RAPE TRAUMA SYNDROME
Sexual assault is a crime problem that is increasing in North America. It is the most common trauma that is likely to produce symptoms
similar to those of PTSD. Ellis (1983) suggests that there are three sequences in reaction to rape: a short-term, intermediate and
long-term reaction. Short-term reaction is characterized by a range of traumatic symptoms, such as somatic complaints, sleep
disturbance and nightmares, fear, suspiciousness, anxiety, major depression and impairment in social functioning. Rosenhan and
Seligman (1989) claim that the crisis immediately following the rape is affected by the emotional style of the victim. Some women express
their feelings, showing fear, anxiety; they often cry and are tense. Other women try to control their expression, mask their feelings and they
attempt to look calm.
Symptoms remain relatively stable after 2 or 3 months. Three months to 1 year post-assault, in intermediate phase, the diffuse anxiety
usually becomes rape-specific. Women then experience depression, social and sexual dysfunction. The long-term reaction, 1 year
following the assault, involves anger, hypervigilance to danger, sexual dysfunction and diminished capacity to enjoy life (Ellis, 1983).
According to the descriptive study, conducted by Renner et al. (1988), only 10% of rape victims do not show any disruption of their
behavior following the assault. The behavior of 55% of them is moderately affected and 35% of the victims are unable to continue their
lives without very severe impairment. Several months down the road after the assault, 45% of women are able to readjust themselves;
however, 55% of the victims suffer from lasting effects.
It may be inferred that more than half of rape victims show some level of rape trauma. Depression and social adjustment usually improve
within several months following the trauma. On the other hand, fear, anxiety, reliving the trauma, sleep disturbances, nightmares,
avoidance of the stimuli reminiscent of the assault, these are the symptoms that persist in many victims for years, if not forever. The
victims also have problems in relationships with significant others and authority; their work satisfaction is lower than that of controls and
their hope for future is negatively affected. In addition, their self-esteem is lower than in other women even 2 years post-assault. (Murphy
et al., 1988)
Factors in development and course of Rape Trauma Syndrome
To understand the situation and feelings of a rape victim, one must take into account several factors. The probability of developing rape
trauma syndrome and its severity are obviously influenced by the victims personal characteristics. It is apparent that women with a large
variety of coping skills and with high emotional and psychological stability are less likely to experience symptoms of rape trauma
syndrome than are women without such equipment. For example, Cohen and Roth (1987) found that both approach and avoidance
coping strategies were negatively related to recovery. However, since rape is an attack on one of the most vulnerable aspects of a
person, it is very hard to cope with for nearly every woman. Therefore, the psychological strength is not only the only factor, but it must not
even be the most important one.
A point must be made that rape has a social nature. The victim must deal not only with the rape and the impact on her, but also with
reactions of others to it. Renner (1988) suggests that the victim is caught in "no win" situation. If the woman decides to fight back at the
time of the assault, she is more likely to receive social support from her family and friends; and police and medical personnel are more
likely to believe her. On the other hand, she has to pay a price for this support. First, she is more likely to be injured from the assault. Thus,
she would need medical attention, the police would be involved, and she would have to give explanation to many people. Her immediate
crisis would be then very severe.
However, if the victim does not risk injury, she is less likely to receive support or to be believed by police and court. She would be blamed
by herself and by others for failing to resist and she would feel more guilt and have more difficulties to resolve the problem in the long run
(Renner et al., 1988).
This is only a part of the social problems associated with sexual assault. The stereotypes about rape are still very prevalent in public and
even worse, in police officers and law courts. This may account for unsensitive treatment that victims receive from representatives of
these institutions. Victims are often asked questions about their own behavior, attire, sexual life and mental health: questions that direct to
impose the blame on the victim. Actually, there are an enormous amount of rape cases that do not pass on to the judicial system because
of certain characteristics of the victim. These features are, for example, consumption of alcohol by the victim, her history of unmanageable
behavior, being divorced, separated or single mother, unemployed or on welfare. Also, if the victim has known the offender (which is true
in about 70% of cases), has accepted a ride in his car, or has voluntarily accompanied the rapist to his home, the police are likely to
reject her case as unfounded (Clark, Lewis, 1977).
