A review of acute stress reactions among victims of violence:

Aggression and Violent Behavior, Vol. 4, No. 3, pp. 293–306, 1999 Copyright  1999 Elsevier Science Ltd Printed in the USA. All rights reserved 1359-1789/99/$–see front matter

PII S1359-1789(98)00002-0

A REVIEW OF ACUTE STRESS REACTIONS AMONG VICTIMS OF VIOLENCE: IMPLICATIONS FOR EARLY INTERVENTION Cheryl Gore-Felton, Michele Gill, Cheryl Koopman, and David Spiegel Stanford University

ABSTRACT. This article reviews research pertaining to the psychological trauma occurring in the immediate aftermath of interpersonal violence. The literature surveyed includes studies of victims and observers of various forms of interpersonal violence: rape, threats by a patient, legal execution, terrorist attack, ambush, and assassination, mass shootings, and other forms of homicide. The empirical evidence indicates that individuals commonly experience disruptive psychological symptoms immediately following violence. Further, there is evidence that acute stress reactions can lead to posttraumatic stress disorder (PTSD). The limited amount of research conducted on treatment interventions on acute stress reactions to violence indicates that there is not one best intervention. However, the high prevalence of acute stress reactions among victims immediately following interpersonal violence, coupled with evidence that acute stress symptoms predict PTSD, underscore the importance of providing early intervention to victims of interpersonal violence.  1999 Elsevier Science Ltd. All rights reserved. KEY WORDS. Acute stress disorder, violence, trauma symptoms, treatment A SUBSTANTIAL BODY OF research on violence, particularly on combat-related violence, indicates that exposure to violence may cause acute and chronic psychological responses that include, but are not limited to: fear, anger, recurrent distressing thoughts, anxiety, depression, and startle responses (Bisson & Shepherd, 1995; Helzer, Robbins, & McEvoy, 1987; Kilpatrick et al., 1989; Marmar, 1991; Solomon, Mikulincer, & Benbenistry, 1989). There is, however, a relatively limited body of research that focuses specifically on the immediate psychological impact of violence that occurs to civilians—the focus of this review. This article reviews the available literature pertaining to the psychological trauma occurring in the acute phase following a violent event in which the individual

Correspondence should be addressed to Cheryl Gore-Felton, Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, Stanford, CA 94305-5718. E-mail: cgore@leland. stanford.edu

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experiences, witnesses, or is confronted with death, threatened death, or serious injury of self or someone else. The intensity of an individual’s initial response to a traumatic event has been found to be associated with an elevated risk of developing posttraumatic stress disorder (PTSD) (Feinstein & Dolan, 1991; Kilpatrick et al., 1989; Koopman, Classen, Spiegel, 1994). McFarlane (1986) observed that the detection of much posttrauma morbidity is delayed, in part due to problems in diagnosis. Moreover, the prevalence of PTSD in the general adult population is estimated to be around 1% (Helzer et al., 1987), and in some subpopulations the rates are estimated to be much higher. For example, the highest rates of lifetime PTSD (38.5%) and current PTSD (17.8%) were found among women who experienced physical assault and women with a history of rape (Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993), and it has been estimated that 15.2% of male Vietnam veterans suffer from PTSD (Marmar, 1991). Therefore, it is important to be familiar with characteristics that are useful in identifying individuals who are at greatest risk for developing PTSD. Detecting early symptoms that may be indicative of chronic psychopathology enables mental health providers to detect and intervene with those who may be at elevated risk for developing PTSD. A growing body of evidence suggests that there are specific acute stress symptoms that occur almost immediately following a traumatic event and predict the development of PTSD (Classen, Koopman, Hales, & Spiegel, 1998; Koopman et al., 1994; Shalev, Peri, Canetti, & Schrieber, 1996; Spiegel, Koopman, Carden˜a, & Classen, 1996). The observation of acute stress reactions, in these and other studies of natural and human-caused disasters (see review by Koopman, Classen, Carden˜a, & Spiegel, 1995), led to the formation of the Acute Stress Disorder (ASD) diagnosis in the Diagnostic and Statistical Manual, fourth edition (DSM-IV; American Psychiatric Association, 1994). This diagnosis has strong relevance to the psychological stress reactions observed among victims and observers of interpersonal violence, the subject of this review.

