Rape victims: Post-traumatic stress responses and their treatment:

Jovmul of Arute~ Dnorders. Vol. 1. PP. 69-86. Prmted m the USA. All rights reserved.

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08X7-hlXS/X7 $3 IX) f ol) 4 19X7 Pergamon Journal\. bd

Rape Victims: Post-Traumatic Stress Responses and Their Treatment: A Review of the Literature GAIL STEKETEE, Boston

University,

M.S.S.* Boston,

MA

EDNA B. FOA, PH.D. Medical

College

of Penns.vl~~ania.

Philadelphia.

PA

Abstract-The literature regarding the immediate and long term reactions of victims of rape is reviewed. Anxiety. as well as depression, is commonly observed. The latter response declines within a three month period for most victims, whereas fear reactions appear to be more persistent. Social and sexual functioning are substantially disrupted immediately following the rape and tend to return to pre-rape levels after a few months, although sexual satisfaction remains low up to 18 months later. Implications of these findings regarding theoretical questions and treatment planning are discussed. Few predictions of response to rape have been identified; among these are history of psychiatric treatment of victimization and of recent life stresses. as well as inadequate social support. With respect to treatment. several cognitive/behavioral procedures and combinations of procedures have been found effective, including desensitization, cognitive therapy. and stress inoculation training. Flooding appears to be a promising treament for rape victims. but has not yet been evaluated in a controlled study. Suggestions for future research are offered with respect to methodology. the search for predictors. and treatment comparisons.

As noted by Kilpatrick, Veronen, and Best (1984), “rape is not a rare event.” Estimates of its prevalence in the US range from 5% (Kilpatrick, Best, & Veronen, 1984) to 22% of adult women (Koss, 1983). With 186.000 reported rapes during 1984 alone, it is particularly disturbing to learn that “being the victim of completed rape appears to be much worse than being the victim of other attempted and completed crimes” (Kilpatrick, Best. & Veronen, 1984, p. 5); nearly one rape victim in five subsequently had attempted suicide. This paper will review the findings re* Address correspondence and reprint requests to Gail Steketee. Boston University. School of Social Work. 3% Bay State Road. Boston, MA 02215. 69

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garding the effects of rape on its victims and the available treatments for those who have failed to recover. The physical, cognitive, and behavioral responses which typically follow rape are consistent with the DSM-III criteria for Post-Traumatic Stress Disorder (PTSD). Indeed, rape victims constitute the largest single group of PTSD sufferers. Rape-related symptoms include: intrusive unpleasant imagery, nightmares, exaggerated startled responses. disturbance in sleep patterns, guilt, impairment in concentration or memory, and fear and avoidance of rape-related situations. For many rape victims. PTSD symptoms (with the exception of fear and anxiety) decline within three months. although the course of these responses and their pattern of decline vary across individuals (Kilpatrick. Veronen. & Resick. 1979b). A sizable proportion of victims, however, continue to exhibit symptoms which disrupt normal functioning (63% according to Burgess & HolStrom, 1979: 33% according to McCahill, Meyer, & Fishman. 1979). Much of the research on responses of victims to rape has focused on fear and anxiety, depression, social functioning, and sexual adjustment. These will be discussed below. RESPONSES

FOLLOWING

RAPE

Fear and Anxiety

Among the most prominent and persistent post-rape reactions are intense fears of rape-associated situations and general diffused anxiety. During and immediately after the assault 80-96% of victims (N = 25) reported feeling scared, terrified, having racing thoughts, shaking, trembling, or racing heart. For 80% of the victims, such intense fear persisted for two to three hours after the assault (Kilpatrick, Resick, & Veronen, 1981). These figures are consistent with those of the Queen’s Bench Foundation (1975), in which 79% reported strong feelings of anxiety after the rape. Nearly half of a sample of 41 victims reported fears and anxiety 15-30 months after being raped: 49% were fearful of going out alone (Nadelson, Notman, Zackson, & Garnick, 1982). Likewise, Veronen and Kilpatrick (1983) observed that only 23% of those in their sample of 46 victims were asymptomatic at one year post-rape on the Modified Fear Survey (Veronen & Kilpatrick, 1980), and only 26% showed no abnormal phobic anxiety on the SCL-90. By contrast, of the non-victims, 44% and 46% were symptom free on these scales, respectively. Comparisons of rape victims with non-victims have consistently shown that the former had higher levels of fear and anxiety. Contact with the criminal justice system was found to increase it. Comparing 46 victims with a matched sample of 35 non-victimized community residents, Kilpatrick, Veronen, and Resick (1979a. 1979b) found the former were significantly more fearful than the latter. At a six month follow-up assessment of the measures of mood states and psychiatric symptoms.