The support that the victim receives from her parents, husband or boyfriend and friends plays a very important role in the victim's coping
with the situation. Their support and understanding are very helpful to the victim. However, these significant others often have a difficult
time dealing with the assault themselves. In some cases, women are rejected by their partners or blamed for not fighting off the offender
(Renner, 1988).
Cohen and Roth (1987) found that individual differences in severity of symptoms were related to the age of victim, socioeconomic status,
and prior history of sexual assault (in childhood or adulthood). The response was also related to whether the victim reported the rape to
the police and whether she confided in someone shortly after the assault. Another factor is the use of force, verbal, physical threats or of a
weapon by the offender
Behavioral approach to rape trauma treatment
Before the discussion about possible treatments for rape trauma syndrome begins, prevention should be mentioned. In this connection,
prevention may have two connotations. The first is prevention of the rape itself. It is beyond the scope of this article to resolve crime
problems. The only thing to be mentioned is the possibility to increase the public awareness of date rape and of ways to avoid it. The
second connotation is prevention of rape trauma syndrome. Rape trauma syndrome does not have to occur immediately after the assault.
If the victim seeks professional help immediately after the rape, she will be less likely to suffer from symptoms of rape trauma syndrome.
(Rosenhan et al., 1989) She may contact some center of service for sexual assault victims or other institution concerned with crisis
intervention. These centers give the victims immediate support, information and they attempt to equip these women with coping skills
needed to deal with the crisis. Early crisis intervention may decrease the probability of onset of rape trauma syndrome. If the symptoms
occur and last for more than one month, the patient is diagnosed with the rape trauma syndrome. In this case, she should engage in some
type of therapy discussed below.
COGNITIVE-BEHAVIORAL THERAPY
Cognitive-behavior therapy is a combination of techniques and principles of both cognitive and behavioral therapies. Since the victim of
rape often needs to acquire new coping skills to deal with her anxiety and her situation, cognitive-behavior therapy may be helpful to the
victim. Stress inoculation in Resick's study (1988), for example, produced lasting effects. In stress inoculation, as in other cognitive-
behavior therapies, the patient goes through three phases. the first sequence consists of uncovering the patients existing coping skills by
both the therapist and the patient. This phase may also include an educative part, in which the victims learn about the development of fear
and anxiety following the rape. In the second sequence, new coping skills are acquired. The patient learns progressive relaxation, new
cognitive techniques, such as thought-stopping, guided self-dialogs and covert rehearsal. The third sequence involves application and
practice. The patient practices new skills in fear-producing but not dangerous situations. In this way, she learns to control fear and she
attempts to interrupt the avoidance behavior. (Zimbardo, 1985; Resick, 1988). The stress inoculation program may be used in individual
therapy or in a group therapy for rape victims. The latter has several advantages, which will be discussed in the cognitive therapy section.
Imagery-Based Cognitive Restructuring
According to a recent review of the trauma treatment outcome literature (Foa, 2003), the most effective therapies for PTSD fall into 3
treatment categories: (1) Extensive Exposure (EE) combines in vivo and imaginal exposure; (2) Extensive Exposure combined with
Cognitive Therapy (EE & CT); (3) Limited Exposure combined with Cognitive Therapy (LE & CT). (Grunert, B.K., Smucker, M.R., Weis, J.,
& Rusch, M.D. (2003). When Prolonged Exposure Fails: Adding an imagery-based cognitive restructuring component in the treatment of industrial
accident victims suffering from PTSD. Cognitive and Behavioural Practice.)
What does Imaginal Exposure Do?
1. Extinction of emotion to thoughts and images
2. Increased tolerance for that emotion
3. Creates/organizes narrative of how the immediate fear would lead to horrible consequences
4. Helps patients learn to confront anxiety instead of avoid
5. Helps patients to distinguish between thoughts and actions or thoughts and reality
6. Helps patients access experiences that cannot be confronted in the real world
7. Patients can learn that the likelihood of such negative events is low, and the cost is less than they think
8. Makes patient feel understood by the therapist
Specific Cognitive Techniques
Cognitive therapies attempt to change irrational or faulty beliefs, expectations, appraisals and attributions. The rape victim can benefit
greatly from cognitive therapy, especially in dealing with self-blame, anxiety attacks and some aspects of sleep disturbances. (Rosenhan
et al., 1989). A woman who feels guilty and blames herself probably has some problems with attributions and appraisals. Anxiety attacks
signify some distortion of expectations and appraisals. With these problems, the therapist may deal at the cognitive level. He may explain
how and why fear and anxiety develop following the rape, why the victim tries to attribute the blame to herself, and why her automatic
thoughts are inappropriate. The therapist, together with the patient, tries to find other solutions, other ways to cope with her anxiety
attacks. The patient may learn new coping skills to deal with her problems.