THE PREVALENCE OF INTERPERSONAL VIOLENCE Interpersonal violence is defined here as an event that threatens or manifests bodily or emotional harm. The violent event may be observed, threatened, or directly experienced. Interpersonal violence can take a wide variety of forms. These include domestic violence, physical, sexual, and emotional abuse of children and spouses, date rape, stranger rape, assault and battery of strangers, terrorists attacks, mass shootings, assassinations, and executions. The studies reviewed here relate to the majority of these forms of violence, and examine acute stress reactions not only among victims but also among observers of violence. Suicide, or other forms of violence that are outside of the realm of interpersonal violence, were not included in this review. Interpersonal violence has become an unfortunately common traumatic experience in the lives of many individuals in the United States. The Centers for Disease Control and Prevention, National Center for Injury Prevention and Control (1997) reported that in 1995, homicide claimed the lives of 22,552 Americans. Also, according to this report, there were over 35,957 firearm-related deaths, including 15,551 firearm-related homicides, 18,503 firearm-related suicides, and 1,225 unintentional deaths related to firearms. Women are particularly likely to be targets of violent behavior. The National Victim Center and Crime Victims Research and Treatment Center (1992) reported that approximately 12 million (12.9%) women had been raped at least once during their life. Moreover, women are likely to be victimized by someone they know (Browne, 1993). When women

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are victimized by male partners they are more likely to be repeatedly attacked, raped, injured, or killed than are women who are assaulted by other perpetrators (Browne & Williams, 1989, 1993; Finkelhor & Yllo, 1985; Langan & Innes, 1986; Lentzner & DeBerry, 1980; Russel, 1982). In an effort to understand the prevalence of violence among women in the United States, Resnick and colleagues (1993) used multistage geographic sampling to conduct telephone interviews on a sample of 4009 adult (18 years or older) women. Respondents were asked about major life events and their experiences of rape, sexual molestation, attempted sexual assault, physical assault, and homicide of close friend or relative. More than one third (35.6%) of the sample indicated experiencing at least one of these criminal events during their lifetime. Of the women who had experienced some type of crime, 32.5% reported experiencing more than two different types of crime. Additionally, 41% had experienced multiple incidents of the same type of crime. Given the high prevalence of interpersonal violence, particularly among women, it is important to understand the psychological consequences of an understudied realm (i.e, the immediate and shortterm effects).

PSYCHOLOGICAL SEQUELAE OF VIOLENCE Research indicates that in the immediate aftermath of a traumatic event, such as interpersonal violence, people may experience distress and impaired psychological functioning to a degree that necessitates clinical intervention (Koopman et al., 1995). These psychological symptoms may be clinical indicators of ASD. The DSM-IV diagnosis of ASD describes psychological symptoms that persist a minimum of 2 days but not longer than 4 weeks following the traumatic event. The occurrence of symptoms beyond 4 weeks of a trauma must be evaluated in accordance with the PTSD diagnosis (American Psychiatric Association, 1994). ASD has five categories of symptoms that occur for 2 or more days within the first 4 weeks following a traumatic event. One symptom category includes the dissociative symptoms, which are three (or more) of the following: numbing, detachment, or absence of emotional responsiveness; reduction in awareness of surroundings (e.g., being “in a daze”); derealization; depersonalization; and dissociative amnesia. The diagnosis then requires one each of the three classical PTSD symptom clusters: intrusion, for example, re-experiencing the traumatic event (flashbacks), intrusive thoughts, or nightmares; avoiding reminders of the traumatic event; and anxiety/hyperarousal, including difficulty concentrating, restlessness, and exaggerated startle response. Finally, the diagnosis requires impairment in important areas of social and vocational functioning (American Psychiatric Association, 1994). To understand acute stress reactions, we examined research that reported acute psychological sequelae post-trauma. Since the diagnosis of ASD was not established until the publication of DSM-IV in 1994, research prior to this time did not have the perspective of examining symptoms systematically according to the ASD time period of 48 hours to 4 weeks post-trauma. Moreover, a number of studies that examined “acute” symptoms focused on assessments taken more than 4 weeks post-trauma. In this review, we have elected to primarily focus on studies assessing stress reactions within this 4-week posttrauma period. We did include one study that reported psychological reactions 6 to 8 weeks post-trauma because its findings were consistent with the research conducted within the 4-week posttrauma period and assisted in furthering our understanding of acute stress reactions to violence (North, Smith, & Spitznagel, 1994). Although most research has not

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been guided by the symptom criteria identified for the diagnosis of ASD, it has the advantage of not being prejudiced by preconceived notions; on the contrary, the ASD diagnosis was empirically driven by the findings of these richly descriptive studies. Only a few empirical studies have focused on acute stress reactions to interpersonal violence.