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only general anxiety and phobic reactions distinguished the two groups. Moreover, rape-related fears had spread, resulting in a general fear of being attacked. At a one year assessment conducted on 20 victims and 20 non-victims, the former group continued to show significantly higher levels of trait anxiety and phobic anxiety, particularly to rape-related cues (Kilpatrick, Resick, & Veronen, 1981). Some increase in rape-related fears from six months to one year was noted. Similar tindings were reported by Ellis, Atkeson, and Calhoun (1981) with 27 victims and 26 controls. Tension scores on the Profile of Mood Status were significantly higher for victims one to 16 years post-rape (mean = 3 years). A more extensive study was conducted by Calhoun, Atkeson, and Resick (1982), who compared t I5 victims assessed at two weeks and 1, 2,4, 8 and 12 months post-rape with 87 non-victims assessed at the same intervals. Ahhough victims’ fearfulness declined somewhat from the first to the two month assessment, they were more fearful than non-victims on the Modified Fear Survey at all assessment periods. Using a different measure of fear (Cornell Medical Index), Selkin (1978) found rape victims to be more anxious as well as more depressed than women who successfully warded off a rape attempt. In the face of this evidence, Kilpatrick, Veronen, and Resick (1979b) noted that “the conclusion that fear and anxiety represent relatively longterm problems for rape victims seems inescapable” (p. 668). Depression Although less persistent than anxiety, depressed mood following rape has also been commonly observed. Frank, Turner, and Duffy (1979) reported that 15 of their 34 victims were moderately to severely depressed as measured by the Beck Depression Inventory immediately after the rape: of these 15, half met Research Diagnostic Criteria for a major depressive episode. A similar picture emerged from later study on a larger sample of 90 victims: 43% of recent victims were diagnosed as having major depression. These symptoms declined by the three month assessment (Frank & Stewart. 1984). Comparisons of victims with non-victims suggested that the former were significantly more depressed soon after the assault and that this difference had diminished three to four months later; no differences between these groups were observed up to one year later (Atkeson, Calhoun, Resick, & Ellis, 1982; Kilpatrick, Veronen, & Resick, 1979b). Inconsistent with the above results are observations from retrospective interviews conducted 15-30 months post-rape. Nadelson. et al. (1982) found that 41% still reported episodes of depression related to the rape. Corroborating this report. Ellis, Atkeson, and Calhoun (1981) observed that victims were significantly more depressed (as measured by the BDI) than matched non-victims three years after the rape. It appears, then. that although most victims suffer immediate depressive reactions,

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for most these responses do not persist beyond a few months. For some individuals, however, depression persists for years. Social Functioning Rape appears to temporarily impair the social functioning of many victims. Fears of strangers, of going out with new people, and of people walking behind were prominent, promoting avoidance of situations where such incidents might be encountered (Kilpatrick, Veronen, & Resick. 1979b). More than half of a sample of 41 women interviewed 15-30 months post-rape reported a restricted social life and ventured out only in the company of friends (Nadelson et al., 1982). Social and leisure adjustment on the SAS-SR (Weissman & Bothwell, 1976) was significantly poorer for victims than conrols at two months post-rape but improved thereafter, reaching the same levels observed in controls (Resick, Calhoun, Atkeson, & Ellis, 1981). Similarly, victims’ social-interpersonal fears on the Modified Fear Survey and the SCL-90 exceeded those of controls only at one to two months post-rape (Kilpatrick, Veronen, & Resick, 1979b; Resick et al., 1981). By four months, most victims’ general social adjustment had returned to pre-rape levels with the exception of work functioning which continued to be impaired eight months later. Familial problems were more often reported by victims than nonvictims in one study of 27 victims (Ellis, Atkeson, & Calhoun, 1981). By contrast, in a larger sample of 93 victims, a combined index of marital, parental, and family functioning failed to differentiate victims from nonvictims at any point, even immediately after the assault (Resick et al.. 1981). Findings by Miller, Williams, and Bernstein (1982). from retrospective ratings of 42 couples (interviewed a mean of 2.4 years after the wife was raped), indicated “serious relationship disturbance” in 57% of these couples. It should be noted, however, that individual psychopathology prior to rape was found to be associated with chronic relationship problems. The absence of a control sample renders the results inconclusive. Additionally, Frank, Turner, and Stewart (1980) observed that greater threat to the victim during the rape was inversely related to poorer household adjustment. They suggested that victims of brutal assaults may be viewed as less culpable and therefore may receive more support from family members. Sexual Adjustments Many victims of sexual assault report problems in sexual functioning which may persist for years. Retrospective studies carried out up to several years post-rape are consistent in their findings: one third reported decreased sexual satisfaction (Norris & Feldman-Summers, 1981) and approximately 50% to 55% reported at least one sexual dysfunction (Becker, Skinner, Abel, & Treaty. 1982; Nadelson et al., 1982). Fear of