Coping imagery may be used to reduce severity of anxiety attacks and sleep disturbances. It is very useful to combine imagery with deep
muscle relaxation. Calming imagery may be substituted for scenes in which the patient relives the trauma. Also, assertiveness imagery
may be used with a client who feels vulnerable in many life situations. (Rosenhan et al., 1989) The victim would imagine as vividly as she
can herself as an assertive person in a situation that she fears. This helps her to get used to such thoughts and the image becomes less
threatening.
To deal with anger and anxiety attacks, the therapist may use assertiveness training. (Rosenhan et al., 1989) Resick (1988) describes
assertion training used in group therapy for rape victims. Resick et al. included an educational phase, in which the patients learned about
the development of anxiety and fear in relation to rape. It was explained how assertive responses are used to counter fear and reduce
avoidance. The reason is that assertive responses are incompatible with fear. Assertion training may be beneficial in dealing with
interpersonal issues. In the Resick study, victims were trained to change non-assertive cognitions and faulty thinking patterns. Several
sessions focused on covert and behavioral rehearsal of assertive responses.
SPECIFIC BEHAVIORAL TECHNIQUES
Flooding
In flooding, the patient is trained in progressive relaxation and then a rapid exposure to a feared object is introduced. (Zimbardo, 1985).
Flooding is not the best way to deal with patient suffering from rape trauma syndrome, because it is too narrow and in its original form, it
would be too aversive to the client. Also, it does not offer what the victim needs most: support. However, rapid exposure in imagery might
be used to reduce anxiety that is aroused by nightmares and flashbacks. (Matlin, 1989). Although this technique may work with some
patients, it should be used with caution, because there may simply be patients who could not take it.
Systematic desensitization
Systematic desensitization is often employed to treat patients with fear and anxiety. Frank in 1988 conducted study comparing SD with
cognitive-behavior therapy in treatment of rape victims. Both techniques seemed to be very successful. The victim is first taught
progressive muscle relaxation, using Jacobson's method. In case of rape victims, the instruction should not be "allow your thought to
ramble", since they would probably ramble to the scenes of the assault. Rather, they may be instructed to focus on a specific pleasant,
happy scene., Then, the target complaint is broken into specific scenes, which are arranged in hierarchy. The patient engages in
relaxation and imagines as vividly as possible the scenes, proceeding from the least threatening to the most threatening one.
Eye movement desensitization
Eye movement desensitization is a procedural technique (not a therapy) which the patient elicits sequences of large-magnitude, rhythmic
saccadic eye movements while holding in mind the most salient aspect of traumatic memory. This results in a lasting reduction of anxiety,
the cognitive assessment of the memory is changed and the frequency of flashbacks, intrusive thoughts and sleep disturbances
decreases. This procedure seems to be very effective in only one session, as Shapiro (1989) claims. It does not require a hierarchical
approach as systematic desensitization does, and it does not produce in the patient as high anxiety levels as flooding does. Note: EMDR
does not show long-standing results if used alone. Recent research has determined that Cognitive Behavior Therapy used in conjunction
with EMDR, or alone results in sustained remission from PTSD symptoms.
Printable copy of the above in Word Format: Rape Trauma Syndrome
RESOURCES:
The International Trauma Institute: www.traumainstitute.net
Fort Wayne Sexual Assault Team: http://www.ftwsatc.com/fwsatc.htm
WomensHealth.gov: http://womenshealth.gov/faq/sexualassault.htm
Medline resources on rape and assault: http://www.nlm.nih.gov/medlineplus/rape.html
The above reprinted from: http://www.queendom.com/articles/mentalhealth/rapealt.html
And http://www.gnesa.org/get_help/victims/rape_trauma_syndrome.html
Sexual assault is a crime problem that is increasing in North America. It is the most common trauma that is likely to produce symptoms
similar to those of PTSD. Ellis (1983) suggests that there are three sequences in reaction to rape: a short-term, intermediate and
long-term reaction. Short-term reaction is characterized by a range of traumatic symptoms, such as somatic complaints, sleep
disturbance and nightmares, fear, suspiciousness, anxiety, major depression and impairment in social functioning. Rosenhan and
Seligman (1989) claim that the crisis immediately following the rape is affected by the emotional style of the victim. Some women express
their feelings, showing fear, anxiety; they often cry and are tense. Other women try to control their expression, mask their feelings and they
attempt to look calm.
