Clinical Case Studies

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Acceptance and Commitment Therapy With Survivors of Adult Sexual Assault: A Case
Study
Caroline J. Burrows
Clinical Case Studies 2013 12: 246 originally published online 13 March 2013
DOI: 10.1177/1534650113479652

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CCS12310.1177/1534650113479652Clinical Case StudiesBurrows

Article
Clinical Case Studies
12(3) 246­–259
Acceptance and Commitment © The Author(s) 2013
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DOI: 10.1177/1534650113479652
Sexual Assault: A Case Study ccs.sagepub.com

Caroline J. Burrows1

Abstract
A number of studies have found experiential avoidance to mediate the relationship between
sexual assault and adverse long-term effects. One treatment approach that has been developed
for the treatment of experiential avoidance is Acceptance and Commitment Therapy (ACT). A
small body of research has demonstrated preliminary efficacy for the use of ACT with trauma
survivors suffering from posttraumatic stress disorder (PTSD). However, no treatment studies
to date have evaluated ACT as a treatment model with survivors of adult sexual assault. In this
case study, ACT was applied to an 18-year-old survivor of adult sexual assault suffering from
PTSD symptoms. The results indicated that ACT was effective in reducing experiential avoidance,
thought suppression, trauma symptomatology, and increasing valued action and quality of life.
The findings of this study suggest that the use of grounding techniques, visual metaphors, and
experiential mindfulness exercises in ACT may be particularly helpful for survivors of adult
sexual assault.

Keywords
acceptance and commitment therapy, sexual assault, rape and trauma

Sexual assault is a violating experience that not only affects a person’s physical body but also his
or her emotionally and socially defined self. The impact of this social issue is far reaching not
only for individual survivors but also for their families, communities, and wider society. The
actual prevalence of sexual assault is not known, as it is the most underreported of all personal
crimes (Australian Bureau of Statistics [ABS], 2002). However, in an Australian study 1 in 3
women and 1 in 6 men reported having been sexually abused before the age of 18 years. This
included penetrative and nonpenetrative abuse (Najman, Dunne, Purdie, Boyle, & Coxeter,
2005). In an Australian Personal Safety Survey (ABS, 2006) 1 in 5 women and 1 in 20 men
reported having experienced some form of sexual threat or assault since the age of 15 years.

1Eastern Centre Against Sexual Assault, Ringwood East, Victoria, Australia

Corresponding Author:
Caroline J. Burrows, Eastern Centre Against Sexual Assault,
17 Ware Crescent, Ringwood East, Victoria 3135, Australia.
Email: [email protected]

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Burrows 247

1 Theoretical and Research Basis for Treatment

Research has demonstrated a connection between sexual assault and long-term psychological
distress, maladaptive behaviors, and impaired social and interpersonal functioning (Petrak,
2002). Recently, researchers have begun to examine mediational models hypothesized to help
account for the relationship between sexual assault and its long-term effects to understand how
psychopathology develops following sexual assault. The theory of experiential avoidance is one
model that has been proposed to help account for this relationship (Merwin, Rosenthal, & Coffey,
2009; Tull & Roemer, 2003).

Experiential Avoidance
Experiential avoidance has been defined as a person’s unwillingness to remain in contact with
aversive internal experiences (thoughts, memories, emotions, and physiological sensations) and
any action taken to alter the form or reduce the frequency of these experiences. This concept was
defined by Hayes, Strosahl, and Wilson (1999)—the researchers who developed Acceptance and
Commitment Therapy (ACT)—as an extension of existing theories of avoidance and thought
suppression.
Experiential avoidance has been found to be a primary coping mechanism in the aftermath of
trauma (Tull, Gratz, Salters, & Roemer, 2004). Examples include avoiding reminders of a sex-
ual assault, social withdrawal, thought suppression, and dissociation. Experiential avoidance
may be adaptive at times by providing a survivor with relief from distress and an increased
sense of control. However, studies have found that avoidance is negatively reinforced over time,
often generalizes to non-trauma-related stimuli, impedes emotional processing of trauma, and
contributes to the maintenance of posttraumatic symptoms (Follette, La Bash, & Sewell, 2010;
Rosenthal, Rasmussen Hall, Palm, Batten, & Follette, 2005; Salters-Pedneault, Tull, & Roemer,
2004; Thompson & Waltz, 2010).
Experiential avoidance has also been found to be detrimental when the internal experiences
being avoided are in the pursuit of something that matters to the person. For example, by focus-
ing wholly on avoiding trauma-related thoughts, emotions and memories, a sexual assault survi-
vor may act in ways that serve to avoid pain at the expense of developing future intimate
relationships (Wilson & Murrell, 2004). The enormous time and effort devoted to experiential
avoidance diminishes their ability to engage with the present moment and to take committed
action that is consistent with their personal values. Finally, many behaviors aimed at avoiding or
controlling distress such as substance use, self-injury, and social withdrawal are in and of them-
selves problematic, life interfering, and exacerbate a person’s level of distress.
A growing body of literature indicates that experiential avoidance has an influential role in the
development and maintenance of psychological symptoms among survivors of sexual assault
(Batten, Follette, & Aban, 2001; Boeschen, Koss, Figueredo, & Coan, 2001; Marx & Sloan,
2002). This has key implications for treatment with this client population. It would seem impor-
tant that treatment models for survivors of sexual assault target experiential avoidance, while
promoting acceptance of aversive internal experiences (Merwin et al., 2009). This is why ACT
has great potential to assist survivors of sexual assault.