MASS SHOOTINGS In 1993, 14 people were shot in an office building at 101 California Street in San Francisco, while many employees were trapped in the building for several hours. Within 8 days of the shooting, 36 employees who worked in the building where the shootings took place completed questionnaires about their acute distress symptoms. Among the questionnaires used was the Stanford Acute Stress Reaction Questionnaire (SASRQ), the Impact of Event Scale (IES), and a PTSD self-rating scale. One third of the subjects met criteria for the ASD diagnosis. It was also found that PTSD symptoms were associated with meeting all symptom criteria for ASD (Classen et al., 1998). North, Smith, and Spitznagel (1994), examined acute traumatic stress symptoms in men and women who were present during a mass shooting in Killeen, Texas in 1991. The gunman began shooting in a cafeteria that was crowded with more than 100 customers. The gunman first drove his truck into the front of the cafeteria, injuring several customers. Then he got out of his truck shooting. The gunman walked round the dining room, systematically shooting people at point-blank range. The gunman fatally shot himself after being shot by police. The gunman killed 24 people, including himself. The researchers interviewed 136 people, 29 of whom were eyewitnesses, approximately 6 to 8 weeks posttrauma. Most participants (82.5%) reported experiencing intrusive recall of the traumatic event, 73.8% experienced insomnia, 75.4% experienced jumpiness (hyperarousal), and over half (56.4%) experienced nightmares. All of these psychological symptoms are consistent with ASD. However, the researchers did not interview the study participants within the time frame of 48 hours to 4 weeks, which is necessary to make a diagnosis of ASD. Interestingly, the researchers were able to make a diagnosis of PTSD in 20.7% of the men and 28.8% of the women who did not have a previous history of PTSD. A study of children’s acute responses to a sniper attack on an elementary school playground shows that children exhibit traumatic responses similar to those of adults. One hundred and fifty-nine children were interviewed (mean age, 9.2 years) approximately 1 month after the event. Each child was interviewed to assess their psychological reaction to the event using the PTSD Reaction Index. The study provides strong evidence that acute stress reactions occur in school-aged children. It also showed that children with less severe degrees of exposure (i.e., were not in the playground at the time of the attack) rarely evidenced acute posttraumatic symptoms as compared to the highly exposed children. The investigation also confirms that school-aged children can be directly assessed for their psychological responses to violent events (Pynoos et al., 1987).

RAPE AND OTHER INTERPERSONAL ASSAULTS OF WOMEN Kilpatrick, Veronen, and Best (1985) gave 125 female participants, ages 16 and older, postrape assessments 6 to 21 days after the rape and again at 3 months. They found that the victims’ level of distress at 6 to 21 days postrape was predictive of high levels of distress at 3 months. Rothbaum, Foa, Riggs, Murdock, and Walsh (1992) conducted a study in which the

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participants were victims of rape or attempted rape. The initial interview with all participants was completed within 30 days of the assault (average, 12.64 days). The questionnaires used for assessing postassault trauma symptoms included the IES. At the initial interview, 94% of the women met the criteria for PTSD. The researchers further discovered that severity of traumatic symptoms was associated with later development of PTSD. For example, the more severe the trauma symptoms, the more likely participants were to later develop chronic PTSD symptoms. This finding is consistent with other research that indicates severe acute stress reactions predicts later development of PTSD (Feinstein & Dolan, 1991; Kilpatrick et al., 1985, 1989; Koopman et al., 1994). Before effective intervention and prevention programs can be implemented, it is important to understand factors associated with the development of PTSD. Therefore, Kushner, Riggs, Foa, and Miller (1993) evaluated the association between perception of controllability and the development of PTSD following a criminal assault. The participants in the study were 140 females (average age, 32 years). Fifty-eight of the women were rape victims and 82 were victims of nonsexual assault in which physical contact occurred (i.e., pushing, grabbing, punching). All participants were assessed at 1 to 2 weeks post-assault. The researchers acknowledged that longitudinal research has shown that approximately 50% of rape victims and 30% of nonsexual assault victims develop PTSD during the 3 months immediately following the violence (Rothbaum et al., 1992). However, past research has shown that characteristics of the assault, such as severity of injury and duration of assault, account for a very small percentage of the variance attributed to the symptom severity of PTSD (Foa, Rothbaum, Riggs, & Murdock, 1991). Kushner et al.’s study revealed that individual differences do account for severity of PTSD symptoms. In particular, the PTSD symptoms of women who perceive negative events as uncontrollable are likely to be more severe than the women who perceive negative events as controllable. Our understanding of acute stress reactions and the later development of PTSD was broadened by Dancu, Riggs, Hearst-Ikeda, Shoyer, and Foa (1996) who conducted a study on 204 women. The researchers compared 74 victims of sexual assault to 84 nonsexual assault victims and 46 women who reported no assault during the year prior to assessment in the study. Assault victims were evaluated four times during a 3-month period beginning within 2 weeks of the assault. Subsequent assessments were conducted at 4-week intervals. The authors found that dissociation, which is one symptom of ASD, was associated with the development of PTSD for women who had been victims of nonsexual assault.