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sex and diminished arousal or desire were the most common dysfunctions reported (Nadelson et al., 1982). In a study of 116 victims interviewed two weeks after the rape, Ellis, Calhoun and Atkeson (1980) found that 61% reported a decline in the frequency of sex since the assault. At four weeks, 43% had avoided sex altogether; but by four months, sexual frequency was improved, and after a year it had nearly recovered to pre-rape levels. By contrast, sexual satisfaction remained somewhat below pre-rape levels one year after the assault. Frequency of orgasms was less affected than sexual frequency and arousal. Flashbacks to rape-related images during sex were reported by 12% of victims one year after the assault. Interviews conducted with rape victims and with non-victims indicated that sexual satisfaction was significantly less in the former group 18 months post-rape (Feldman-Summers, Gordon, & Meagher, 1979; Orlando & Koss, 1983). This discrepancy in satisfaction occurred despite the lack of difference between the two groups on frequency of sex and on orgasm. It is interesting to note that satisfaction in masturbatory activity and expression of affection was unaffected by the rape. Others Responses

to Rape

In addition to fear, depression, and social and sexual impairment, rape victims have also reported a variety of other symptoms following assault. These included fatigue (Ellis, Atkeson, & Calhoun, 1981; Kilpatrick, Veronen, & Resick, 1982); suicide attempts (Kilpatrick, Best, & Veronen, 1984); hostility (Kilpatrick, Resick, & Veronen, 1981; Nadelson et al., 1982): somatic complaints (Kilpatrick, Resick, & Veronen, 1981; Selkin, 1978); sleep disturbance including nightmares and insomnia (Ellis, Atkeson, & Calhoun, 1981; Nadelson et al., 1982); poor concentration and intrusive thoughts (Nadelson et al., 1982); poor self-esteem (Veronen & Kilpatrick, 1980); and obsessive-compulsive symptoms (Ellis, Atkeson, & Calhoun, 1981). Implications The overall picture emerging from the literature on the aftermath of rape indicates that virtually all of the symptoms which define post-traumatic stress disorder appear in rape victims. With the exception of fear and anxiety, most of these symptoms dissipate within three to four months for the majority of victims. The finding that fear persists longer than depression in rape victims is of interest in light of the strong relationship between these two mood states in psychiatric populations (for review, see Foa & Foa, 1982). This calls for further investigation about the association between anxiety and depression. Does a strong initial depressive reaction potentiate the development of strong phobic responses which then persist while depression

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declines? Are the two responses unrelated throughout’? Relatively little is known about the specific course of emotional processing of the rape experience during the first critical four-month period. Investigations of effects of rape have typically assessed victims at one week and again at one or two months post-rape (Calhoun, Atkeson, & Resick, 1982: Kilpatrick. Veronen, & Resick, 1979b). To investigate differences in the course of recovery of the different PTSD responses. more frequent assessments (possibly weekly) are needed. Identification of recovery patterns in rape victims has both theoretical and practical implications. On the theoretical side, it bears on the general issue of emotional processing of traumatic experience (e.g., death of loved one, divorce, etc). Sutherland and Scherl’s (1970) widely cited conceptualization of the rape trauma syndrome proposes three stages of responses to rape: acute reaction, outward adjustment (denial and suppression), and integration and resolution. Similar concepts emerge from Burgess and Holstrom’s (1979) description of four defense mechanisms: explanation, minimization, suppression, and dramatization. Both formulations imply a non-linear course of recovery. The investigation of this hypothesis again requires frequent assessments. On the practical side. knowledge of the course of recovery can guide rape counselors in making decisions about their clients. Victims with “normal” patterns should be reassured that recovery is expected: those with “abnormal” patterns should be directed to specialized professional help. PREDICTORS OF RESPONSE

TO

RAPE

Numerous variables (demographic, personality, historical, victim’s response, and environmental) have been studied in an effort to identify those which influence recovery from rape trauma. Few have proven consistently predictive. Demographic

Variubles

The findings on the effects of race and age on responses to rape are unclear. Three studies reported no effect of race (Kilpatrick, Veronen, & Best, 1984; Morelli, 1981, cited by Kilpatrick, Veronen, & Best, 1984: Ruth & Leon, 19831, but Ruth and Chandler (1983) found that non-caucasians suffered greater trauma. With respect to age, again, three studies observed no effect (Becker, Skinner, Abel, & Treaty, 1982; Kilpatrick, Veronen, & Best, 1984; Ruth & Leon, 19831, whereas a fourth (Atkeson et al., 1982) found that older victims were more depressed than younger ones I2 months post-rape. The former also showed greater avoidance following the rape, less emotional resilience, more self-blaming attitudes, and possibly had less social support. Whereas education had no effect on resonse to rape, economic status was inversely related to recovery (Kilpatrick, Veronen, & Best, 1984).