ACT
ACT is a mindfulness, acceptance and values-based psychotherapy grounded in the behavioral
and cognitive behavioral traditions (Hayes et al., 1999). This model of psychotherapy may be
particularly suited to the treatment of survivors of sexual assault, as it was “specifically devel-
oped to reduce experiential avoidance” (Batten & Hayes, 2005, p. 248).

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248 Clinical Case Studies 12(3)

In contrast to treatment models that emphasize cognitive restructuring and symptom reduc-
tion, the goal of ACT is not to change trauma-related thoughts or reduce symptoms. Rather, ACT
targets experiential avoidance by providing the client with an alternative stance of willingness
and acceptance. The aim is for the client to transform their relationship with their aversive inter-
nal experiences so that they no longer perceive them as “symptoms” but rather as harmless (albeit
uncomfortable) transient psychological events. It is believed that this process frees the client
from engaging in a struggle with their internal experiences and allows them more “psychological
flexibility”—an ability to engage in valued activities while also making room for distressing or
unwanted internal experiences (Hayes, Luoma, Bond, Masuda, & Lillis, 2006).
Symptom reduction often occurs as a result of these processes, but it is seen as a by-product
and not a goal. The client’s progress in therapy is not measured solely by symptom reduction, but
more importantly, by a decrease in experiential avoidance, an increase in willingness to remain
in contact with aversive internal experiences and an increase in values-guided action and quality
of life (Harris, 2006).
ACT is a treatment model that utilizes a mix of metaphor, paradox, mindfulness skills, experi-
ential exercises, and values-guided behavioral interventions. Each intervention is intended to
increase the client’s acceptance of aversive internal experiences and commitment to taking values-
guided action. There are six core processes in ACT: acceptance, defusion, self-as-context, contact
with the present moment, values, and committed action. A full description of each process is
beyond the scope of this case study, but can be found in an ACT textbook by Harris (2009).
A growing number of studies have supported the use of ACT with a range of disorders, includ-
ing depression (Bohlmeijer, Fledderus, Rokx, & Pieterse, 2011), generalized anxiety disorder
(Roemer, Orsillo, & Salters-Pedneault, 2008), panic disorder (Levitt, Brown, Orsillo, & Barlow,
2004), psychosis (Bach & Hayes, 2002), substance abuse (Hayes et al., 2004), smoking (Gifford
et al., 2004), diabetes management (Gregg, Callaghan, Hayes, & Glenn-Lawson, 2007), chronic
pain (McCracken, Vowles, & Eccleston, 2005), and borderline personality disorder (Gratz &
Gunderson, 2006).
Several case studies have demonstrated preliminary efficacy for the use of ACT with trauma
survivors suffering from posttraumatic stress disorder (PTSD; Orsillo & Batten, 2005; Twohig,
2009), including one case study with a 19-year-old survivor of childhood sexual abuse presenting
with comorbid PTSD and substance abuse (Batten & Hayes, 2005). ACT has also been applied
as a group treatment model to Australian war veterans suffering from PTSD (Williams, 2007).
However, no treatment studies to date have evaluated ACT as a treatment model with survivors
of adult sexual assault. This provided the impetus for the current case study.