Symptoms remain relatively stable after 2 or 3 months. Three months to 1 year post-assault, in intermediate phase, the diffuse anxiety
usually becomes rape-specific. Women then experience depression, social and sexual dysfunction. The long-term reaction, 1 year
following the assault, involves anger, hypervigilance to danger, sexual dysfunction and diminished capacity to enjoy life (Ellis, 1983).
According to the descriptive study, conducted by Renner et al. (1988), only 10% of rape victims do not show any disruption of their
behavior following the assault. The behavior of 55% of them is moderately affected and 35% of the victims are unable to continue their
lives without very severe impairment. Several months down the road after the assault, 45% of women are able to readjust themselves;
however, 55% of the victims suffer from lasting effects.
It may be inferred that more than half of rape victims show some level of rape trauma. Depression and social adjustment usually improve
within several months following the trauma. On the other hand, fear, anxiety, reliving the trauma, sleep disturbances, nightmares,
avoidance of the stimuli reminiscent of the assault, these are the symptoms that persist in many victims for years, if not forever. The
victims also have problems in relationships with significant others and authority; their work satisfaction is lower than that of controls and
their hope for future is negatively affected. In addition, their self-esteem is lower than in other women even 2 years post-assault. (Murphy
et al., 1988)
Factors in development and course of Rape Trauma Syndrome
To understand the situation and feelings of a rape victim, one must take into account several factors. The probability of developing rape
trauma syndrome and its severity are obviously influenced by the victims personal characteristics. It is apparent that women with a large
variety of coping skills and with high emotional and psychological stability are less likely to experience symptoms of rape trauma
syndrome than are women without such equipment. For example, Cohen and Roth (1987) found that both approach and avoidance
coping strategies were negatively related to recovery. However, since rape is an attack on one of the most vulnerable aspects of a
person, it is very hard to cope with for nearly every woman. Therefore, the psychological strength is not only the only factor, but it must not
even be the most important one.
A point must be made that rape has a social nature. The victim must deal not only with the rape and the impact on her, but also with
reactions of others to it. Renner (1988) suggests that the victim is caught in "no win" situation. If the woman decides to fight back at the
time of the assault, she is more likely to receive social support from her family and friends; and police and medical personnel are more
likely to believe her. On the other hand, she has to pay a price for this support. First, she is more likely to be injured from the assault. Thus,
she would need medical attention, the police would be involved, and she would have to give explanation to many people. Her immediate
crisis would be then very severe.
However, if the victim does not risk injury, she is less likely to receive support or to be believed by police and court. She would be blamed
by herself and by others for failing to resist and she would feel more guilt and have more difficulties to resolve the problem in the long run
(Renner et al., 1988).
This is only a part of the social problems associated with sexual assault. The stereotypes about rape are still very prevalent in public and
even worse, in police officers and law courts. This may account for unsensitive treatment that victims receive from representatives of
these institutions. Victims are often asked questions about their own behavior, attire, sexual life and mental health: questions that direct to
impose the blame on the victim. Actually, there are an enormous amount of rape cases that do not pass on to the judicial system because
of certain characteristics of the victim. These features are, for example, consumption of alcohol by the victim, her history of unmanageable
behavior, being divorced, separated or single mother, unemployed or on welfare. Also, if the victim has known the offender (which is true
in about 70% of cases), has accepted a ride in his car, or has voluntarily accompanied the rapist to his home, the police are likely to
reject her case as unfounded (Clark, Lewis, 1977).
The support that the victim receives from her parents, husband or boyfriend and friends plays a very important role in the victim's coping
with the situation. Their support and understanding are very helpful to the victim. However, these significant others often have a difficult
time dealing with the assault themselves. In some cases, women are rejected by their partners or blamed for not fighting off the offender
(Renner, 1988).
