Overview of the Client
The client considered in the biopsychosocial assessment is referred to by the code name “Sarah.” She is a 30-year-old white woman who was raised in a Catholic family, but she does not have any religious affiliation at the moment. Sarah is a lesbian, and she is in a 2-year romantic relationship with a woman with whom she has been living for one year. When Sarah was six years old, a then friend of the family, an adult man, sexually abused her. This event led to Sarah gradually changing her behavior, withdrawing from her family, repressing her emotions, and denying her sexual orientation. Moreover, Sarah developed post-traumatic stress disorder (PTSD) and continues to suffer from nightmares, disturbed sleeping, flashbacks, and periods of hypervigilance. Although the client has worked with a therapist and has come a long way in her self-acceptance, she still has many symptoms of PTSD that can be addressed in therapy.
Impact of Individual Characteristics
Looking at Sarah’s case, one can see that gender, sexuality, and religious affiliation have played a role in the client’s trauma. The intersection of these three characteristics has affected her response to the hurtful event. First, one has to consider the client’s family’s religious upbringing – Sarah’s parents are devout Catholics who actively engaged the client in regular church visits and other related events. Moreover, they talked to Sarah about complex topics, such as love, familial and romantic relationships, sex, and sexuality, using the worldview of religiosity and rigid gender roles. In particular, Sarah recalls that she has heard her parents say negative things about homosexuality in her childhood. Thus, it is possible that she internalized this view of being gay and denied her sexuality for many years.
Similarly, the client’s gender has played a role in her emotional response to trauma. As Niles et al. (2017) find, sexual minority women have higher rates of child maltreatment than men or heterosexual women. In her childhood and adolescence, the client has had a very emotional and energetic personality, often speaking loudly, being very active in games, and reacting emotionally to people’s actions and words. However, her parents would restrict her expression of feelings, saying that women should be humble, patient, and reserved. Moreover, Sarah’s emotional responses were often devalued – her anger and sadness would not be explored but subdued. As an outcome, Sarah may have learned not to express emotions or openly talk about her problems. Sarah did not speak with her parents about the abuse for several years, and she pushed her feelings away when pursuing romantic partners. Finally, such upbringing has led to the client blaming the abuse on herself, feeling shame and guilt as though her actions or her supposed “wrongness” were to blame for what had occurred.
Finally, the client’s sexuality has contributed to her later response to the traumatic event. Sarah was only six years old when the instance of abuse happened, and she did not know about her attraction to girls at that moment. Nevertheless, when the client later tried to find the possible cause of the sexual assault, she considered the idea of homosexuality “sinful.” Interestingly, in Sarah’s mind, the fact that she liked women and did not like men was seen as both the possible cause of the assault and the outcome. According to Woulfe and Goodman (2020), one’s affirmative identity can greatly help mitigate the effects of PTSD brought on by abuse. In contrast, instances of heterosexism, including internalized ideas of the client, could exacerbate her PTSD (Dworkin et al., 2018). For some years, the client thought that she was simply scared of men, and thus she tried to enter heterosexual relationships even though she did not feel any romantic attraction to her male partners. Here, the problems of emotional control, self-guilt, and denial were combined, resulting in Sarah avoiding treatment for a long time.
Treatment Approach: Cognitive Processing Therapy (CPT)
The first model that can be considered for the client is cognitive processing therapy (CPT). CPT is a type of cognitive-behavioral therapy (CBT) that was developed in the 1980s with the specific goal of treating PTSD (Resick et al., 2016). Currently, the American Psychological Association ([APA], 2020) strongly recommends CPT as a baseline treatment for PTSD, especially in cases of rape and child abuse. Similar to CBT, CPT has a rigid structure and assignments that clients have to complete outside of sessions. Generally, CPT lasts for 12 sessions, each about 50 minutes long (Resick et al., 2016). During these meetings, the therapist and the client discuss the traumatic event and focus on a particular problem related to it.
In Sarah’s case, the center of the discussion would be Sarah’s childhood sexual assault. The therapist would ask Sarah to describe this event, which would encourage the client to open up about her trauma and stop avoiding feelings related to the past. Next, CPT argues that Socratic questioning is necessary to deconstruct the client’s thought process which connects the traumatic response to defense mechanisms (Resick et al., 2016). This form of dialogue targets maladaptive thinking and allows the client to develop skills to notice and change unhelpful thinking patterns after therapy is complete.