2 Case Introduction
Sandra was an articulate 18-year-old student in her final year of high school. At the commence-
ment of her ACT treatment, she was residing with her mother, grandmother, and 2 half sisters,
aged 7 and 2 years. She was in poor physical health, suffering from chronic respiratory infections
and joint pain. Her mother referred her for sexual assault counseling, expressing concern that
Sandra was frequently teary and withdrawn.
During the intake call, Sandra reported to the therapist that 6 months earlier her boyfriend had
raped her. He had also been emotionally abusive and controlling throughout their 3-month rela-
tionship. Although Sandra ended the relationship the day after the rape occurred, she did not
disclose what had happened until 3 months later when she confided in a friend. She did not wish
to report the assault to police. Sandra expressed anxiety about coming for counseling but agreed
with her mother’s assessment that she was not coping emotionally and would benefit from having
someone to talk to about how she was feeling. Sandra attended her first session 1 week later.

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3 Presenting Complaints
In the intake session, Sandra appeared highly anxious. She clutched onto her handbag, her hands
were trembling, and she withheld eye contact. Sandra reported that in the 6 months since the
assault, she had been fearful and hypervigilant, particularly when in public. She experienced
anxiety and flashbacks when triggered by stimuli that reminded her of the assault. As a result, she
stayed home much of the time and avoided going out alone. She experienced repetitive night-
mares that reenacted the assault and stayed up late each night to avoid going to bed, for fear of
having a nightmare. This lack of sleep exacerbated her distress, as she felt physically sick,
exhausted, and irritable.
Sandra revealed that she suffered from anxiety and depression and was taking Prozac, pre-
scribed by her general practitioner. She had suffered from low self-worth for many years, but in
the months following the assault, this had developed into “self-loathing and hatred.” Sandra
viewed herself as “disgusting.” Although she knew intellectually that she was not responsible for
the sexual assault, she continued to struggle with guilt and self-blame and chastised herself for
having remained in the relationship with her boyfriend as long as she did, given how poorly he
treated her.

4 History
Sandra reported an emotionally tumultuous childhood. Her father suffered from bipolar disorder
and abused drugs and alcohol. He was violent toward her mother and they separated when Sandra
was aged 2. For much of her childhood, Sandra’s father was incarcerated for drug-related
offenses. Sandra did not have any face-to-face contact with him between the ages of 2 and 17,
due to an intervention order that prohibited him from contacting her. When Sandra was aged 8,
her mother repartnered and she witnessed intimate partner violence. Over time, her mother devel-
oped depression and relied on Sandra for emotional and practical support. Sandra described their
relationship as “more like sisters than mother and child.” She was a bright student but found it
difficult to juggle her schoolwork with her responsibilities at home.
At age 14, Sandra was diagnosed with anxiety and depression and received treatment from
a psychiatrist over the next 2 years. Sandra’s grandmother moved into the family home when
her mother separated from her partner. Sandra reported that her grandmother suffered from
borderline personality disorder and was “emotionally reactive and unpredictable.” Strong
restrictions were placed on Sandra’s social life and she believed that her mother and grand-
mother felt threatened by her growing independence. She found it difficult to stand up for
herself or assert her needs.

5 Assessment
The following self-report questionnaires were administered pre- and post-treatment and at 8
months follow-up.

Acceptance and Action Questionnaire-II (AAQ-II)

The AAQ-II (Bond et al., 2011) is a 7-item questionnaire that measures psychological flexibility
and experiential avoidance. It uses a 7-point Likert-type scale (1 = never true, 7 = always true) to
measure a participant’s agreement with a range of statements. A score is obtained by summing all
of the responses together, with higher scores indicating greater levels of psychological inflexibil-
ity and experiential avoidance. The AAQ-II was not designed as a tool for diagnosing mental
disorders. However, the researchers found that a score range of 24 to 28 on the AAQ-II was

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250 Clinical Case Studies 12(3)

associated with the cutoff points of three measures of psychopathology: the Beck Depression
Inventory-II (BDI-II), General Health Questionnaire-12 (GHQ-12), and Symptom Checklist-90.
This suggests that AAQ-II scores in this range or above may indicate a clinically relevant level
of distress (Bond et al., 2011). Sandra’s pretreatment score of 36 on the AAQ-II suggested a high
level of psychological inflexibility and experiential avoidance, and a clinical level of distress.

White Bear Suppression Inventory (WBSI)

The WBSI (Wegner & Zanakos, 1994) is a 15-item self-report questionnaire designed to measure
the tendency to suppress unwanted thoughts. Participants are asked to rate the truth of each state-
ment as it applies to them, using a 7-point Likert-type scale (A = strongly disagree, E = strongly
agree). A total score between 15 and 75 is obtained by summing all of the responses together.
Higher scores on the WBSI indicate greater tendencies to suppress thoughts. Sandra’s pretreat-
ment score of 73 on the WBSI indicated a very high level of thought suppression.
In a case study conducted by Batten and Hayes (2005), an older version of the AAQ and the
WBSI were used to evaluate the effectiveness of ACT with a female 19-year-old survivor of
childhood sexual abuse presenting with comorbid PTSD and substance abuse. Over the course
of treatment, the client reported a reduction in experiential avoidance and thought suppression
on the AAQ and WBSI and these gains were maintained at 12-month follow-up. The AAQ
results in this study were comparative to Sandra’s results on the AAQ-II. Sandra showed a
greater reduction on the WBSI over the course of ACT treatment, but this may be explained by
her pretreatment score being much higher than that of the client in Batten and Hayes’ study (73
compared with 48).

