Cognitive restructuring is a therapy that focuses on "restructuring" or changing negative thoughts to improve problem emotions. Very simply, the theory is that thoughts—also called cognitions—create emotions or feelings. For example, the thought "I'm a loser" will create feelings of sadness or depression. The thought "I'm a success" will create happy, positive feelings. Cognitions are thoughts, beliefs, ideas, attitudes, values, and even the stream of thoughts that run in our heads continuously. Cognitions, thoughts, and beliefs are terms that will be used interchangeably throughout the chapter. Thoughts can be positive, negative, and neutral. They may be current or may be long-standing, such as attitudes, morals, and ideals. Cognitions or beliefs about ourselves and the world begin forming during childhood and may change with new experiences, as we age and mature. How we view ourselves is based on thoughts created by parents, important people, and significant experiences, both positive and negative. Thus, cognitions are very powerful in influencing how we think about ourselves, our world, and the direction of our lives. Cognitive therapy is about "listening" to the thoughts in our heads; identifying the negative, erroneous, or judgmental thoughts; and changing them to more realistic, positive, or even neutral thoughts. In the example above, the thought "I'm a loser" creates feelings of depression;
to change the depression, the therapy suggests changing the thought to "I'm successful at some things." Note that the second thought is not the opposite of "I'm a loser," leading to "I'm the most successful person in the world," but rather to a more realistic belief to create positive and hopeful feelings. Recognizing the link between our thoughts and feelings is essential,8,9 and many self-help books8 have been written to guide individuals in identifying negative thoughts, modifying them, and thus improving feelings. The book Feeling Good: The New Mood Therapy by David Burns9 and the supplemental workbook10 are written for nonprofessionals and specifically target depression. The workbook contains many useful exercises that can be used to target PTSD symptoms in rape survivors as well.
Cognitive therapy has a long history of research supporting its effectiveness with different psychological problems or problem emotions, such as depression, anxiety, and anger.11 In the PTSD arena, cognitive therapy has been identified as one of the two most effective treatments for PTSD. Negative or irrational beliefs/thoughts develop after a life-threatening event or trauma such as rape. The type and extent of negative beliefs that develop after a rape are influenced by beliefs prior to the rape, beliefs about the rape, and society's or family's messages toward the woman and about rape in general. Recovery after a rape will be influenced by these messages. Attitudes and beliefs about women, including roles and relationships with men, can make the aftershock of a rape worse. For example, if a woman grows up believing that she is responsible for her family's problems, she will most likely blame herself after being raped for "letting it happen." It is important to note that most people tend to blame themselves after a trauma even if the trauma is not as personal as a rape. This self-blame is reinforced with society's message of "blame the victim" and will further negatively impact a woman after a rape. Society's messages about women experiencing rape have varied over the years. Long ago, society clearly blamed women for being raped by bringing into focus how they dressed seductively, "teased" a man, or enjoyed the sex, all messages suggesting women somehow "caused" the rape. Regarding men who have been raped, society's messages are just as harsh in the opposite direction, such as "men can't be raped." Therefore common negative beliefs of the man are "Why did they pick me? I must look gay; they must think I wanted it." For both male and female rape victims, these are all negative, irrational, distorted beliefs, and how strongly a woman or man believes these thoughts will determine the severity of the negative feelings after a rape. Negative beliefs or messages persist unless they are actively challenged or questioned. The beliefs held prior to and after a rape contribute to the severity of symptoms and/or recovery. Cognitive therapy works by examining one's beliefs, challenging and changing negative or distorted beliefs as a way of improving feelings and lessening symptoms.
One specific and highly developed cognitive restructuring therapy for trauma survivors is Cognitive Processing Therapy (CPT).12 CPT will be described in detail in this chapter because it is one of the most widely used cognitive therapies for PTSD. The manual Cognitive Processing Therapy for Rape Victims is written for trained therapists, and while a brief description and a few suggestions will be offered in this chapter, a trained CPT therapist should be consulted to obtain the full, positive effects of the therapy.
Like general cognitive therapies, CPT teaches the rape survivor how to listen to thoughts, challenge the irrational/distorted thoughts, and change them to more realistic ones. However, CPT12 goes further to identify five belief themes that are often negatively altered after a rape. The five themes are beliefs about (1) safety, (2) trust, (3) power/control, (4) esteem, and (5) intimacy. CPT is an extensive, twelve-session therapy, and the full version includes writing in detail about the rape event twice. CPT-C is the version where the trauma writing is omitted; writing is a form of exposure, which will be described in detail in the second part of this chapter. The first seven sessions of CPT teach the rape survivor the causal link between thoughts and feelings and to progressively develop skills for questioning and challenging negative beliefs. The negative beliefs are called "automatic thoughts" or "stuck points" that result after a rape. A list of challenging questions helps determine if the belief is negative or distorted. The goal is to change the negative thought to a more adaptive, realistic belief. An example of a challenging question is "Are you thinking in all-or-none terms?" (pg. 69)12 All-or-none thinking is a common cognitive distortion in PTSD because it represents the dualistic, life/death nature of the trauma. Examples of other types of general cognitive distortions can be found in Burns's8 book. Work on the five themes begins with a homework assignment to write at least one page on how the rape affected beliefs on each theme, beginning with safety. The client brings the writing to the session and reads aloud the writing, and the therapist and client analyze it for distorted, negative, or judgmental thoughts. Using worksheets, each distorted thought is challenged and modified to an alternative, more realistic thought. The client is asked to rehearse the process of checking, challenging, and changing thoughts, as well as practicing the new, adaptive thoughts. Thoughts are examined for those held before the rape, whether positive or negative; those developed after the rape; and thoughts about self and others. This chapter will provide only a few common examples for illustration.