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Poorer victims showed more symptoms four to six years after the assault (Burgess & Holstrom, 1978) and more depressive symptoms one year later (Atkeson et al., 1982). Two studies reported that married victims had greater difficulties after the rape (McCahill, Meyer, & Fischman, 1979; Ruth & Chandler, 1983). This finding was not replicated by Kilpatrick. Veronen, and Best (1984) or Ruth and Leon (1983). A seemingly contradictory observation was reported by Burgess and Holstrom (1979); victims who had stable partners recovered more quickly. Correspondingly, Kilpatrick, Veronen, and Best (1984) found that a lower frequency of intimate relationships with men was associated with greater distress post-rape. These contradictory findings may be explained by the fact that being married does not necessarily imply a stable or positive relationship. Perhaps the energy required to relate to a spouse constitutes an additional stress. Supportive partners, however. may be helpful in overcoming the trauma. With few exceptions, the literature on rape suggests that social support is an important factor in lessening its immediate impact and in speeding recovery from it. Ruth and her colleagues found that social support accounted for a significant proportion (5%) of the variance of the acute reaction to rape in one study (Ruth & Chandler, 1983) but not in another (Ruth & Leon, 1983). Greater support after the assault was related to less immediate psychological impact (Norris & Feldman-Summers, 1981). lower depression scores several months post-rape (Atkeson et al., 1982), and better recovery up to six years later (Burgess & Holstrom, 1978; Ruth & Leon. 1983).

The relationship between prior stressful life events and the victim’s response to rape appear somewhat complex. Ruth and her colleagues (Ruth. Chandler & Harter, 1980; Ruth & Leon, 1983) observed a curvilinear relationship between life changes occurring one year prior to the assault and the acute and long-term impact of rape; those with a moderate degree of change fared best. These data are consistent with the findings of Kilpatrick, Veronen, and Best (1984) that fewer of the low distress group three months post-rape had lost a loved one (a highly stressful event) during the one year prior to the rape, whereas the highly and moderately distressed groups were both highly likely to have suffered such a loss. The observation by Burgess and Holstrom (1978) that family grief stress within the two year period before the assault led to Detter recovery is difficult to reconcile with the above data. Perhaps the longer period of observation (two years) resulted in including more victims who had successfully coped with this stressor and that this coping process facilitated coping with the losses (e.g., sense of safety, trust) involved in the rape experience. The lack of association between recent (within 6 months) life changes and recovery found by Burgess and

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Holstrom may have been due to the fact that most of these changes had only a modest impact. With a restricted range located in the mid-spectrum of stressor severity, such a finding of no correlation would be expected in a curvilinear relationship. Among life events, the specific experience of prior \~ictimization did not appear to affect the immediate level of anxiety, fear, or depression in recent victims (Frank, Turner, & Stewart, 1980; Ruth & Leon. 1983). However, prior sexual victimization was the most critical variable in explaining increase in trauma levels a few weeks later (Ruth & Leon, 1983). When degree of recovery was examined four to six years post assault. 47% of those previously victimized did not yet feel recovered versus 14% of those who had not had such an experience (Burgess & Holstrom, 1978). Ellis, Atkeson, and Calhoun (1982) found that recidivist victims were poorer, more transient, and more dysfunctional in intrapersonal and interpersonal adjustment than their single-incident counterparts. The data cannot tell us whether these differences were caused by the prior assault or led to multiple assaults. It is conceivable that individuals who are less well-adjusted may exhibit behaviors which draw the attention of a would-be assailant. According to most studies (five of six), prior psychiatric history predicted greater distress post-rape. A history of previous psychiatric consultation was related to more negative feelings about men immediately after the rape (McCahill, Meyer & Fishman. 1979) and to poorer initial work, school, and family adjustment, although not to greater symptoms of depression or anxiety (Frank, Turner, Stewart, Jacob, 62 West, 1981). Prior psychiatric history was predictive of greater long-term difficulty (4 months to 6 years post-rape depending on the study) with depressive symptoms (Atkeson et al., 1982), marital. and sexual difficulties (Miller, Williams, & Berstein. 1982), and general recovery (Burgess & Holstrom, 1978). Histories of drug and alcohol abuse were strong predictors of increased PTSD symptomatology (Burgess & Holstrom, 1978; Miller, Williams, & Bernstein, 1982; Ruth & Leon. 1983). Aspects

of the Rape

Situution

The majority of studies report no relationship between specific aspects of the rape experience (e.g., presence of a weapon, stranger versus known assailant, place of assault, number of assailants) and immediate or long-term PTSD symptoms (Atkeson et al., 1982; Becker et al., 1982: Frank, Turner, & Stewart, 1980; Kilpatrick, Veronen, & Best. 1984; McCahill, Meyer, & Fishman, 1979; Ruth & Chandler, 1983). The data with regard to the severity or brutality of the rape are conflictual. Three studies found that the more brutal the attack, the more likely was the victim to experience long-term psychiatric difficulties, including psychosomatic symptoms (Norris & Feldman-Summers. 1981). adjustment problems (McCahill, Meyer, & Fischman, 1979), and mood state distur-