Trauma Symptom Checklist-40 (TSC-40)

The TSC-40 (Briere & Runtz, 1989; Elliott & Briere, 1992) is a research instrument that mea-
sures symptomatology in adults who have experienced childhood or adult traumatic experiences.
It is a 40-item self-report questionnaire consisting of six subscales: Anxiety, Depression,
Dissociation, Sexual Abuse Trauma Index, Sexual Problems, and Sleep Disturbance. Participants
rate each symptom according to how frequently it occurred in the previous 2 months, using a
4-point Likert-type scale (0 = never, 3 = often). Individual subscale scores can be obtained by
summing particular items together. However, for the purposes of this case study, only an overall
total score of between 0 and 120 was calculated. Sandra’s pretreatment score of 70 indicated a
moderate level of trauma symptomatology. This is comparative to a mean score of 71.81 in a
study with 95 female inpatients with a history of childhood sexual abuse (Zlotnick et al., 1996).
In a survey with 2,963 professional women, the TSC-40 was found to be reliable and display
predictive validity with regard to childhood sexual abuse. Women who reported a sexual abuse
history scored significantly higher on the TSC-40 than did those without such a history (Elliott &
Briere, 1992).

Valued Living Questionnaire (VLQ)

The VLQ (Wilson & Groom, 2002) is a two-part questionnaire designed to assess valued living,
or the extent to which an individual lives consistently with his or her values. In the first part of
the questionnaire, participants rate on a 10-point Likert-type scale (1 = not at all important,
10 = extremely important) the importance of 10 common life domains. In the second part, partici-
pants rate how consistently they have lived according to their values across each life domain over
the previous week (1 = not at all consistent with my value, 10 = extremely consistent). A valued
living composite ranging from 1 to 100 is calculated by multiplying the two responses for each

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Burrows 251

life domain and then calculating the mean of those scores. A high composite indicates that an
individual is living consistently with their values. Separate “importance” and “consistency”
scores can also be calculated. Sandra’s pretreatment valued living composite of 38 and impor-
tance and consistency scores of 63 and 53, respectively, indicated a disparity between her stated
values and behavior. To the author’s knowledge, this is the first study to use the VLQ as an
assessment measure with a survivor of sexual assault.

6 Case Conceptualization
Drawing on an ACT model of psychopathology, the therapist conceptualized Sandra’s concerns
as largely the result of ineffective and pervasive efforts at experiential avoidance. When con-
fronted with intrusive trauma symptoms, Sandra did everything she could to prevent such experi-
ences from reoccurring. She used internal control strategies such as thought suppression and
rumination and engaged in behavioral avoidance, particularly delaying going to bed, staying at
home, withdrawing from friends, and avoiding disclosing the assault.
These actions provided Sandra with short-term relief, which may have assisted her func-
tioning in the immediate aftermath of the assault. However, this initial relief negatively rein-
forced her reliance on avoidance strategies, which became a chronic form of coping (Follette
et al., 2010). Over time, Sandra’s avoidance generalized to non-trauma-related stimuli and
made it very difficult for her to cope with stress at home and school. Sandra’s self-blame for
the assault may have also functioned to provide her with an increased sense of control over the
experience and a belief that she could protect herself from possible future assaults. However,
the more Sandra blamed herself, the more entangled she became in unhelpful thoughts and
self-loathing.
The therapist hypothesized that Sandra’s childhood trauma complicated her response to the
sexual assault and that she had relied on experiential avoidance since a young age. Sandra
appeared to find it extremely difficult to connect with a sense of self beyond her life experiences
of trauma, defining herself as “broken.” When she presented for treatment, she felt overwhelmed
by a variety of life stressors. A lack of social support and severe conflict in the family home had
exacerbated her posttraumatic stress and hindered her recovery from the assault.

7 Course of Treatment and Assessment of Progress

Course of Treatment
Sandra’s ACT treatment was conducted by a social worker and psychotherapist (the author) at a
sexual assault counseling clinic. Sandra attended an intake session followed by 18 ACT treatment
sessions over a 10-month period. Sessions were 50 min in duration.