Sarah often becomes afraid or hypervigilant in silent surroundings – one can assume that she associates silence with the absence of protection from others. Thus, her hypervigilance extends to scenarios where she is surrounded by her friends, but she continues to feel isolated, which indicates a maladaptive response. The therapist could use CPT to change this connection and remove the negative connotation from the client’s thinking by asking questions about the client’s beliefs (Resick et al., 2016). Thus, the specific alignment of CPT for dealing with trauma makes it a valuable suggestion for Sarah.
A special point should be made when advising CPT for LGBTQ clients. Livingston et al. (2020) point out that, while hypervigilance is a symptom of PTSD, vigilance is also a vital part of LGBTQ people’s survival mechanism for navigating surroundings that present actual danger. Thus, the authors suggest adding tactical modifications to the therapy approach to keep it effective for LGBTQ individuals. Nevertheless, APA (2020), Livingston et al. (2020), and Resick et al. (2016) highly recommend CPT as the best approach to treating PTSD. The evidence of this model implies that the maladaptive cognitive responses that people develop as a result of trauma can be approached with the focused exercises of CPT.
Benefits and Drawbacks
Starting with this strategy’s strengths, CPT is a highly structured and rather short treatment that lasts only 12 sessions. Thus, the client has a clear understanding of what is going to be discussed in each meeting. Moreover, both the therapist and the client will have a clear goal in mind. Second, if Sarah is doing well with changing her thinking and behavioral patterns, she may quickly see a result. Finally, the third benefit of CPT is that, by using it, the therapist teaches the client a set of self-efficacy principles that can be used in the future. For instance, Sarah may learn not to associate silence with danger and understand her thinking process better, which she can use to detect and challenge other maladaptive responses.
Nevertheless, CPT also has some limitations, some of which are directly related to treating minority clients. The practical nature of CPT implies that the client will commit to completing various exercises and actively working on changing their behavioral patterns. Therefore, it also takes up time outside of sessions, which may be difficult for the client (Resick et al., 2016). Sarah has a rather stressful job that requires preparation outside of working hours. Thus, it may be challenging for her to manage her time with both her job and intensive CPT.
Furthermore, one of the first assignments in CPT is the client’s recollection of the traumatic event. As Sarah’s usual response is avoidance, she may struggle with such confrontation, increasing the risk of quitting therapy or worsening symptoms. Another drawback is that CPT investigates only one traumatic event and connects it to the present. It may not acknowledge the influence of underlying factors, such as Sarah’s upbringing. Finally, as stated above, the failure to modify CPT for LGBTQ individuals will likely lead to the client and therapist not finding a common ground on which of the behaviors are maladaptive or necessary for the client’s survival.
Treatment Approach: Psychodynamic Therapy
The second model that takes a different approach to deal with the client’s PTSD is psychodynamic therapy (PDT). In contrast to other models, such as CPT and CBT, PDT is much less structured and focused. This model is utilized to raise the client’s awareness about the connections between their past and present behavior. Here, much attention is paid to one’s childhood, including the relationship with parents and events that happened during the formative years. As such, a conversation between a therapist and a client is at the center of each session – the client is guided to consider how past events have influenced the present and what these links mean to the client’s current life. This aim can be compared to CPT’s objective, but PDT does not have a strict path for changing one’s cognitive patterns.
PDT is one of the oldest approaches to psychotherapy, and it is still used by many therapists to treat PTSD. According to Lazaratou (2017), PDT interprets trauma as a life event that disrupts one’s responses and creates long-lasting pathological effects on cognition. Here, PDT tries to reveal how trauma affects one’s thinking, pointing out how maladaptive responses may have formed. Alessi and Kahn (2019) argue that PDT aligns with the idea of trauma-informed practice because this therapy model provides the client with a safe space for discussing past events. Lastly, Steinert et al. (2017) find that PDT is as effective as other therapy approaches in targeting symptoms of most mental disorders. The considered research shows that PDT is still effective at dealing with PTSD by engaging the client in meaningful discussion.
Benefits and Drawbacks
PDT has some strong and weak sides. It is a therapy model based on insight, which allows the client to look deep into their history and gain a deep understanding of one’s cognitive and emotional processes. Thus, it has the potential to have a long-lasting effect on the client. Sarah’s trauma is directly connected to her childhood, and her response to the abuse was based on her gender, sexuality, and religious affiliation. Therefore, PDT could help her consider these elements as part of her mental health and find how they influenced her current state. In contrast to CPT, PDT also provides the client with much more time to talk (Paintain & Cassidy, 2018). For Sarah, it may be beneficial as she currently struggles with expressing emotions about past events.