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bances (Ellis, Atkeson, & Calhoun, 1981). However, seemingly contradictory findings were reported in two studies; greater threat to the victim was associated with higher self-esteem (Cluss, Boughton. Frank, Stewart, & West, 1983) and sexual satisfaction (Orlando & Koss, 1983) after the assault. Perhaps the context of the rape has differential effects on the various aspects of the victim’s emotional and behavioral adjustment. Greater threat may produce less guilt about the rape, and hence may lead to less loss of self-esteem: nevertheless, it constitutes an extremely frightening event producing persistent fearful behavioral, cognitive, and physiological reactions. Initial

Reaction

to the Rape

The level of initial distress provoked by the rape was a strong predictor of later adjustment according to findings reported by Kilpatrick, Veronen. and Best ( 1984). Less disturbance in mood state (tension, depression. anger) was characteristic of those in the low distress group three months post-rape. Correlations of depression and anxiety (immediately after the rape) with the distress index at follow-up were .38 and .33, respectively. Rapid resumption of normal activity was also related to faster recovery (Ellis, 1983). Such activity is likely to result in confrontation with rape-related feared situations. There is ample evidence that exposure to fear evoking situations leads to a reduction in such fears. The relationship found between activity and recovery, then, may be due to the beneficial effect of exposure imbedded in normal activities. Contact

\t*ith the Criminal

Justice

System

Involvement in court proceedings was found to increase levels of fear six months post-rape (Kilpatrick, Veronen, & Resick, 1979a). However, Cluss et al. (1983) reported that it did not lead to increased levels of depression at 12 months and that women who elected to prosecute their assailant reported higher self-esteem. The effect of trial verdicts on longterm response is not known, probably because follow-ups rarely exceeded one year. a period which typically falls short of that required for completion of a criminal trial. Implications

Elucidation of predictors for recovery from PTSD symptoms has important practical value. Early identification of victims for whom routine rape crisis counseling may be insufficient to promote recovery will enable mental health professionals to direct them toward more intensive or specialized services and thereby speed their return to normal functioning. In the studies discussed above. only a few variables were found predictive of recovery. including history of psychiatric treatment, prior victimiza-

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tion, recent life events, and lack of social support. The relative scarcity of predictors may have resulted from a focus on single variables and a failure to examine the effects of victim’s response patterns and their interrelationship on recovery. Indeed, some of the relationships among predictors and outcome appear complex. The finding, for example, that marriage predicts poor recovery and that supportive partners predicts good recovery points to the need to examine interactions among predictors of recovery. The frequent (e.g., weekly) examination of victim’s reactions over time may reveal relationships among a variety of variables relevant to rape and provide information about how such patterns of variables are related to degree of recovery. TREATMENT OF RAPE VICTIMS Perhaps the most complete description to date of the “rape trauma syndrome” has been provided by Burgess and Holstrom (1974a, 1974b). On the basis of their observations of a large sample of victims, these authors proposed various therapeutic techniques to relieve symptoms consequent to rape, including crisis intervention counseling for typical reactions, and additional professional help for “compounded reactions.” These crisis intervention treatments were derived from conceptual models: medical, social network, behavioral, and psychological, and were directed, respectively, at treating medical complications, mobilizing social support, reducing fears and avoidance behaviors, and addressing dynamic personality issues. Burgess and Holstrom did not provide detailed descriptions of the treatment methods they proposed nor did they present data on their efficacy. Nonetheless, their writings have called attention to the need for professional intervention with rape victims and have inspired some empirical investigations into various methods for treatment of rape victims. As is often the case in pioneering research, the existing studies are flawed in their methodology. Inadequate assessment methods, non-random assignment to groups, and the omission of comparison groups were the main problems. In view of the repeated observation that the majority of victims show symptomatic improvement within three months with little or no professional intervention (for review, see Ellis, 19831, the failure of some investigators to include a wait-list control group is particularly disturbing. The findings with respect to treatments utilized for rape victims are discussed below. Dynamic Psychotherapy

Treatment by dynamic cated as a final component by Turner & Frank, 1981; & Scherl, 1972). However, lected. Cryer and Beutler

psychotherapy methods has often been advoof crisis intervention (e.g.V Bart, 1975, cited Burgess & Holstrom, 1974b; Evans, 1978; Fox few data regarding its efficacy have been col(1980) investigated the impact of short-term