Terrorist Attack Survivors of a terrorist attack on a civilian bus in Israel in 1989 were assessed for traumatic symptoms on the second and sixth days of their admission into the hospital for treatment of the physical injuries. The IES was used to evaluate symptoms of intrusion and avoidance (Shalev, 1992; Shalev et al., 1996). Survivors scored high on IES intrusion scores, suggesting the presence of intense symptoms of intrusion, such as intrusive thoughts, images and feelings or dreams of the traumatic event (Shalev, 1992).

Ambush Feinstein (1989) explored traumatic stress in fourteen members of an army patrol who were ambushed in a war zone in Namibia. All the men involved in the ambush plus an additional three men who had been left at base camp, were interviewed the day after the ambush and were followed for one month. A checklist of post-traumatic symptoms was administered at weekly intervals. All the men involved in the ambush experienced signifi-

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cant symptoms of traumatic stress. Furthermore, 86% of the soldiers reported recurrent and intrusive recollections of the event, and half experienced recurrent dreams of the event.

Assassination Maldonado, Page, Koopman, Stein, and Spiegel1 examined acute stress reactions to the assassination of a presidential candidate. On March 23, 1994, Mexican presidential candidate Luis Donaldo Colosio Murieta was shot dead during a rally. Colosio was the leading candidate for the presidency at the time of his death. During the fourth week after the assassination, 97 participants were recruited to complete self-report measures on the SASRQ, the IES, measures of demographic characteristics, emotional impact of the assassination, coping behaviors, and exposure to a previous traumatic event. This study found that having experienced previous traumatic events was associated with greater acute stress reactions.

Media Eyewitness to an Execution There is little question that being the target of violence is psychologically traumatic, as suggested by research on the soldiers ambushed in Namibia (Feinstein, 1989). However, few studies have examined the psychological impact of violence on adults who witness it. Therefore, Freinkel, Koopman, and Spiegel (1994) examined the psychological responses of journalists who witnessed a state execution of a prisoner. In 1992 California’s first execution in 16 years took place in the San Quentin prison gas chamber and 18 invited journalists attended as media eyewitnesses. To assess their psychological reactions during and shortly after the execution, the attending journalists were contacted and asked to complete the SASRQ and a semi-structured phone interview. Eighty-three percent of the journalists completed the SASRQ and 80% participated in the phone interviews. Many of the journalists reported considerable short-term psychological distress resulting from witnessing the execution, however no evidence of long-term trauma was found (Freinkel et al., 1994).

Threatening Patient Koopman, Zarcone, Mann, Freinkal, and Spiegel (1998) surveyed staff in a university psychiatric clinic who had received threats made on the telephone and in person by a patient who was an outpatient at the facility. The patient threatened to kill several administrative personnel as well as himself. Approximately 2 weeks after security implemented increased security measures in response to the threatening patient, security officers conducted a briefing for employees. It was during this time that questionnaires were distributed to employees. The response rate was 75.9% (63 of 83) nonfaculty staff. Participants completed demographic information, SASRQ, IES, exposure to event, history of previous threats, interference in functioning, and protective actions. The researchers found that greater acute stress symptoms were present among persons who reported more exposure to a threatening patient, viewed the episode with the patient as threatening, and served as a clinic administrative staff person (i.e. had more of an opportunity of a face-to-face interaction with the threatening patient compared to nonclinic administrators).