Cohen and Roth (1987) found that individual differences in severity of symptoms were related to the age of victim, socioeconomic status,
and prior history of sexual assault (in childhood or adulthood). The response was also related to whether the victim reported the rape to
the police and whether she confided in someone shortly after the assault. Another factor is the use of force, verbal, physical threats or of a
weapon by the offender
Behavioral approach to rape trauma treatment
Before the discussion about possible treatments for rape trauma syndrome begins, prevention should be mentioned. In this connection,
prevention may have two connotations. The first is prevention of the rape itself. It is beyond the scope of this article to resolve crime
problems. The only thing to be mentioned is the possibility to increase the public awareness of date rape and of ways to avoid it. The
second connotation is prevention of rape trauma syndrome. Rape trauma syndrome does not have to occur immediately after the assault.
If the victim seeks professional help immediately after the rape, she will be less likely to suffer from symptoms of rape trauma syndrome.
(Rosenhan et al., 1989) She may contact some center of service for sexual assault victims or other institution concerned with crisis
intervention. These centers give the victims immediate support, information and they attempt to equip these women with coping skills
needed to deal with the crisis. Early crisis intervention may decrease the probability of onset of rape trauma syndrome. If the symptoms
occur and last for more than one month, the patient is diagnosed with the rape trauma syndrome. In this case, she should engage in some
type of therapy discussed below.
COGNITIVE-BEHAVIORAL THERAPY
Cognitive-behavior therapy is a combination of techniques and principles of both cognitive and behavioral therapies. Since the victim of
rape often needs to acquire new coping skills to deal with her anxiety and her situation, cognitive-behavior therapy may be helpful to the
victim. Stress inoculation in Resick's study (1988), for example, produced lasting effects. In stress inoculation, as in other cognitive-
behavior therapies, the patient goes through three phases. the first sequence consists of uncovering the patients existing coping skills by
both the therapist and the patient. This phase may also include an educative part, in which the victims learn about the development of fear
and anxiety following the rape. In the second sequence, new coping skills are acquired. The patient learns progressive relaxation, new
cognitive techniques, such as thought-stopping, guided self-dialogs and covert rehearsal. The third sequence involves application and
practice. The patient practices new skills in fear-producing but not dangerous situations. In this way, she learns to control fear and she
attempts to interrupt the avoidance behavior. (Zimbardo, 1985; Resick, 1988). The stress inoculation program may be used in individual
therapy or in a group therapy for rape victims. The latter has several advantages, which will be discussed in the cognitive therapy section.
Imagery-Based Cognitive Restructuring
According to a recent review of the trauma treatment outcome literature (Foa, 2003), the most effective therapies for PTSD fall into 3
treatment categories: (1) Extensive Exposure (EE) combines in vivo and imaginal exposure; (2) Extensive Exposure combined with
Cognitive Therapy (EE & CT); (3) Limited Exposure combined with Cognitive Therapy (LE & CT). (Grunert, B.K., Smucker, M.R., Weis, J.,
& Rusch, M.D. (2003). When Prolonged Exposure Fails: Adding an imagery-based cognitive restructuring component in the treatment of industrial
accident victims suffering from PTSD. Cognitive and Behavioural Practice.)
What does Imaginal Exposure Do?
1. Extinction of emotion to thoughts and images
2. Increased tolerance for that emotion
3. Creates/organizes narrative of how the immediate fear would lead to horrible consequences
4. Helps patients learn to confront anxiety instead of avoid
5. Helps patients to distinguish between thoughts and actions or thoughts and reality
6. Helps patients access experiences that cannot be confronted in the real world
7. Patients can learn that the likelihood of such negative events is low, and the cost is less than they think
8. Makes patient feel understood by the therapist
Specific Cognitive Techniques
Cognitive therapies attempt to change irrational or faulty beliefs, expectations, appraisals and attributions. The rape victim can benefit
greatly from cognitive therapy, especially in dealing with self-blame, anxiety attacks and some aspects of sleep disturbances. (Rosenhan
et al., 1989). A woman who feels guilty and blames herself probably has some problems with attributions and appraisals. Anxiety attacks
signify some distortion of expectations and appraisals. With these problems, the therapist may deal at the cognitive level. He may explain
how and why fear and anxiety develop following the rape, why the victim tries to attribute the blame to herself, and why her automatic
thoughts are inappropriate. The therapist, together with the patient, tries to find other solutions, other ways to cope with her anxiety
attacks. The patient may learn new coping skills to deal with her problems.