Safety. Beliefs and thoughts about safety are important because the rape violated a woman's sense of safety. The rape is a life-threatening event that produced fear and helplessness. Rape occurs in a range of situations; it can be from childhood through adulthood, and it can range from extremely violent with physical injuries to more subtle coercion by someone in power. It can be a single episode or a series of rapes in an ongoing relationship. For example, if the woman is raped as an adult by a coworker at a company party one evening and had a troubled past (growing up beaten by her mother and father, unsupported, in poverty, possibly molested as a child), then her safety beliefs might be "I'm never safe and I never will be. Everyone is out to hurt me." The link between thoughts and feelings is the key here. In her present life, the "I am never safe" thoughts create feelings of anxiety, panic, and fear. The degree of anxiety will depend on the strength of the negative thought. Each day that she walks out of her home with the "I am never safe" thought, she creates feelings of anxiety. The anxiety can be immobilizing, leading to daily functioning problems, such as avoiding work and relationships, and potentially creating a need to use drugs or alcohol to manage these intense feelings. The goal of CPT is to lower the intensity anxiety by modifying the "I am never safe" thought. Remember, it is not possible to erase or eliminate feelings, but they can be lowered to manageable levels; extreme levels of emotions cause problems. The figure below shows how the automatic thoughts might come up in various situations, such as getting ready to go to the grocery store. The automatic thought may end up creating so much anxiety that the woman decides not to pursue the activity. The change thought is more realistic, allows for the possibility of not-so-safe situations, and gives the woman the opportunity to use judgment in creating safety.
The change thought of "Not everyone is dangerous; I can keep myself safe" creates feelings of moderate anxiety and some calm. The calm, moderate anxiety feelings make it possible to function at daily tasks, such as grocery shopping or going to work. In this example, the absolute words like never create an expectation that generalizes the terror and danger of the
rape to relatively safe situations like going to work or the grocery store. The absolute words create terror in everyday activities. "Everyone is dangerous" is also a distorted belief, because although the rapist was dangerous, the absolute of "everyone" dismisses even the safe people in the woman's life, resulting in her treating safe people similarly to the rapist.
Trust. Beliefs about trust impact a woman after a rape because the rape violated trust beliefs, whether the perpetrator was a friend, family member, or stranger. The betrayal of trust of a friend or family member is obvious because of the expectation for love and trust; the stranger may violate her trust of the world. Let's take the earlier example of the woman with the troubled past. Her previous betrayals of trust by loved ones will bring in beliefs such as "I should have known better; I can't trust myself. Nobody can be trusted" when raped by the coworker. The loss of trust in one's self can undermine the core of our being and the sense that we can keep ourselves safe in a world that is sometimes dangerous. It is important to understand that perpetrators are extremely skilled at manipulating women by first creating a seemingly safe situation, and then by making it impossible for the woman to leave or protect herself before the danger is realized. Instead of the belief that "perpetrators are skilled manipulators" the rape victim believes "I should have known better; I can't trust myself," which creates feelings of doubt and fear. To lower the intensity of the emotion, the change thought can be "Rapists are good manipulators and can't be trusted." Notice that the blame has appropriately shifted from the rape survivor to the perpetrator. It should be noted that in this chapter we refer to male perpetrators and female victims because it is most common; however, it is also important to remember that sexual assault can be perpetrated by both males and females against any individual. It is important to note also that rape is a crime and an exertion of power and not to be minimized as merely a sexual act.
Automatic Thought Feeling/Emotion
Automatic Thought Feeling/Emotion
Change Thought Feeling/Emotion
Change Thought Feeling/Emotion
Trust beliefs about others focus on external situations and/or people. An example might be "Men can't be trusted," which create feelings of fear and anxiety in daily life, as men make up half of the population. This belief does not account for already-established trust in others nor will it allow a woman to develop new relationships. The change thought "Some people are more trustworthy than others. Not all men rape. I can practice trust by opening up to others slowly to make sure I don't get hurt" will help the woman gain perspective on existing relationships and create calmer feelings and the ability to function in life effectively. As you might have noticed, the five themes can and do overlap, as between trust and the previous theme of safety. Most of the five themes overlap to some degree, and while the separation between the five may seem arbitrary, the separation is intended to help understand the link between thoughts and feelings.