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dynamic group therapy for nine rape victims before and after treatment. Unfortunately, no control group was included and the content of the therapy sessions was not specified. Fear and hostility showed significant reduction, but three of the seven victims who completed the study reported only slight change in their overall condition. Behavior-al Treatment Research on treatment outcome for rape victims has focused almost exclusively on cognitive-behavioral methods. The treatments employed have concentrated primarily on rape-related symptoms as targets for the treatment interventions. Such targets included fear or anxiety and accompanying avoidance patterns, depression, and social and sexual functioning. Some investigations have tested a specific intervention, usually directed at one or two problem areas (e.g., systematic desensitization for fear. cognitive therapy for changing thought processes). On the other hand, Kilpatrick and Veronen (1983) have developed and studied behavioral treatment packages (e.g., stress innoculation training) aimed at alleviating a host of symptoms. We will first describe studies using single methods and then discuss composite treatments. It should be noted that the above distinction is somewhat arbitrary, since even single procedures were often comprised of several components. For example, desensitization includes relaxation and exposure, and cognitive therapy often includes instruction for in vivo exposure. Systematic desensitization. Widely applied in the treatment of phobias, systematic desensitization (SD) was employed effectively by Wolff (1977) to treat the fear responses of a 20-year old female raped seven years earlier. In a series of nine cases, Turner (1979) found that SD effected improvement in measures of fear, anxiety, depression, and social adjustment. Frank and Stewart (1983a) corroborated these findings with a sample of 17 assault victims. Fourteen sessions of SD resulted in a decrease in the targeted fear and anxiety, as well as an increase in social adjustment. The authors note that 75% of their subjects voluntarily exposed themselves in vivo to situations desensitized in imagination. As noted above, in the absence of a control group. these positive effects are subject to alternative explanations such as spontaneous recovery. Cognitilse ther-apx. The effects of cognitive therapy (CT) targeted at depression and anxiety was studied in 21 rape victims who entered treatment an average of two weeks after their assault (Frank & Stewart, 1983b). This treatment included self-monitoring of activities and of mastery and pleasure responses, graded task assignments (e.g., going out alone), identification, and modification of maladaptive cognitions and of basic assumptions. In this trial. as well as in an earlier study on the efficacy of CT with a sample of 10 patients (Frank, 19791, the outcome of CT

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was similar to that of SD: ratings of fear, anxiety, depression. and social adjustment showed significant gains. Although no direct comparison between SD and CT was reported by the authors, examination of the mean changes following the two treatments suggests that they produced equivalent outcomes. Again, the failure to include a control group limits the conclusions that can be drawn about the value of cognitive therapy with rape victims. Two other cognitive procedures, cognitive restructuring and thought stopping, have been successfully applied in single case studies (Forman, 1980), but no information is available on their general utility with this population. Flooding. Flooding (prolonged imaginal or in vivo exposure to moderately disturbing fear cues) has been markedly successful in treating anxiety disorders, including Vietnam veterans with post-traumatic stress disorder (Fairbank & Keane, 1982; Keane & Kaloupek, 1982: Minisek, 1984). Few reports exist about its efficacy with rape victims. Imaginal flooding proved effective for a series of four physical and sexual assault victims (Haynes & Mooney, 1975) and for a case of incest (Rychtarik, Silverman, Van Landingham, & Prue, 1984). Despite these preliminary successes, the use of flooding in sexual assault victims has drawn pointed criticism (Kilpatrick & Best, 1984; Kilpatrick, Veronen, & Resick, 1982). The following concerns have been expressed: (a) flooding focuses too much on anxiety as a target for change, to the exclusion of irrational cognitions; (b) flooding may result in an inappropriate reduction of anxiety to nonconsensual forced sex; (c) flooding may result in higher treatment dropout rates because of the aversiveness of the procedure; and (d) flooding fails to enhance the development of coping strategies. In a rebuttal, Rychtarik et al. (1984) noted that irrational thoughts, feelings of anxiety, and avoidance are not independent of each other. Therefore, reduction of anxiety to rape-related cues may result in the amelioration of associated negative irrational cognitions. Moreover, as noted by Foa and Kozak (1983, cognitive mechanisms underlie some of the changes produced by exposure (flooding) and therefore are expected to influence fear, avoidance, and associated thoughts. With respect to the second concern, flooding has often been directed at unduly intense fears of realistic concerns (e.g., death, falling from heights). Decreasing such fears does not, however, lead to carelessness about one’s safety. In the same vein, decreasing a woman’s fear of leaving her apartment alone in the evening need not lead to disregard for her well being. As to the third point, Rychtarik et al. noted that high dropout rates did not occur in studies of flooding with Vietnam veterans. Since flooding with rape victims has not been studied to date, no evidence relevant to this criticism with this population is yet available. Finally, Rychtarik et al. (1984) pointed out that flooding is applied to irrational anxiety to specific stimuli which provoke maladaptive behavior patterns. The experience of reduction of these symptoms following exposure renders this procedure a potential coping strategy which can be utilized systematically by clients