Sessions 1 to 6. The first phase of Sandra’s treatment focused on increasing her contact with the
present moment, as much of her time was spent reliving the past trauma or fearing the future.
She was taught to ground herself by planting her feet into the ground, following her breath and
connecting with her five senses. Sandra requested that treatment initially focus on her night-
mares as a lack of sleep was exacerbating her physical health complaints and hindering her
ability to concentrate at school. Although she attributed her impaired functioning to her night-
mares, the therapist conceptualized that it was her avoidance of going to sleep (for fear of hav-
ing a nightmare) that was more problematic. Sandra had not considered this possibility before
but surmised that avoiding going to bed increased her fear of nightmares, which paradoxically
increased the occurrence of nightmares. The therapist suggested that treatment not explicitly

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252 Clinical Case Studies 12(3)

focus on trying to reduce her nightmares but on establishing a sense of safety in the present so
that she no longer felt engulfed by nightmares or the need to avoid going to sleep. Sandra
expressed some skepticism of this approach but agreed to give it a try.
Sandra experienced a high level of external stress in the early phase of treatment. She was
living in an “intolerable” home environment while trying to complete the final months of high
school. Sandra believed that these stressors were impeding her recovery from the trauma, so
treatment shifted to targeting values and committed action. The therapist worked with Sandra
to identify her values in the domains of self-care, education, and boundaries in personal rela-
tionships. Sandra identified a number of small steps that she could take toward communicat-
ing her needs to her mother and exploring options for alternative accommodation. Sandra
identified the goal of moving out of home so that she could focus on preparing for her school
exams. However, she was anxious about her mother’s possible reaction and felt guilty for
“abandoning her.” Sandra’s guilt appeared to be long-standing and not just a response to the
sexual assault.
Defusion was the next core process targeted in treatment, as Sandra frequently ruminated on
negative self-evaluations such as “I am hideous.” The therapist explained defusion didactically
and then facilitated a classic ACT exercise to enable her to experience it directly. With her eyes
closed, Sandra was invited to bring to mind a recurring self-judgment, dwelling on it for a few
seconds. Then, she was asked to silently repeat the exact same thought but to preface it with the
phrase “I’m having the thought that . . . ” Next she was invited to repeat the same thought again,
but with a longer phrase in front of it: “I notice that I’m having the thought that . . . ” After each
step, she was asked to simply notice what happened.
On reflection, Sandra reported that the thought had not gone away but that it seemed less literal,
more like a hypothesis of her mind than an objective fact. Sandra was encouraged to regularly
practice this technique whenever she noticed her mind fusing with self-critical or otherwise
unhelpful thoughts. No attempt was made to challenge or eliminate her thoughts. The aim was to
change Sandra’s relationship with her thoughts, so that she experienced more flexibility to take
action that was guided by her values, rather than dictated by the content of her thoughts.

Sessions 7 to 12. The therapist waited until the middle phase of treatment to explore Sandra’s
experiential avoidance in detail, as some time was needed to create a safe holding environment
due to Sandra’s psychological fragility and external stressors. By the seventh session, Sandra had
started to relate differently to her internal experiences and was taking effective steps to address
the stressors in her life. She had moved out of her family home and in doing so made room for
feelings of guilt, anxiety, and pressure from her mother to move back home. This decision was
affirmed by the positive changes that she noticed in her sleeping and ability to focus on her
schoolwork.
Although Sandra had not thought much about the concept of avoidance before, she now
noticed that the more she fought against her feelings of guilt about the sexual assault, the more
anger she felt when she could not get rid of her guilt. This led her to become entangled in a
cycle of frustration and distress. During an experiential mindfulness of the breath exercise
Sandra noticed that “resting into” uncomfortable sensations reduced her fear of these internal
experiences and need to struggle against them. In future sessions, she used the metaphor of
“struggling in a rip” to describe times when she noticed an increase in her level of experiential
avoidance.
“Self-as-context” was a key focus throughout Sandra’s treatment as she appeared to be
attached to a sense of being “broken” by her experience of sexual assault and reported feeling
consumed by her painful emotions. The therapist worked with her to connect with a transcendent
sense of self so that she could experience herself as the context in which her thoughts, emotions,

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Burrows 253

memories, and sensations occurred, rather than being defined by the content of these experiences.
Metaphors such as the “sky and weather” were used to describe this concept and exercises were
facilitated to help Sandra experience a core sense of self that remained stable in the midst of her
transient internal experiences. Not surprisingly, given Sandra’s long history of struggling with
her sense of self, she found this very difficult.

