89 Brief Treatment of Complicated PTSD and Peritraumatic Responses in a Client With Repeated Sexual Victimization Terri L. Messman-Moore, Miami University Patricia A. Resick, Center for Trauma Recovery, University of Missou~J-St. Louis The present case study describes the successful treatment of a woman with a history of sexual, physical, and psychological abuse in childhood and multiple rapes in adulthood, utilizing a relatively brief cognitive-behavioral treatment, Cognitive Processing Therapy (CPT). Treatment addressed assault-related PTSD, major depression, suicidality, compulsive self-harm behaviors, and primary and secondary dissociative responses. Treatment also addressed related issues of low self-esteem, social isolation, and the client's sense of helplessness, which had resulted in her failure to implement active selfJrrotection strategies. Client symptomatology was tracked throughout treatment using the PTSD Symptom Scale (PSS) and the Beck Depression Inventory (BD[) at regular intervals owr the course of 34 sessions and for 3 months posttermination. The relatively short course of therapy (22 weeks) and treatment strategies are described, including cognitive and behavioral components of CPT, supportive strategies, safety planning in the context of ongoing threats and victimization, and the importance of the therapeutic relationship. Particular emphasis is given to adaptation of the b~4ef treatment to complex symptomatology and patterns of symptomatic change in relation to cognitive and behavioral intervention. Find- ings indicate that treatment for individuals with extensive victimization histories does not require different strategies or a signifi- cantly longer period of treatment than does treatment for those with a single traumatic experience. E MPIRICALINVESTIGATIONS now strongly support a be- lief long held by clinicians working with child sexual abuse (CSA) survivors, specifically that CSA survivors are at increased risk for further sexual victimization in ado- lescence and adulthood (Messman & Long, 1996; Po- lusny & Follette, 1995). Both CSA and adult rape are as- sociated with numerous acute and chronic psychological difficulties, including PTSD symptomatology, depression, suicidality and self-harm behaviors, anxiety, substance abuse, dissociation, interpersonal difficulties, low self- esteem, and feelings of guilt and self-blame (for reviews see Goodman, Koss, & Russo, 1993; Polusny & Follette; Resick, 1993). It has been proposed that traumatic experiences and life stresses tend to be cumulative, such that individuals who have experienced many stressors tend to cope less effectively than people with fewer stressors (Hanson, 1990). Interpersonal violence in particular appears to have this cumulative effect. Previous victimization, in- cluding many different forms of child and adult abuse, is associated with more depression and longer recovery in women who have been raped (Kilpatrick, Saunders, Veronen, Best, & Von, 1987). Follette, Polusny, Bechde, and Naugle (1996) found that women with a history of three different forms of abuse (CSA, adult sexual assault, Cognitive and Behavioral Practice 9, 89-99, 2002 1077-7229/02/89-9951.00/0 Copyright © 2002 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved. [~ Continuing Education Quiz located on pp. 168-169. and adult physical abuse) reported higher levels of anxi- ety, depression, dissociation, sexual problems, and sleep disturbances than women with a history of only two forms of abuse, who in turn were more distressed than women with a history of only one form of abuse, and so on. Mur- phy and colleagues (1988) also found that women who were sexually victimized both in childhood and adult- hood reported higher levels of general distress, somatiza- tion, obsessive-compulsive behavior, depression, anxiety, hostility, and interpersonal sensitivity than women with a single sexual assault (either childhood or adulthood) or no history of victimization. Given that revictimized women have greater levels of psychological distress and trauma-related sequelae, clini- cians can anticipate that such women will have a more complicated clinical presentation, with severe levels of psychopathology, often accompanied by self-injurious be- haviors, impaired interpersonal relations, and maladap- tive coping skills. The question is, how does a history of repeated and often prolonged victimization affect the cli- ent in therapy? Will her problems require more time in treatment? Does treatment need to directly address every victimization experience, or even focus on every present- ing problem to be successful? Current research has strongly supported the efficacy of cognitive and behavioral interventions for treatment of PTSD symptomatology in trauma victims, particularly female rape victims (Foa, Rothbaum, Riggs, & Murdock, 1991; Resick & Schnicke, 1992). Neither of these studies excluded women with a prior history of victimization. Howevei, some may criticize such investigations, empha-