Nevertheless, as PDT does not have a defined program for dealing with particular symptoms, it may take a long time for the therapist and the client to establish a trusting relationship and uncover all connections between past and present events. PDT is based on self-exploration, and such conversations may last for months before the client sees the result of the sessions. Another potential drawback of PDT is the emphasis on the therapist-client relationship. An in-depth analysis of trauma requires the dyad of the therapist and client to work closely, and the clinician may also use this relationship to explore the client’s habits of relating or assigning roles to other people. While this approach may reveal additional information, it also implies that the therapist has to possess great knowledge and experience working with trauma.
The dynamic between the therapist and the client in the discussed case can significantly influence the outcome of therapy. In terms of transference, Sarah may redirect her feelings for her parents, past partners, or her current romantic partner to the therapist. In the first scenario, where Sarah perceives the clinician in a parental role, she may show mistrust and fail to engage in a meaningful discussion of her trauma (Arundale & Bellman, 2018). Similarly, her past romantic relationships with men were defined by denial and self-blame. If the client makes this connection to the therapist, the sessions will concentrate on her inability to acknowledge that she cannot be blamed for the abuse that happened to her. It is vital to recognize whether Sarah still has an unresolved conflict with her parents and see how she experiences romantic relationships.
At the same time, countertransference can help the therapist understand which emotional responses the client anticipates receiving. One may feel parental toward the client due to a history of trauma or guiding the client’s emotions and thoughts (Arundale & Bellman, 2018). Sarah possibly expects authority figures, such as her parents and past partners, to take control of her emotional state, denying her free expression of her feelings. It is vital to address the client’s tendency to blame herself for abuse, her parents’ behavior, past romantic relationship problems, and other events. The client may place the blame on herself and expect the therapist to show a similar response. By exploring Sarah’s feelings towards the therapist and the relationship on this dyad, the client may gain a better understanding of how she interacts with the world at present.
Sarah’s case shows that a single instance of abuse cannot be viewed in isolation from other factors. The client’s family history, gender and sexuality, and past religious affiliation contributed to her response to the sexual abuse she went through as a child. Thus, Sarah engaged in self-blame and felt guilt and anger towards herself, withdrawing from her family and honest relationships. CPT and PDT are the two models that can be suggested to treat Sarah’s PTSD. These therapies present significantly varying approaches and have their weak and strong sides. However, in both types of treatment, it is crucial to establish a trusting relationship between the therapist and the client and overcome Sarah’s avoidance of facing her traumatic experience.
Alessi, E. J., & Kahn, S. (2019). Using psychodynamic interventions to engage in trauma-informed practice. Journal of Social Work Practice, 33(1), 27-39.
American Psychological Association. (2017). Cognitive processing therapy (CPT).
Arundale, J., & Bellman, D. B. (Eds.). (2018). Transference and countertransference: A unifying focus of psychoanalysis. Routledge.
Dworkin, E. R., Gilmore, A. K., Bedard-Gilligan, M., Lehavot, K., Guttmannova, K., &Kaysen, D. (2018). Predicting PTSD severity from experiences of trauma and heterosexism in lesbian and bisexual women: A longitudinal study of cognitive mediators. Journal of Counseling Psychology, 65(3), 324-333.
Lazaratou, H. (2017). Interpersonal trauma: Psychodynamic psychotherapy and neurobiology. European Journal of Psychotraumatology, 8(sup4), 1351202.
Livingston, N. A., Berke, D., Scholl, J., Ruben, M., & Shipherd, J. C. (2020). Addressing diversity in PTSD treatment: Clinical considerations and guidance for the treatment of PTSD in LGBTQ populations. Current Treatment Options in Psychiatry, 7, 53-69.
Niles, A. N., Valenstein-Mah, H., Bedard-Gilligan, M., & Kaysen, D. (2017). Effects of trauma and PTSD on self-reported physical functioning in sexual minority women. Health Psychology, 36(10), 947-954.
Paintain, E., & Cassidy, S. (2018). First‐line therapy for post‐traumatic stress disorder: A systematic review of cognitive behavioural therapy and psychodynamic approaches. Counselling and Psychotherapy Research, 18(3), 237-250.
Resick, P. A., Monson, C. M., & Chard, K. M. (2016). Cognitive processing therapy for PTSD: A comprehensive manual. Guilford Publications.
Steinert, C., Munder, T., Rabung, S., Hoyer, J., & Leichsenring, F. (2017). Psychodynamic therapy: As efficacious as other empirically supported treatments? A meta-analysis testing equivalence of outcomes. American Journal of Psychiatry, 174(10), 943-953.
Woulfe, J. M., & Goodman, L. A. (2020). Weaponized oppression: Identity abuse and mental health in the lesbian, gay, bisexual, transgender, and queer community. Psychology of Violence, 10(1), 100-109.