• Subject Name : Nursing

Cognitive Behavioural Therapy for Insomnia




Historical origin..

Elements of the theories.

Application of the counselling theories.



Introduction to Sexual Assault

Sexual abuse or assault is one of the confusing and perplexing issues facing whole worlds. Though, it is not possible to assess the problem extent fully as major of the victim do not speak up due to associated stigma and fear of rejection by society. Sexual assault can be defined as the sexual commotion between two or more person, though one of the people is threatened for forceful involvement into the sexual activity (Dworkin, 2018). In this report, Caleb’s (16 years-old-male) case would be discussed as the sexual assault is the area of concern in this modern era. Caleb was sexually assaulted by his aunt since he was 4 years of age. After the death of his aunt, he had reported flashbacks, altered cognition, avoidance, altered arousal and intrusion. Congenital behaviour therapy (CBT) and family system therapy would be discussed as the therapeutic intervention for Caleb. Additionally, the historical origin of the included theories, legal/ethical issues and outcomes of the patient would be encompassed.

Discussion on Sexual Assault

Historical Origin

Historically, there are two approaches for treating the victim of sexual assault/abuse: child welfare approach and the family system approach. As per the piece of literature, researchers and clinician have determined the effectiveness of including both approaches (child welfare and family system) together (Ruggiero et al., 2018). Therefore, in the present report, congenital behaviour therapy (CBT) and family system therapy would be deployed. The origin of CBT has been indicated as the clinical correspondent of the intellectual revolution in the scientific psychology filed thanks to Newell et al., Miller et al., Chomsky and others (Ruggiero et al., 2018). The revolution contained the inclusion of the cognitive mediator intervened between the behavioural response and environmental elicits. The cognitive mediators have been ordered in self- schemata format. Self-schemata have a paramount role in CBT as it aids in providing integration, coordination, consistency and guide to the mental conditions. In the first wave of the behavioural model, the cognitive mediators were absent. Therefore, the behavioural model consist of cognitive mediators is known as the second wave. The second wave is divided into the rationalist approach and a constructivist approach. "Rationalist” approach consisted of comprehended cognition, Ellis’ REBT and Beck’s CT (Lecomte et al., 2016). However, “constructivist” approaches considered cognition as emotionally laden, tacit and hermeneutical information restricting from human connections. Further, the third wave is the integrated functional procedure and consist of the centred model concept from the functionalist model (Lecomte et al., 2016).

Involvement of the family to help an individual suffering from any illness has been a part of various cultures. This system approach had been developed by the psychiatrist Murray Bowen (1950s). The origin of this theory had been from the social work movements in the 19th century in the United States and the United Kingdom. This theory roots can be detected in the late to the initial 20th century with the starting of the marriage counselling and child guidance. In accord to the piece of literature, the formal development of this theory periods is from the 1940s and the initial 1950s with the emerging of the American Association of Marriage counsellors (Dworkin, 2018). Various clinicians and independent groups had contributed for the origin of this theory- John Bowlby, John Elderkin Bell, Liebermann, Christian Midelfort and many more. By the middle of the 1960s, various schools of family therapy had developed. By the late 1970s, many changes had been made in the original theory to render holistic care to the people suffering from severe mental disorders. The Liberty Founded Healing outline for family therapy renders the complete change while working with the family members while addressing the communication of sexual orientation, class, races and gender identity. Increased technology usage and changes in the ethics code in the American Association for Marriage and Family Therapy has influenced family therapy in a positive manner (Falloon, 2015).

Elements of the Theories

CBT is structured and short term psychotherapy that emphases on the patient's present situation. In this therapy, the client and clinician work as a team to identify the distorted beliefs and thoughts of the client. The aim is to evaluate and identify the thoughts and attitude of the client towards a particular situation and then modify and challenge those attitudes. This model helps the clients to understand the relationship between their thoughts and associated behaviour pattern. Therefore, during the treatment session, the clinician challenge and identify the client’s distorted thoughts pattern. Further, the clinicians also help the client to recognize the impact of the thoughts on the feeling and behaviour pattern. In this whole process, both the client and the clinician come up with more positive thought and that lead to a shift in the behaviour pattern. The client's collaboration and active participation are paramount in the whole therapy session. Core belief and automatic thoughts are considered to be the key component of the therapy. These two key elements work together in any situation and lead to a specific response. This model has great application as it emphasises on human feelings and thoughts (Hayes & Hofmann, 2018).

In the family system therapy, the clinician not only works with the client but also with whole family members to evaluate the condition of the client (Lebow, 2017). When the family members work together they can understand their group potential and dynamics. Additionally, it is paramount to understand that the behaviour of any member of the family can affect the thought and behaviour of others. The core principle is “What happens to a family member, happen to every person in the family.” According to this theory, emotions, for instance, anxiety or stress originate from one person and spreads to all family members. One of the goals of this intervention is to educate all the family members and motivate them to find a solution to relieve the anxiety of the patient. Dr Bowen illustrated that change is the one member of the family member affect the other (Lebow, 2017).

