Efficacy of a two-session program of cognitive restructuring and imagery modification to reduce the feeling of being contaminated in adult survivors of childhood sexual abuse: A pilot study

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Abstract

Background and objectives

Cognitive restructuring and imagery modification (CRIM) to reduce the feeling of being contaminated (FBC) was tailored to adult survivors of childhood sexual abuse (CSA) suffering from this distressing feeling. A cognitive model of maladaptive appraisal and two factor learning theory can explain the development and maintenance of the FBC. CRIM combines cognitive interventions with imagery modification in a two-session treatment.

Methods

To evaluate CRIMs feasibility and efficacy, we consecutively treated 9 women suffering from chronic CSA-related posttraumatic stress disorder (PTSD) plus the FBC. Ratings regarding intensity, vividness, and uncontrollability of this feeling, and related distress as well as the Posttraumatic Diagnostic Scale (PDS) were administered prior to (t0), post (t1), and six weeks after (t2) treatment.

Results

When comparing t0 and t2 Cohen’s d was large for intensity of the FBC (d = 2.23; p < .01), its vividness (d = 1.83; p < .01), uncontrollability (d = 2.79; p < .01), and the related distress (d = 2.45; p < .01), as well as for PDS scores (d = .99; p < .05).

Limitations

Results are limited by the lack of a control group.

Conclusions

Data suggest that CRIM has the potential to reduce the FBC as well as PTSD symptoms after CSA.

Highlights

► Survivors of childhood sexual abuse often suffer from feeling of being contaminated. ► Lack of treatment addressing these distressing symptoms. ► We propose combination of cognitive restructuring plus imagery modification. ► Pilot data imply strong effect sizes, also for PTSD symptoms.

Introduction

Clinical experience shows that many survivors of childhood sexual abuse (CSA) suffer from a feeling of being contaminated (FBC) for years or decades after experiencing sexual violence. Patients for example feel disgusted when touching or looking at their own bodies, or worry that others can see that they have been victimized. PTSD literature describes this distressing symptom (e.g. Calhoun, 1991, Foa and Rothbaum, 1998, Herman, 1992, Rachman, 2006), but lacks an intervention especially targeting it.

Patients who suffer from an FBC after CSA typically report cognitions such as “It is like a dirty film that covers my body and can’t be eliminated”, or “Sometimes it is as if I can still sense or smell the perpetrator’s body fluids or touch on my skin”. Typically they describe the FBC as permanent, becoming more aware of it when triggered by memories of the abuse or sexual intimacy for example. Often the FBC is accompanied by vivid images of how the remains of the perpetrator’s body fluids can be seen or felt on the patient’s body.

As consequences of the FBC, patients might show excessive washing behavior which can be mistaken as obsessive behavior. Some patients use strong cleansing materials like disinfectant when washing to reduce the feeling. Patients might avoid or leave social situations, or avoid touching or looking at their own bodies, thus contributing to sexual problems. For survivors of CSA the FBC can be a very distressing problem, massively impairing daily life. So far, research on the FBC predominantly refers to the construct of mental pollution. Mental pollution was first postulated by Rachman in 1994, as a phenomenon with different origins, not exclusively sexual violence. Mental pollution was only explored in women who suffered from an urge to wash. Our clinical experience shows that some of the women suffer from a strong FBC without an urge to wash and excessive washing behavior; many patients use other (dysfunctional) coping strategies to reduce the FBC. In the present study we decided to use the more open and explorative but also more focused concept of feeling contaminated after CSA.

As Fig. 1 shows, development and maintenance of the FBC can be explained by two different routes: In a cognitive model persistent images and thoughts induce the affects of self-disgust, shame, and self-contempt and preserve the belief of being contaminated (Jung, Dyer, Priebe, Stangier, & Steil, submitted for publication). Most of the patients report that the FBC started years after the experience of CSA. In conclusion the FBC can be viewed as a secondary trauma-related emotion, based on maladaptive cognitive appraisals which developed after traumatization. As some patients report that they already felt disgusted by the perpetrator and his body fluids during the traumatic events and that the FBC began immediately afterwards, a second route can be considered: Disgust tends to spread widely and quickly towards objects which have been in contact with the primary source of disgust (Rozin, Millman, & Nemeroff, 1986). So FBC could also be viewed, according to Mowrer’s (1947) two factor learning theory, as a result of classical conditioning and subsequent negative reinforcement of avoidance. Research on a model of development and maintenance of the FBC is needed.