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when experiencing intense fear. The evaluation of flooding with rape victims awaits further investigation (Holmes & Lawrence, 1983). Other treatments. Additional interventions have been proposed for, or employed to treat post-rape symptoms. Turner and Frank (1981) suggested the use of behavior rehearsal, in vivo desensitization, thought stopping, and sex therapy: however, they did not provide data on these methods. The effect of group and of individual sex therapy for rape and incest victims with sexual dysfunctions was studied by Becker and Abel (cited by Frank & Stewart, 1983a). Victims were at least two months post assault. Ten sessions of treatment included specification of goals, body awareness training (with or without masturbation training), sexual fantasy discussion, sexual assertiveness training, and pleasuring exercises. A wait list control condition led to high (50%) dropout rates. Preliminary data on 35 clients indicated that about 80% improved to some degree on targeted behavioral goals and that a group treatment led to greater change than individual therapy. Similar results were obtained with a time limited Sexual Dysfunction Treatment Program (SDTP) which appears to be identical to that described above (Becker & Skinner, 1983). For 43 women progress was made on 92% of their goals. Composire treatment programs. Two treatment packages for rape victims were developed by Kilpatrick, Veronen and their colleagues. The first, srl’ess inoculation training (SIT) was developed for victims who remained highly fearful three months after being raped (Kilpatrick, Veronen, & Resick, 1982). SIT consists of an educational phase in which conditioning theories of rape-related anxiety are explained, followed by several anxiety reduction methods, including relaxation exercises, role play, covert modeling. thought stopping, and guided self-dialogue. These methods are applied first to primary and then to secondary target fears. Victims are instructed to practice the skills which they find most beneficial. In an empirical investigation of this method, Veronen and Kilpatrick (1983) selected only victims who showed elevated fear and avoidance to specific phobic stimuli three months post-rape. Ten sessions each of SIT, peer counseling, and systematic desensitization (SD) were compared. Victims were permitted to select one of these three treatments. More than 50% rejected any type of therapy. Of the 15 who opted for treatment. 11 selected SIT, three chose peer counseling, and none elected SD. The one subject who failed to make a choice was randomly assigned to SIT. Obviously. under these circumstances no comparison among treatments was possible, Although no formal statistical analyses were conducted on the six who had completed SIT, the authors reported noticeable improvement from pre- to post-treatment on most measures. Successful use of a method similar to SIT (with the inclusion of systematic desensitization) was reported for a woman with longstanding fears of rape-related situations (Pearson, Poquette, & Wasden, 1983).

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A second treatment program, Brief Beha\~iornl Inter\.rtltion Progrurn (BBIP) was designed for use immediately after rape (Kilpatrick & Veronen, 1983). This four to six hour treatment package was viewed as a prophylactic treatment to prevent the development of phobic reactions and other PTSD symptoms. First the victim is encouraged to reexperience the rape events in imagery and to permit herself to feel and express feelings associated with the rape. She is then educated in learning theory models of the development and maintenance of fear and in the three systems model of fear responses (behavioral, cognitive. physiological). In the third phase attempts are made to reduce feelings of guilt and responsibility for the rape via discussion of societal expectations and myths about rape. Finally, coping skills, such as self-assertion. relaxation, thought stopping, and methods for resuming normal activities are tau_eht. The outcome of a study in which recent victims were randomly asslgned to one of three treatment conditions (repeated assessment, delayed assessment, and BBIP) has not yet been reported. Further Considerations The most common professional assistance to date for rape victims is individual counseling provided in rape crisis centers. Nevertheless, Kilpatrick and Veronen (1983) titled their paper, “Crisis intervention is not enough.” With the behavioral conceptualization of rape-related responses as conditioned reactions to a traumatic event, several cognitive/ behavioral treatment programs have been developed or adopted for rape victims. All treatments have been found to yield significant gains from pre- to post-therapy, but as yet no comparisons of their relative efficacy have been reported. As with much pioneer research, the methodology applied is not yet vigorous enough to allow strong inferences. A serious problem lies in the fact that most investigators, with the notable exception of Veronen and Kilpatrick, did not delay the application of treatments for three months, the critical period during which most PTSD symptoms resolve themselves without treatment. Moreover, it has been noted that repeated assessment may in itself be therapeutic (Kilpatrick et al., 1979: Resick et al., 1981; Shore, 1980). Therefore, changes observed from pre- to post-treatment may not reflect the effects of the procedure applied. To eliminate the alternative explanations of passage of time and of repeated testing, a no-treatment control condition should be included in future studies. Assessment methods have improved considerably over those used in early studies in which only self-rated questionnaires measuring general psychiatric symptoms were employed (e.g., Cryer & Beutler. 1980). Recent investigations typically utilize several instruments which are designed to measure the specific symptoms associated with rape (i.e., anxiety, depression, sexual and social functioning). To date. no single scale which purports to assess the full range of rape-induced symptoms has