Application of the Counselling Theories

In both CBT and family system therapy, psychologist before conduction of the therapy, assessment and counselling must obtain the informed consent form from the client and family individually. Conduction of the therapeutic session without informed consent form is mandated by government regulations. Further, psychologists take proper steps to avoid any harm to their patients. Additionally, the clinician must terminate the therapy session when it became clear that the patient needs no longer the intervention services. In the present case, consent form from Caleb and his family members must be considered prior conduction of the session (Springer et al., 2018).

CBT and family system therapy would be deployed to support Caleb by evaluating his mental status and thoughts. After identification of the critical behaviour; frequency, intensity and duration would be evaluated in the present case. Goal setting would be the next phase and involvement of Caleb in goal setting would be paramount. In the present case, self-instruction and self-help strategies would be deployed with the aim of cognitive restructuring. Self-awareness technique seems to be an effective therapeutic process in Caleb's case as the sexual assault victims usually have a feeling of self-guilt, self-doubt and self- blame. Caleb also feels that he is responsible for his aunt died. Post-traumatic stress disorder is usually a common symptom in sexual assault survivor, further short term CBT therapy would be an effective way to treat Caleb. The two key components included while delivering therapy would be: marinating and developing a trusting relationship with Caleb and communicating one survivor’s story about the sexual assault that help him to overcome his post-traumatic stress and self-guilt. Further, behaviour therapist would aid Caleb to decrease the emotional impact of his flashbacks so that nightmares and intrusive thoughts eventually vanish (Cunningham & Shapiro, 2018). Additionally, Involvement of Caleb's family members would help him to come out of his self-guilt. It is paramount to educate the victim’s family about the condition of the survivor so that they can help the survivor to regain depression free and stable life (Minuchin, 2018).

The CBT would only concentrate on the Caleb and family centred therapy would include whole family members to formulate goals and achieve it within the decided time frame. With these two interventions, Caleb will regain his confidence and stable life. He will overcome with the feeling of self-guilt, self-doubt and self-blame. Caleb's flashbacks and intrusive thoughts would reduce with the advancing stages of the therapy. Approximately 2 years of therapy would be deployed to treat Caleb. Initially, 30 days session would be an individual session. In an individual session, the therapist would formulate a relationship with Caleb and motivate him to speak about his thoughts. Family system therapy would be started after 30 days of the CBT. In that whole family would be included to discuss the cause and goal to achieve. Approximately 3 months the session would be thrice a week then after that twice a week, further, based on the client's condition, the session would be once a week for the next 1 year (Lebow, 2017).

Conclusion on Sexual Assault

It can be concluded that sexual assault victim suffers from post-traumatic stress, intrusive thoughts, flashbacks and self-blame. Therefore, it is essential to give individual therapy to the victim and involve the family too in the intervention process. In the present case, CBT and family centred therapy would be an effective treatment as these therapies would help the victim to come out of his intrusive thoughts. Further, support of family members would help the client to regain his self-confidence.

References for Sexual Assault

Cunningham, J. E., & Shapiro, C. M. (2018). Cognitive Behavioural Therapy for Insomnia (CBT-I) to treat depression: A systematic review. Journal Of Psychosomatic Research106, 1-12.

Dworkin, E. R. (2018). Risk for mental disorders associated with sexual assault: A meta-analysis. Trauma, Violence, & Abuse, 1524838018813198.

Falloon, I. R. (Ed.). (2015). Handbook of Behavioural Family Therapy. London: Routledge, https://doi.org/10.4324/9781315685298

Paul, Howard. (2018). Process-Based CBT: The Science and Core Clinical Competencies of Cognitive Behavior Therapy. Child & Family Behavior Therapy, 40, 1-7. 10.1080/07317107.2018.1522153.

Lebow, J. L. (2017). Editorial: Emerging principles of practice in couple and family therapy. Family Process, 56(3), 535–539. https://doi.org/10.1111/famp.12309

Lecomte, T., Samson, C., Naeem, F., Schachte, L., & Farhall, J. (2018). Implementing cognitive behavioral therapy for psychosis: An international survey of clinicians’ attitudes and obstacles. Psychiatric Rehabilitation Journal, 41(2), 141–148. https://doi.org/10.1037/prj0000292

Minuchin, S. (2018). Families and family therapy. Routledge. https://books.google.co.in/books?hl=en&lr=&id=9nh0DwAAQBAJ&oi=fnd&pg=PT6&dq=Minuchin,+S.+(2018).+Families+and+family+therapy.+Routledge.+&ots=QO6tGIXbLf&sig=sbTvILGOWiH_2KDae1T5vm1KI84&redir_esc=y#v=onepage&q=Minuchin%2C%20S.%20(2018).%20Families%20and%20family%20therapy.%20Routledge.&f=false

Ruggiero, G. M., Spada, M. M., Caselli, G., & Sassaroli, S. (2018). A historical and theoretical review of cognitive behavioral therapies: From structural self-knowledge to functional processes. Journal of Rational-Emotive & Cognitive-Behavior Therapy36(4), 378-403.

Springer, K. S., Levy, H. C., & Tolin, D. F. (2018). Remission in CBT for adult anxiety disorders: A meta-analysis. Clinical Psychology Review61, 1-8.

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