However, in case reports, state of the art treatment of PTSD reduced classical PTSD symptoms but not the FBC (DeSilva & Marks, 1999). Gershuny, Baer, Radomsky, Wilson, and Jenike (2003) found that patients with PTSD after sexual abuse and excessive washing behavior resulting from feeling contaminated showed weak responses to exposure and response prevention. Thus, additional treatment components focusing particularly on the FBC may improve standard treatments of PTSD.

Cognitive restructuring may be a promising approach to address the patients’ dysfunctional appraisals relating to the FBC (i.e. that other people can see what has happened to them in their face or that they can still feel or smell the perpetrator’s body fluids or cells on their body). Additionally, imagery modification has been proven to be effective in modifying implicitly stored associations contributing to affective reactions in emotional disorders (Arntz et al., 2005, Holmes et al., 2007, Holmes and Mathews, 2005, Holmes et al., 2006, Holmes et al., 2008, Holmes et al., 2009). Treatment studies on PTSD (Arntz, Tiesema, & Kindt, 2007), social anxiety disorder (Wild, Hackman, & Clark, 2007), bulimia nervosa (Cooper, Todd, & Turner, 2007), and depression (Wheatley et al., 2007) showed that imagery modification is a powerful method in changing dysfunctional beliefs, and intrusive images in particular (Holmes et al., 2007).

In the present pilot study, we tested the efficacy of a brief two-session intervention comprising of cognitive restructuring and imagery modification (CRIM) especially designed to reduce the FBC. We examined the hypothesis that the intensity, vividness, and uncontrollability of the FBC, and the resulting distress are reduced after treatment. Due to the complexity and severity of PTSD after CSA, we also examined the acceptance and safety of this intervention.

Section snippets

Patient recruitment

Nine female patients were included consecutively. Patients were recruited via newspaper and journal articles or had been referred to our specialized PTSD outpatient centre by their local psychiatrist or psychotherapist. After initial contact, patients were screened for inclusion and exclusion criteria in a telephone interview. In an intake assessment, patients were tested for meeting all inclusion and none of the exclusion criteria. Four of 13 women who were eligible (30.8%) refused to

Results

All patients were Caucasians aged 28–57 years (M = 43.78, SD = 8.98). Four were married, 3 divorced, 2 were single. All patients had completed their school leaving certificate, 5 held a university degree, and 4 had completed their apprenticeship. All patients had prior computer skills. Time between the end of CSA and treatment intake ranged from 18 to 50 years (M = 33.78, SD = 10.56) and time suffering from the FBC from 17 to 41 years (M = 29.56, SD = 8.00). Patients had an average of 3.44

Discussion

The results of our pilot study show that strong pre-follow-up changes were found on the ratings regarding the FBC. The specific target of the present treatment was the FBC. Thus, we did not expect CRIM to reduce PTSD. However, contrary to our expectations, we also observed significant reductions on the PDS.

The rating on the FBC and PDS scores decreased further after discharge. Patients initially reported severe PTSD, as indicated by mean PDS scores of 2.03. Improvements in PTSD symptoms are

References (34)

  • J. Wild et al.

    When the present visits the past: updating traumatic memories in social phobia

    Journal of Behavior Therapy and Experimental Psychiatry

    (2007)
  • Diagnostic and statistical manual of mental disorders

    (1994)
  • Understanding child sexual abuse. Education, prevention, and recovery

    (2001)
  • K.S. Calhoun

    Treatment of rape victims – Fascilitating psychosocial adjustment

    (1991)
  • M. Cooper et al.

    The effects of using imagery to modify core emotional beliefs in bulimia nervosa: an experimental pilot study

    Journal of Cognitive Psychotherapy

    (2007)
  • A. Foa et al.

    Treating the trauma of rape: Cognitive-behavioral therapy for PTSD

    (1998)
  • D. Griesel et al.

    Psychometric porperties of the German version of the posttraumatic diagnostic scale (PDS)

    Psychological Assessment

    (2006)
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