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Maldonado, J., Page, K., Koopman, C., Stein, S., & Spiegle, D. Acute stress reaction in the immediate aftermath of the assassination of Mexican presidential candidate Colasio. Manuscript submitted for publication.

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ACUTE STRESS REACTIONS On the basis of the kinds of studies reviewed in this article, five types of symptoms have been included within the diagnostic criteria for ASD, which are described in detail below. These symptoms include: (a) dissociation, (b) re-experiencing trauma, (c) avoidance of reminders of trauma, (d) anxiety/hyperarousal, (e) and impairment in social and occupational functioning (American Psychiatric Association, 1994).

Dissociation Dissociation is a disjunction in memory, perception, or identity either during or after experiencing the distressing event. Research indicates that dissociative experiences follow different types of traumatic experiences, including childhood sexual abuse (Briere, Evans, Runtz, & Wall, 1988; Heath, Bean, & Feinauer, 1996), combat (Marmar et al., 1994), and natural disasters (Koopman et al., 1994, 1995). Further, dissociation appears to be an acute reaction to interpersonal violence. For example, Dancu et al. (1996) found that immediately following sexual and nonsexual assaults, victims experienced more dissociative symptoms in comparison with individuals who had not been victimized. Additionally, among women who had been raped or who were victims of an attempted rape (Rothbaum et al., 1992), approximately 85% of the women reported experiencing the feeling of being detached. These results are consistent with other acute trauma research, for example, among survivors of a mass shooting in a cafeteria, 11% reported having amnesia and 8% reported experiencing emotionally numb feelings (North et al., 1994). Also, among media eyewitnesses to an execution, 53% reported experiences of psychic numbing, such as feeling distant from their emotions and no longer feeling interested in previously enjoyable activities (Freinkel et al., 1994). Moreover, 53% of the eyewitnesses also reported that things around them seemed unreal and a sense of timelessness (i.e., symptoms of derealization). Forty percent of the witnesses experienced themselves as strangers and felt distant from their own thoughts (i.e., symptoms of depersonalization).

Re-experiencing the Traumatic Event Re-experiencing the trauma in the DSM-IV criteria for ASD is indicated by persistent unbidden intrusions, such as by recurrent images, thoughts, dreams, illusions, or flashbacks (American Psychiatric Association, 1994). Additionally, upon exposure to the reminders of the traumatic event, there is often a strong sense of reliving the experience or extreme distress. Re-experiencing the traumatic event is not uncommon among victims of violence. For example, in the study of psychological reactions of media eyewitnesses to an execution, flashbacks were experienced by 13% of the journalists who attended the execution. Forty percent of the participants experienced repeated and unwanted memories of the execution, and 27% reported repeated distressing dreams about the execution (Freinkel et al., 1994). Among the children who had been present in the school playground at the time of a sniper attack, 97.1% reported intrusive thoughts, and 88.6% reported intrusive imagery and sounds (Pynoos et al., 1987). Providing even more evidence that re-experiencing the traumatic event occurs almost immediately following a trauma in some individuals, are the intrusive thoughts that were experienced by the survivors of the terrorist attack in Israel (Shalev, 1992). Also, 86% of the soldiers caught in the Namibia ambush reported recurrent and intrusive recollections of the event, and half experienced recurrent dreams of the event (Feinstein, 1989). Further-

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more, 82% of the people involved in the mass shooting in Killeen, Texas in 1991, experienced intrusive thoughts and 37% reported flashbacks (North et al., 1994). Classen et al. (1998) found that when examining acute stress reactions to a mass shooting in an office building in San Francisco, the average respondent experienced at least one symptom of re-experiencing the traumatic event. Nearly all of the participants in the study of victims of rape or attempted rape (Rothbaum et al., 1992) experienced trauma-related intrusive thoughts and images at the initial assessments (which were conducted an average of 12.64 days post-assault); 74% reported a sense of reliving the experience; and 86% reported experiencing flashbacks. In the study of nonsexual and sexual forms of assault against women, perceptions about general controllability of negative events were related to greater symptoms of re-experiencing the trauma (Kushner et al., 1992).