Sessions 13 to 18. Sandra’s low self-worth was a recurring theme throughout her treatment. She
continually struggled with negative self-evaluations and found it particularly difficult to defuse
from thoughts that she believed to be true, such as “I’m ugly.” The concept of “workability” was
introduced, which is a key concept in ACT that relates to how well something works in the long
term toward creating a rich and meaningful life (Hayes et al., 1999). The therapist suggested that
it might be more helpful for Sandra to look at her thoughts not in terms of whether they were true
or false but whether it was helpful for her to get caught up in them. Sandra learned thereby that
her thoughts did not equate to reality nor need to dictate her action. This realization appeared to
be liberating for Sandra, as it loosened her attachment to the labels that had previously defined
her. She reported that it was no longer as important what thoughts passed through her mind,
because she could decide whether she engaged with them or let them go.
The 16th session was a turning point in treatment. Sandra had not attended a session in 8
weeks, after cancelling consecutive sessions due to ill health and new employment. She arrived
in a highly anxious state and reported that she had been “struggling in the rip again.” When asked
to identify where she felt the strongest sensation in her body and to give it a character and a name,
Sandra visualized a friendly dragon that was safely contained within a cave, which represented
her. The cave was strong and could not be harmed or engulfed by the dragon.
Sandra was encouraged to nurture and create space for the dragon, noticing how it changed
over time. There was a marked shift in Sandra’s relationship to her emotions after this exercise.
She came to view her anxiety as a companion to be lived with, “kind of like a difficult house-
mate,” rather than an enemy to be feared. She communicated with the friendly dragon in a light-
hearted way and in the following sessions would report on how “active” the dragon had been in
the previous week. Drawing on a unique ACT technique, Sandra found it helpful to defuse from
self-diminishing thoughts by saying them in a “dragon’s voice” as this enabled her to develop a
more flexible relationship with her thoughts and take them less literally.
Treatment concluded fairly abruptly, as Sandra commenced a full-time job and was no longer
able to attend sessions during business hours. She reported some anxiety about concluding treat-
ment but felt confident that she had learned a range of skills that she could continue to implement
in her everyday life. In the final two sessions, the therapist worked with Sandra to review her
values and continue to approach situations that evoked anxiety but took her in the direction of her
stated values. Sandra found it helpful to replace the word “but” with “and” when describing situ-
ations (e.g., “I want to go to work and I’m feeling anxious”) to remind herself that she had control
over her actions, even in the face of difficult internal experiences.

Assessment of Progress
In contrast to more traditional treatment models, symptom reduction was not an explicit goal in
this treatment. However, a reduction in Sandra’s experiential avoidance was accompanied by a
reduction in trauma symptoms. This finding lends support to the literature suggesting that expe-
riential avoidance accounts for much of the psychological distress experienced by survivors of
trauma (Walser & Westrup, 2007). Sandra’s progress was measured not solely by symptom
reduction but more importantly by a reduction in experiential avoidance and thought suppression
and an increase in valued living.

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254 Clinical Case Studies 12(3)

Table 1. Sandra’s Assessment Questionnaire Scores.

First session Final session 8 months follow-up

AAQ-II 36 26 26
WBSI 73 57 48
TSC-40 70 45 35
VLQ (composite) 38 42 44
VLQ (importance score) 63 66 64
VLQ (consistency score) 53 56 61

Note: AAQ-II = Acceptance and Action Questionnaire-II; WBSI = White Bear Suppression Inventory;
TSC-40 = Trauma Symptom Checklist-40; VLQ = Valued Living Questionnaire.