Coping imagery may be used to reduce severity of anxiety attacks and sleep disturbances. It is very useful to combine imagery with deep
muscle relaxation. Calming imagery may be substituted for scenes in which the patient relives the trauma. Also, assertiveness imagery
may be used with a client who feels vulnerable in many life situations. (Rosenhan et al., 1989) The victim would imagine as vividly as she
can herself as an assertive person in a situation that she fears. This helps her to get used to such thoughts and the image becomes less
threatening.
To deal with anger and anxiety attacks, the therapist may use assertiveness training. (Rosenhan et al., 1989) Resick (1988) describes
assertion training used in group therapy for rape victims. Resick et al. included an educational phase, in which the patients learned about
the development of anxiety and fear in relation to rape. It was explained how assertive responses are used to counter fear and reduce
avoidance. The reason is that assertive responses are incompatible with fear. Assertion training may be beneficial in dealing with
interpersonal issues. In the Resick study, victims were trained to change non-assertive cognitions and faulty thinking patterns. Several
sessions focused on covert and behavioral rehearsal of assertive responses.
SPECIFIC BEHAVIORAL TECHNIQUES
Flooding
In flooding, the patient is trained in progressive relaxation and then a rapid exposure to a feared object is introduced. (Zimbardo, 1985).
Flooding is not the best way to deal with patient suffering from rape trauma syndrome, because it is too narrow and in its original form, it
would be too aversive to the client. Also, it does not offer what the victim needs most: support. However, rapid exposure in imagery might
be used to reduce anxiety that is aroused by nightmares and flashbacks. (Matlin, 1989). Although this technique may work with some
patients, it should be used with caution, because there may simply be patients who could not take it.
Systematic desensitization
Systematic desensitization is often employed to treat patients with fear and anxiety. Frank in 1988 conducted study comparing SD with
cognitive-behavior therapy in treatment of rape victims. Both techniques seemed to be very successful. The victim is first taught
progressive muscle relaxation, using Jacobson's method. In case of rape victims, the instruction should not be "allow your thought to
ramble", since they would probably ramble to the scenes of the assault. Rather, they may be instructed to focus on a specific pleasant,
happy scene., Then, the target complaint is broken into specific scenes, which are arranged in hierarchy. The patient engages in
relaxation and imagines as vividly as possible the scenes, proceeding from the least threatening to the most threatening one.
Eye movement desensitization
Eye movement desensitization is a procedural technique (not a therapy) which the patient elicits sequences of large-magnitude, rhythmic
saccadic eye movements while holding in mind the most salient aspect of traumatic memory. This results in a lasting reduction of anxiety,
the cognitive assessment of the memory is changed and the frequency of flashbacks, intrusive thoughts and sleep disturbances
decreases. This procedure seems to be very effective in only one session, as Shapiro (1989) claims. It does not require a hierarchical
approach as systematic desensitization does, and it does not produce in the patient as high anxiety levels as flooding does. Note: EMDR
does not show long-standing results if used alone. Recent research has determined that Cognitive Behavior Therapy used in conjunction
with EMDR, or alone results in sustained remission from PTSD symptoms.
Printable copy of the above in Word Format: Rape Trauma Syndrome
RESOURCES:
The International Trauma Institute: www.traumainstitute.net
Fort Wayne Sexual Assault Team: http://www.ftwsatc.com/fwsatc.htm
WomensHealth.gov: http://womenshealth.gov/faq/sexualassault.htm
Medline resources on rape and assault: http://www.nlm.nih.gov/medlineplus/rape.html
The above reprinted from: http://www.queendom.com/articles/mentalhealth/rapealt.html
And http://www.gnesa.org/get_help/victims/rape_trauma_syndrome.html
| CBT The Center for Brief Therapy, PC, 10319 Dawson's Creek Blvd, Suite J, Fort Wayne, Indiana, USA 46825 260-969-5583; fax 260-969-5584; email: freemancbt@aol.com |
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