Avoiding Reminders of the Traumatic Event Several research studies indicate that avoiding reminders of the traumatic event occurs in many individuals across various types of violent situations. For example, avoiding reminders of the traumatic event was reported among 88% of children approximately 1 month after they experienced the sniper attack at their school playground (Pynoos et al., 1987). Additionally, survivors of a mass shooting in Texas reported avoiding reminders (47%) and thinking (37%) about the event, when they were assessed approximately 1 month post-disaster (North et al., 1994). Also, in the study examining acute stress reactions to a mass shooting in an office building in San Francisco, respondents experienced a mean of 1.0 possible symptoms of avoiding reminders of the traumatic event (Classen et al., 1998). In the study of rape and attempted rape victims, 93% of the victims who were assessed an average of 12.6 days post-assault, reported avoidance symptoms (Rothbaum et al., 1992). Although Kushner et al. (1992), in their research on sexual and nonsexual criminal assaults on women, did not report the prevalence of symptoms of avoiding reminders of the traumatic event, they found that participants who perceived less control experienced more avoidance symptoms.

Anxiety/Hyperarousal Symptoms of hyperarousal/anxiety in the DSM-IV criteria for ASD are indicated by marked difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, and motor restlessness (American Psychiatric Association, 1994). The available empirical literature indicates that this response is not uncommon among victims who experience violence. For example, difficulty in concentrating and a loss of interest in significant activities was observed approximately 1 month after the incident took place among 65.7% of children survivors of the sniper attack in their school playground (Pynoos et al., 1987). Additionally, 97% of the women who were raped or victims of attempted rape exhibited a startle response (Rothbaum et al., 1992). Furthermore, among survivors of a mass shooting (North et al., 1994), 44% were found to experience irritability, 75% were jumpy and startled easily, and 74% suffered from insomnia. In research on sexual and nonsexual criminal assaults on women, Kushner et al. (1992) did not report how many of the their sample experienced PTSD symptoms; however, they did report that arousal was inversely associated with perceived controllability of negative events: the less perceived control women thought they had, the more severe were their hyperarousal symptoms.

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Impairment in Social, Occupational, and Other Important Areas Severe impairment in social, occupational, or other important areas of functioning has been included as a diagnostic criteria for ASD among survivors of a recent traumatic event (American Psychiatric Association, 1994). The available literature on acute stress reactions indicates that this occurs among victims of interpersonal violence. Rothbaum et al. (1992) found 81% of women who were assessed soon after a rape or an attempted rape (on average 12.6 days post-assault) reported an impairment in leisure activities. Difficulty in concentrating and a loss of interest in significant activities was observed among 65.7% of children survivors of the sniper attack in their school playground approximately 1 month after the incident took place (Pynoos et al., 1987).

CLINICAL IMPLICATIONS The studies reviewed here indicate that individuals commonly experience disruptive psychological symptoms almost immediately following violence. Additionally, the research cited provides evidence that many individuals suffer from acutely disabling psychological symptoms that are consistent with ASD. It is important to note that the research reviewed demonstrates that not all victims of violence will suffer from severe psychological difficulties in response to violence. However, empirical evidence indicates that a subpopulation of victims will develop moderate to severe psychopathology if left untreated. Therefore, it is important to understand what treatment methods are effective in treating the psychological sequelae of victimization. To explore the effectiveness of treatment, we reviewed the following four types of clinical strategies that have been used to treat acute stress reactions: cognitive behavioral, immediate versus delayed, brief psychotherapy and critical incident stress debriefing.

Cognitive-Behavioral Treatment Foa, Hearst-Ikeda, and Perry (1995) conducted a study examining the treatment efficacy of a brief cognitive-behavioral program on recent assault victims. The goal of treatment was aimed at preventing the development of chronic PTSD. Participants in this study were 20 women who had either been recently sexually or nonsexually assaulted. Half of the women were placed into one of two different groups, a brief prevention group of cognitive-behavioral therapy and an assessment control group. Eighteen of 20 women were less than 14 days post-assault, and were thus in the early acute stress phase of responding to the traumatic event. The women in the assessment control group were selected to match those in the brief prevention group in the following: initial PTSD severity, type of assault, severity of the assault, demographics, and time since assault. The brief prevention program was four 2-hour weekly sessions of cognitive-behavioral therapy. The sessions incorporated education about reactions to assault, breathing and relaxation training, reliving the assault, in vivo exposure, and cognitive restructuring. The women in the assessment control group were given five assessment interviews, each lasting 90 minutes during a 12-week period. A sixth assessment was administered to the assessment group 5 1/2 months post-assault. The researchers found that brief cognitive-behavioral therapy administered shortly after the assault increased the rate of improvement on trauma-related psychological symptoms. For example, 2 months post-assault the therapy group reported less severe re-experiencing of the trauma and arousal symptoms, as compared with the assessment group. Moreover,