Sandra’s self-reported questionnaire scores (Table 1) indicated improvement across all four
measured domains. Her pretreatment score of 36 on the AAQ-II suggested a high level of psy-
chological inflexibility and experiential avoidance. At the end of treatment, her score had
decreased to 26, which suggested a moderate reduction in experiential avoidance and increase in
psychological flexibility over the course of treatment. However, her posttreatment score was still
within the AAQ-II range of 24 to 28 that may indicate a clinically relevant level of distress (Bond
et al., 2011).
Sandra’s pretreatment score of 73 on the WBSI indicated a very high level of thought suppres-
sion. At the end of treatment, this had reduced to 57, indicating a reduction in thought suppression.
Although symptom reduction was not a direct goal of treatment, there was a marked reduction in
Sandra’s level of trauma symptomatology over the course of treatment. Her pretreatment score of
70 on the TSC-40 reduced to 45 by the end of treatment.
Sandra’s initial valued living composite of 38 on the VLQ indicated a disparity between her
stated values and behavior. This did not change much over the course of treatment, only increas-
ing to 42 when measured posttreatment. Her importance and consistency scores on the VLQ also
only increased marginally, from 63 and 53 at pretreatment to 66 and 56 posttreatment. These
results were surprising to the therapist, as her observations and Sandra’s reflections suggested
that there had been a significant increase in her valued action over the course of treatment. The
therapist hypothesized that this may have been due to the structure of the VLQ. This question-
naire measured the extent to which Sandra had acted in accordance with her values in the previ-
ous week. The particular circumstances of that week (such as stress in her new job) may have
affected Sandra’s level of valued action, and thus her responses on the VLQ.
At the end of ACT treatment, Sandra reported that there had “definitely been evident changes
in [her] life” over the course of treatment. In the early sessions, she was extremely fearful of her
emotions and spent most of her time reliving the sexual assault or worrying about the future.
Over time, however, she experienced a shift in her relationship with her internal experiences. She
lived more in the present moment and made a choice to stop struggling to think and feel better
and instead focus on what was important in her life. She started to move forward with her fear,
anxiety, and depression rather than standing still and battling it. In addition, to her surprise, these
emotions started to lose their power over her life.
By the end of the treatment, Sandra had moved out of home and asserted clear boundaries
with her mother and reported that she was communicating openly with her boyfriend, socializ-
ing more often and attending work regularly. She had also seen a marked reduction in flash-
backs and nightmares and improvement in her sleep, concentration, and physical health. There
was also a noticeable change in Sandra’s in-session presentation. In the early sessions, she with-
held eye contact, trembled, and spoke rapidly. In the later sessions, she appeared to be more
confident and settled, as indicated by her maintaining eye contact, sitting comfortably in her
chair without fidgeting and speaking at a more relaxed pace.

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Burrows 255

An area in which Sandra continued to struggle post-treatment was her self-image. She con-
tinued to frequently experience self-diminishing thoughts, which was not surprising to either
her or the therapist because her low self-worth was an issue that predated the sexual assault.
However, the value of ACT was that she learned how to defuse from these thoughts, rather than
take them literally. Sandra also reported that her feelings of guilt about the sexual assault
shifted and that by the end of the treatment she realized that “it was not [her] fault.” She identi-
fied that it had been very important to be believed and validated by the therapist, as this taught
her to have compassion for herself and start to “respect” her own feelings rather than fight
against them.
The following statements made by Sandra in her final session demonstrate her changed per-
ception of acceptance over the course of treatment:

I entirely rejected the idea [of acceptance] to begin with. I thought it was stupid, actually. I didn’t think
there would be any merit, but my entire concept of that has changed. I have found the ACT approach
very refreshing . . . I am far more willing now . . . acceptance has been an integral step in my recovery.

8 Complicating Factors
Sandra’s physical health conditions affected the flow of her treatment. She frequently cancelled
appointments, owing to chronic respiratory infections and joint pain. It is common for survivors
of sexual assault to experience physical health complaints, as trauma symptoms often manifest in
somatic form (Rothschild, 2000). Sandra’s physical complaints might have also functioned to
distract her from painful thoughts, emotions, and memories. The frequent interruption to Sandra’s
sessions may have prolonged her treatment. Nonetheless, Sandra still achieved significant change
over the course of treatment.
A potential confounding factor in this study was that Sandra received pharmacological treat-
ment (Prozac) for anxiety and depression while undergoing ACT treatment. However, she was
already taking Prozac when she commenced ACT sessions and her dosage remained the same
throughout her ACT treatment and the follow-up period.

9 Access and Barriers to Care

Treatment was provided from a free service where there was no restriction to the number of ses-
sions that Sandra could access. She was able to access counseling for as long as was clinically
indicated. However, Sandra’s treatment ended fairly abruptly when she commenced full-time
work because the center where she was receiving treatment only offered appointments during
business hours. As a result, sessions could not be tapered out in the final stages of treatment, as
the therapist and Sandra believed would have been ideal.

10 Follow-Up
Sandra received a phone call 8 months after treatment ended. She reported that she was doing
well and continued to regularly implement the strategies that she had learned in her ACT ses-
sions. The next day, the therapist mailed Sandra four self-report questionnaires (AAQ-II, WBSI,
TSC-40, and VLQ) to measure whether her clinical improvement had been maintained. Sandra
completed these questionnaires at home and mailed them back to the therapist within a week. As
seen in Table 1, there was a further decrease in trauma symptomatology and thought suppression
and a marginal increase in her valued living composite. Sandra’s level of psychological flexibil-
ity had remained the same.

