there was a step-by-step process in which
she was helped to tell her story and experience the emotions associated
with the memory of the rape. This began with the initial construction of the
narrative, moved to working with her drawing the scene, and then on to
her reliving the whole episode. This allowed the critical features of these
emotions and associated cognitions to be identified and targeted. Zinhle’s
progress was helped by the fact that she was motivated, intelligent, and
resourceful. She soon learned that she could tolerate the distressing emotions
associated with the memory, so much so that she could allow herself to expe-
rience the flashbacks at home without suppressing them while recognizing
that they were just memories of a past event.
Yet, even as she gave her initial narrative in the assessment phase, it
became clear that the disruption of relationships within the family was a sig-
nificant contributing factor to the maintenance of her distress. To address this,
while working with the trauma memory, appraisals were identified about the
meaning of the responses of her parents and brother. These were targeted
through reframing while working with the memory and also tested through
conducting behavioral experiments with family members (Ehlers & Clark,
2000).
There is considerable evidence from the case narrative that it was the
treatment that resulted in remission of Zinhle’s PTSD. Kazdin (1981)and
Elliott (2002) have summarized the kinds of evidence within a single case
that support a conclusion that positive change is the result of treatment.
One of these is that there was “early change in stable problems” (Elliott,
2002,p.6)orwhatKazdin(1981, p. 185) called a “slam-bang effect.” The
evidence showed that Zinhle had suffered from PTSD and depression for
nearly 10 years, and although there had been some fluctuation of symp-
toms, there had been no “spontaneous remission.” However, a relatively
brief intervention was enough to effect lasting remission of her symptoms.
Although no further assessment was done at the end of the academic year
when Zinhle phoned to say she had decided to study in her hometown the
following year, this decision, and the appreciative call, were evidence that
the symptoms had not returned and that resolution of the ruptured family
relationships were proceeding smoothly.
The second piece of internal evidence is that Zinhle herself attributed
the change to the therapy. That is, she clearly experienced a causal connec-
tion between what happened in the therapy sessions and the remission of
her symptoms. Elliott (2002, p. 6) calls this “retrospective attribution.” Finally,
there are several examples of “process-outcome mapping” and “event-shift
sequences” (Elliott, 2002, p. 6) in which the narrative shows that specific
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190 A. Padmanabhanunni and D. Edwards
events in the therapy occurred that were related to positive outcome both
chronologically and in terms of theoretical coherence. For example, the early
behavioral experiment in which she initiated a reengagement with her sis-
ter gave her hope about rebuilding connections with her family, something
that she systematically followed up from then on. Another example is that,
following psychoeducation about the impact of suppression on maintaining
PTSD reexperiencing symptoms and the experience of reliving the trauma
with the therapist, she discovered she could tolerate the flashbacks and allow
them to happen and pass and that after this they spontaneously subsided.
This is a process that fits in with Ehlers and Clark’s (2000) cognitive model
of maintenance of symptoms and what is needed to bring about remission.
The case also provides evidence that supports Tarrier and Humphreys’s
(2004) social cognitive model for the treatment of PTSD. It is one of sev-
eral case studies in the series in which attention to social support was an
important part of the treatment plan (Padmanabhanunni & Edwards, 2013).
Reviewing the qualitative accounts of the cases in the series, Edwards (2010,
p. 265) concluded that it was valuable “to help clients build strong support-
ive relationships with significant others to whom they could disclose their
experiences and feelings and expect to receive empathy and understand-
ing.” Although Zinhle was able to take the initiative to address her isolation
from the family on her own, there would be a case for family interven-
tions where this is feasible, as Tarrier and Humphreys recommend. A similar
family-based approach to treating depression in adolescents has been shown
to be very effective (Shpigel, Diamond, & Diamond, 2012).
This case study is a further example of the effective application of Ehlers
and Clark’s treatment model for PTSD and thus lends support for its clinical
usefulness in other countries, including South Africa, where this and several
other similar case studies have been conducted (Edwards, 2013).
We do not seek to generalize inappropriately from this study. Using a
case formulation driven model means that the actual process of treatment
can vary considerably from case to case. Specific techniques employed with
Zinhle may be inappropriate or unhelpful in some case. In other cases,
such a focus on social support, may be unnecessary or less central. As the
American Psychological Association’s Presidential Taskforce on Evidence
Based Practice in Psychotherapy recognized, the pacing of sessions and
timing of interventions is also important (Levant, 2005). The formulation
guides the clinician so that an intervention that is appropriate in session
6 may have been counterproductive in session 3. Edwards (2013) pointed to
“the complexity involved in the ‘translation of theory into therapy’” (Tarrier,
2006, p. 4) and cited Norcross and Lambert’s (2011) observation that “psy-
chotherapists endeavor to create a new therapy for each patient” (p. 10). The
evidence from this case study supports these broad principles and provides
some detail with respect to their application within the particular context of
the lived reality of PTSD in a particular human life.
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Social Cognitive Treatment of PTSD in Rape Survivor 191
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AUTHOR NOTES
Anita Padmanabhanunni is a senior lecturer and counseling psychologist
in the Department of Psychology at the University of the Western Cape
(UWC), South Africa. Her research has focused on evaluating the trans-
portability of specialist Cognitive Behavioral treatment (CBT) models for
posttraumatic stress disorder (PTSD) to the South African context. In this
regard, her research has contributed to the creation of a contextualized
knowledge base regarding the treatment of vulnerable population groups in
the country, particularly survivors of rape. This has gone a considerable way
toward providing practitioners with guidelines around the flexible applica-
tion of efficacious treatments in local clinical settings. Anita’s research areas
include psychotherapy outcome research, CBT, schema therapy, trauma and
PTSD, and gender-based violence. She is involved in Master’s clinical training
and supervision, and lectures on CBT, qualitative research methods, and psy-
chopathology. Her current research focuses on investigating the therapeutic
value of participation in activism against gender-based violence for survivors
of rape.
David Edwards has been a clinical psychologist and practicing thera-
pist for over thirty years. He is a founding fellow of the Academy of
Cognitive Therapy, having trained at Beck’s Center for Cognitive Therapy in
Philadelphia. Professor Edwards has a longstanding interest in psychotherapy
integration and has done experiential training in a variety of humanistic and
transpersonal approaches. David is a professor at Rhodes University, where,
until his recent retirement, he provided professional training and supervision
in cognitive therapy for two decades. Over a long career, he has published
some 70 academic articles and book chapters, covering areas as diverse as
the use of imagery methods in psychotherapy, the history of imagery meth-
ods, case studies of the treatment of simple and complex PTSD, guidelines
on the treatment of trauma related disorders, case studies of the treatment of
other disorders including conduct disorder, ADHD, and social phobia, and
case study as a research methodology.
Downloaded by [University of Rhodes] at 05:17 08 March 2015