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none of the participants in the therapy group compared to 33% of the participants in the assessment group had more than six PTSD symptoms at the 5 1/2-month assessment. Also noteworthy, is that the therapy group was effective in reducing depression. For example, there were no reports of depression among the group therapy participants, while 56% of the assessment group reported moderate to severe depression. Echeburua, de Corral, Sarasua, and Zubizarreta (1996) designed a study that compared the effectiveness of cognitive restructuring with progressive muscle relaxation in treating rape victims who were suffering from acute PTSD symptoms. The average time since the rape for the participants was approximately 5 weeks. Twenty women were randomly assigned to one of two treatment conditions. All participants received baseline assessments and follow-up assessments were conducted post-treatment at 1-, 3-, 6-, and 12-month intervals. The researchers defined therapeutic success as the disappearance of PTSD symptoms according to Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R; American Psychiatric Association, 1987) criteria. When looking at global intensity of PTSD symptoms, the researchers found that women who were in the cognitive restructuring and coping skills group showed slight improvement at the 1- and 6-month follow-up, as compared with the muscle relaxation group. However, at the 12-month follow-up the cognitive restructuring group showed significant improvement in PTSD symptoms, as compared with the muscle relaxation group. When the researchers examined which PTSD symptoms were effected by the cognitive-restructuring and coping skills group, they found that there was marked improvement in re-experiencing and avoidance symptoms. This is an extremely important clinical finding in light of the fact that the most frequently experienced symptoms in PTSD are re-experiencing and autonomic arousal symptoms (Foa, Zimbarg, & Rothbaum, 1992; Resnick, Foy, Donahoe, & Miller, 1989; Rothbaum et al., 1992). Veronen, Kilpatrick, and Resick (1978) developed a cognitive-behavioral treatment program for rape victims called stress inoculation training. Veronen and Kilpatrick (1982, 1983) report that this treatment has been effective in reducing fear, anxiety, and depression related to rape trauma. To further this research, a study was conducted examining the effectiveness of stress inoculation training, prolonged exposure, supportive counseling, and wait-list control (Foa et al., 1991). Forty-five women who had been raped at least 3 months prior to entering the study were randomly assigned to one of the four treatment conditions. The researchers found that stress inoculation training and prolonged exposure were more suitable treatment methods than supportive counseling or wait-list control in reducing PTSD symptoms.

Immediate Versus Delayed Treatment Frank et al. (1988) compared cognitive behavior therapy and systematic desensitization therapy in women contacting a rape crisis center. The study differentiated two types of treatment seekers: early-treatment seekers, who began treatment within days or weeks of the assault, and late-treatment seekers, who began treatment several months postassault. Participants were randomly assigned to one of the two treatment modalities, cognitive-behavioral therapy (CBT) or systematic desensitization therapy (SDT). A total of 71 participants were assigned to CBT and 67 were assigned to SDT. The participants were matched on all demographic features and severity of assault (i.e., location of rape, use of a weapon, number of assailants, and degree of physical violence). Participants completed self-report measures on depression, anxiety, fear, feelings of inadequacy, selfesteem, social adjustment, and demographics. The researchers found no significant differences between the two different treatment

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modalities on psychological or social adjustment measures. Furthermore, there was no difference between early-treatment seekers and late-treatment seekers at the end of treatment on self-report measures of psychological symptomatology.