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256 Clinical Case Studies 12(3)

Sandra phoned the therapist 4 months later to update her on how she was doing. Sandra
reported that she was moving interstate with her boyfriend and had enrolled in a psychology
degree. Although she was experiencing some anxiety about these life changes, she was confident
that she was working toward increasing her quality of life in the long term. She felt proud that her
actions were increasingly guided by her values rather than efforts to avoid or control emotional
distress.

11 Treatment Implications of the Case

The findings of this study have a number of implications for the treatment of survivors of adult
sexual assault. This study provided an example of how promoting acceptance as an alternative to
experiential avoidance can lead to a reduction in psychological distress and increased quality of
life. This provides supporting evidence for the ACT conceptualization of the long-term sequelae
of sexual assault and suggests that reducing experiential avoidance is an important target when
working with this client population.
This study adds to the existing evidence for ACT as an effective treatment model in reducing
experiential avoidance and shows how ACT may be well suited to the treatment of survivors of
adult sexual assault. In this case study, it was concluded that ACT reduced Sandra’s experiential
avoidance and increased quality of life by offering willingness as an alternative, grounding her in
the present moment, reducing her fear of trauma symptoms, restoring her personal values, and
engaging her in committed action. The findings of this study suggest that the visual metaphors
and experiential exercises in ACT and its emphasis on values and committed action make it an
effective and distinct model of treatment for survivors of adult sexual assault. Although the find-
ings validate the use of grounding techniques within ACT, it is important to note that the concept
of grounding is not unique to ACT. Grounding techniques are commonly taught to trauma survi-
vors within a range of trauma therapies (Briere & Scott, 2013).
This study contributes to the small body of literature on the effectiveness of ACT as a treat-
ment model for trauma survivors. To the therapist’s knowledge, this was the first case study to
directly examine the use of ACT with a survivor of adult sexual assault. A limitation of this study
was that it was a single case study, which prevented the therapist from being able to confidently
draw conclusions of a wider applicability. As such, more empirical evidence is necessary to
determine the effectiveness of ACT in the treatment of survivors of adult sexual assault.

12 Recommendations to Clinicians and Students

The findings of this study support three specific recommendations for those considering using
ACT with survivors of adult sexual assault.
First, it may be helpful to start with the “contact with the present moment” phase of ACT treat-
ment. Survivors of sexual assault commonly spend much of their time reliving the assault or
fearing the future. It is possible to overwhelm or even retraumatize a client if adequate attention
is not first given to teaching them differentiate the past from the present and establish a sense of
safety. Therefore, it is recommended that trauma treatment begin with an emphasis on safety and
stabilization (Briere & Scott, 2013). An initial focus on grounding the client in the present
moment will also help to forge a strong foundation for ACT treatment. Clients may be less likely
to avoid or control their unwanted internal experiences if they are confident that in moments of
distress they have a range of tools to anchor them in back in the present moment.
Second, clinicians and students are encouraged to make particular use of visual metaphors and
experiential exercises when using ACT with survivors of sexual assault. In this case study, Sandra
reported that these interventions were instrumental in reducing her experiential avoidance by
alleviating her fear of trauma symptoms. She learned that while the total effect of an emotion

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Burrows 257

seemed overwhelming, when examined in its individual parts and conceptualized differently
(e.g., as a friendly dragon), there was nothing fearsome there after all. A reduction in Sandra’s
fear of trauma symptoms was accompanied by an increase in her willingness to create space for,
rather than fight against these unwanted internal experiences.
Third, researchers could consider using depression and anxiety measures to further assess the
effectiveness of ACT on symptom alleviation among adult survivors of sexual assault. A limita-
tion of this study was that the therapist did not administer any anxiety or depression measures,
which limited her ability to assess the effect of ACT on these symptoms over the course of
Sandra’s treatment. Clinicians and students are encouraged to utilize these measures when using
ACT to treat survivors of sexual assault, particularly with clients presenting with symptoms of
anxiety or depression.
The findings of this case study suggest that ACT is a promising treatment model for survivors
of adult sexual assault. Clinicians and students working in this field are encouraged to conduct
further research into the effectiveness of ACT with this client population.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publi-
cation of this article.

Funding
The author received no financial support for the research, authorship, and/or publication of this article.

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Author Biography
Caroline J. Burrows is a social worker and psychotherapist in Melbourne, Australia. She currently works
at the Eastern Centre Against Sexual Assault, providing counseling and advocacy services to child, adoles-
cent, and adult survivors of sexual assault.

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