Power/control. Beliefs and thoughts about power and control are based in the feeling of helplessness the woman experienced during the rape, because of the inescapable, life-threatening nature of the situation. Extreme helplessness often translates into the need for control or power after rape. A rape survivor may exert excessive control in relationships, home, and work, which can interfere with functioning in these areas. While control may create a sense of predictability and safety for the survivor, it can also result in rigidity and compulsive behaviors. The minor tasks of everyday life are treated with the same life/death intensity as the rape, oftentimes creating crises where none exist. Negative power/control beliefs in the previous example might be "I must be in control [and if I'm not somebody will die].If someone else is in control, I will get raped again." The thought in the brackets suggests that the woman might not be aware of this thought, but it is "in the back of her head." The "somebody will die" thought is quite powerful and creates feelings of terror and fear, which interfere with daily functioning, in developing and/or maintaining intimacy in existing relationships. While the woman may outwardly acknowledge there is not a threat of death
in daily situations like going to the grocery store, her behavior will reflect the life/death intensity in the situation.
Change thoughts can be "Sharing power does not mean I'll get raped again. Some people die, but I can be careful; I can't control everything." The feelings created by the change thoughts are calm and create mild to moderate anxiety.
Esteem. Negative thoughts regarding self-esteem are core to recovery because the act of rape is a deeply personal attack. It is common for a rape survivor to blame herself, especially if everyone else is blaming her. Common negative beliefs about esteem are "What's wrong with me? Why can't I get over this? Nobody else has this problem." There are many different versions of negative self-blame, and it is important to examine those that are specific to each individual. Negative self-esteem beliefs create feelings of sadness and depression, which can be debilitating.
To lessen the intensity of the depression, the change thought can be "I did all I could; my reactions are normal." The changed thoughts will create feelings of confidence and hope. Negative thoughts around esteem are typically associated with depression, and here is where the overlap of depression and PTSD symptoms is noted. Burns's8 exercises directly target depression and negative self-beliefs about esteem and can help with PTSD as well.
Intimacy. Thoughts about intimacy are typically associated with sexual intimacy, which is negatively affected because the rape was aggression of a sexual nature. While some people minimize rape as "just sex," it is an act of violence and aggression and is against the law. However, because the violence involved sex, negative beliefs about sexual intimacy develop in the woman, like "Sex is dangerous; I can't cuddle or he'll want sex and then I won't be able to stop him." These thoughts create feelings of fear and typically arise when the woman is about to become physically or emotionally close to another person.
The change thought is "Sex is not dangerous—rape is. I can say no." The changed thoughts produce feelings of hope and confidence in the woman. It is important to note that women who have been raped often struggle with sexual intimacy because having sex, even when it is safe, triggers memories of the rape. Those that have overcome difficulties engaging in sex have done so by having patience with themselves and having a patient, accepting partner. Improvement in sexual functioning begins with listening for distorted thoughts about sex, separating the rape thoughts from the safe-sex thoughts, challenging negative thoughts, and creating adaptive thoughts.
Practical suggestions. Again, if a rape survivor continues to have PTSD or other symptoms after a rape, especially if the symptoms persist beyond a year, she should seek professional treatment from a trained CPT therapist. While cognitive restructuring or CPT is an effective therapy intended to treat PTSD, the process of listening to negative thoughts and challenging and changing them is not a new concept, and most people have used some form of cognitive restructuring on their own without calling it cognitive restructuring. For example, when you tell yourself "I'm just not going to think that way anymore," you are engaging in cognitive restructuring. Other examples of cognitive change are "positive affirmations" used in general or alcohol recovery programs. Rehearsing positive affirmations is not technically cognitive restructuring, but rather replacing a negative thought with a positive one, and it also produces positive results. It is possible to change thoughts on your own. The biggest challenge in effectively using the cognitive restructuring strategy is practice. The cognitive change strategy is a type of hard work that requires the practice of "listening" to our thoughts daily to catch the distorted, negative thoughts and change them. You can remind yourself by setting a timer to "listen" three times a day, writing all the thoughts down in a journal, and reviewing them at the end of the day. If you chose to use a journal to jot down your thoughts, you will need to sort through and pick out the distorted or negative thoughts for change; identify new, positive, or neutral thoughts; and practice the new thoughts in your head daily. An important point here is that many thoughts become like habits. We often repeat the same negative thought in our head regularly, and change requires repeating and practicing the new thoughts to counter the old, distorted, negative ones. Cognitive restructuring is a very powerful tool to improve PTSD and other symptoms, but it must be done daily. This work is much like starting a diet or exercise program. Unless you set a routine to do it, the change will not happen. If you do, however, you will be surprised at the improvement you will see in your life. Do not hesitate to contact a therapist to help you through the process.
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