RAPE VICTIMS

a3

been developed. Behavioral measures of avoidance and assessment of physiological responses to feared stimuli, as well as other post-traumatic manifestations (e.g., sleep disturbance) are still rarely used (for exceptions see Blanchard & Abel, 1976: Rychtarik et al., 1984; Veronen & Kilpatrick, 1983). Since anxiety is the most persistent symptom exhibited by victims, it seems useful to adopt the multisystem assessment approach (behavioral, cognitive, and physiological), suggested by Lang (19791, to the study of rape victims’ responses and their treatment. As advances are made in evaluating the outcome of treatments for rape victims, investigation of predictors for success and failure will become possible. Given the relatively small numbers of individuals who have participated in treatment studies, it is not surprising that little information is available to date regarding predictors. Indeed, only Frank and Stewart (1983b) report on factors associated with outcome. They found that physical beating during rape, absence of previous suicidal thoughts and attempts, and the victim’s perception that the assailant was under the influence of drugs or alcohol were associated with lower depression scores after treatment. No significant relationship to outcome was noted for demographic variables or other aspects of the rape circumstance. Identification of such predictive factors for the various treatments which are applied to victims’ PTSD symptoms will ultimately enable us to direct victims to treatments which will maximize the likelihood of a successful outcome: REFERENCES Atkeson. B. M.. Calhoun. K. S.. Resick. P. A.. & Ellis, E. M. (1982). Victims of rape: Repeated assessment of depressive symptoms. Joftrnal of Consrclrin~ and Clinica/ Psycltolog.~. 50, 96-102. Bart. P. (1975. May). Unalienating abortion. demystifying depression, and restoring rape victims. Paper presented at the 128th annual meeting of the American Psychological Association. Anaheim. CA. Becker. J. V.. & Skinner. L. J. (1983). Assessment and treatment of rape-related sexual dysfunctions. The Clinical Ps.vcl~olopist, 36, 102- 105. Becker. J. V.. Skinner. L. J.. Abel. G. G.. & Treaty. E. C. (1982). The incidence and types of sexual dysfunctions in rape and incest victims. Jolrrnal ofSex_ and Muritul Tllerupx. 8, 65-74. Blanchard. E. B.. & Abel. G. G. (1976). An experimental case study of the biofeedback treatment of a rape-induced psychophysiological cardiovascular disorder. BehcrlYor 7herrrp.v. 7. 113- 119. Burgess. A. W.. 6 Holstrom. L. L. (1974a). The rape trauma syndrome. Americun Jotrrnul of‘Ps~cl~iurr~. 131, 981 -986. Burgess. A. W.. & Holstrom. L. L. (1974b). Rape: Vicrims of Crisis. Bowie. MD: R. J. Brady Company. Burgess. A. W.. &I Holstrom. L. L. (19781. Recovery from rape and prior life stress. Rescnrch it? h’r/rsitlg nnd Heulrll. 1. 165- 174. Burgess. .4. W.. & Holstrom. L. L. (1979). Adaptive strategies and recovery from rape. Amc,rictr!l Jorrrr~trl of Ps)~cllicrtr?~. 136. 1278- 1282.

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Calhoun. K. S.. Atkeson. B. M.. & Resick, P. A. (1982). A longitudinal examination of fear reactions in victims of rape. Journal of Counseling Psychology. 29. 655-661, Cluss. P. A., Boughton, J., Frank, L. E., Stewart. B. D., & West. D. (1983). The rape victims: Psychological correlates of participation in the legal process. Criminal Jlrsrice and Behavior, 10, 342-357. Cryer, L., & Beutler, L. (1980). Group therapy: an alternative treatment approach for rape victims. Journal of Sex and Mariral Therapy, 6, 40-46. Ellis, E. M. (1983). A review of empirical rape research: Victim reaction and response to treatment. Clinical Psychology Review, 3, 473-490. Ellis, E. M., Atkeson, B. M., & Calhoun, K. S. (1981). An assessment of long-term reaction to rape. Journal of Abnormal Psychology, 90, 263-266. Ellis, E. M., Atkeson, B. M., & Calhoun, K. S. (1982). An examination of differences between multiple- and single-incident victims of sexual assault. Journal of Abnormul Psychology,

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Keane. T. M., & Kaloupek. D. G. (1982). lmaginal flooding in the treatment of a posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 50, l38- 140. Kilpatrick. D. G., Best. C. L.. & Veronen, L. J. (1984). Mental health consequences of criminal victimization: A random community survey. Paper presented at the meeting of the American Psychological Association, Toronto, Canada. Kilpatrick, D. G.. Resick. P. A.. & Veronen. L. J. (1981). Effects longitudinal study. Journul qf Social Issues, 37, 105- 122.

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