Brief Psychotherapy Brom, Kleber, and Defares (1989) conducted a comparative outcome study in which they examined three types of psychotherapy: trauma desensitization, hypnosis, and psychodynamic therapy. The trauma desensitization therapy merged cognitive restructuring techniques, whereby the patient learns how to relax, then with visual imagery techniques reexperiences the traumatic event and learns to confront avoided stimuli. Hypnosis was used to assist the patient in confronting the traumatic event and at the same time decrease conditioned physiological responses that are triggered by the trauma. The psychodynamic component was aimed at solving the intrapsychic conflicts that resulted from the trauma. There were 112 participants in this study, 79% were women and 21% were men. Nineteen participants experienced a violent crime, 4 were in auto accidents, and 83 lost a loved one from murder/suicide, and 6 patients experienced some other type of trauma. Participants were randomly assigned to one of four conditions, trauma desensitization, hypnosis, psychodynamic therapy, or wait-list control. The length of treatment for the trauma desensitization, hypnotherapy, and psychodynamic averaged 15, 14.4, and 18.9 sessions, respectively. Assessment measures were administered at baseline, immediately following treatment, and 3 months post-treatment. Results showed that symptoms of intrusion and avoidance were lessened considerably in the treatment groups but not in the control group. Trauma desensitization and hypnosis were found to be significantly more useful in improving both intrusion and avoidance symptoms compared to the control group, whereas psychodynamic therapy was only significantly better at lessening avoidant symptoms compared to the control group. Therefore, it appears that brief psychodynamic therapy is not the best treatment for ameliorating both avoidant and intrusion symptoms in cases where the trauma is fairly recent (i.e., 5 weeks). This finding is consistent with Marmar (1991), who asserts that brief dynamic psychotherapy has its greatest applicability in cases where PTSD symptoms have occurred from several months to several years following a traumatic event.

Critical Incident Stress Debriefing Critical Incident Stress Debriefing (CISD) was developed in the late 1970s to provide early interventions in group settings for emergency service personnel providing education, ventilation, and support (Freedy, Kilpatrick, & Resnick, 1993; Mitchell & Dyregrow, 1993). Later, this treatment was termed psychological debriefing (PD) and has been used extensively with individuals involved directly in trauma, such as emergency service workers and providers of psychological aftercare in situations such as natural disasters (Bisson & Deahl, 1994). There have been no empirical studies conducted on this type of treatment, despite its wide usage. Although there is a great deal of anecdotal evidence reporting the effectiveness of PD, it is not clear how effective this treatment is in diminishing PTSD symptoms in the acute and chronic phases of the disorder.

Summary of Clinical Treatment for Victims of Violence No treatment strategy has been found to be the most appropriate in treating victims of violence. However, a variety of treatment methods have been and continue to be used with survivors of traumatic events in the immediate aftermath of trauma. Most crisis

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intervention methods have not been empirically studied, which makes the clinical efficacy of these methods unknown. However, the research reviewed comparing different treatment models indicates that studies that compare control groups with treatment groups and have good follow-up data tend to use the well-established principles of the cognitivebehavioral perspective (Richards, Lovell, & Marks, 1994). Moreover, treatment studies that have examined the effectiveness of psychotherapy on posttraumatic stress symptoms to traumatic events have used imagined and live exposure to trauma cues (Foa et al., 1991; Frank et al., 1988). Further, exposure to the traumatic memory has been shown to be more effective than stress inoculation training, supportive counseling, and no-treatment control (Foa et al., 1991). Given the apparent success of therapies that use behavioral techniques, it is noteworthy that Solomon, Gerrity, and Muff (1992) reviewed several different types of treatment for PTSD symptoms. Consistent with other clinical findings, they found that behavioral therapy was more effective than drug therapy, particularly in reducing intrusive symptoms. However, the researchers caution that using behavioral techniques, such as systematic desensitization (gradual increase in exposure to trauma cues) and flooding (high intensity exposure to trauma cues), have had severe complications in people suffering from psychiatric disorders.

SUMMARY The initial psychological response to violence can be severe and may represent ASD. If the symptoms are not managed, other psychological problems, such as posttraumatic stress disorder, anxiety disorders, depressive disorders, and substance abuse or dependence may develop (Bisson & Shepherd, 1995). The psychological impairment that results from violence may have a deleterious effect on the lives of victims, which impacts their ability to function on personal, social, and occupational levels. In considering the findings of this body of research examining reactions to many types of interpersonal violence, it is notable that high rates of ASD symptoms occur across these many types of interpersonal violence. These symptoms are important to consider because they cause considerable distress and because they indicate for a subpopulation of individuals a high risk for developing longer-term PTSD. Given the need for systematic empirical evidence evaluating the effectiveness of interventions for ameliorating acute stress reactions among victims of interpersonal violence, mental health providers should be flexible in determining which treatment to provide to the trauma survivor by assessing the client’s acute stress reactions and matching the appropriate treatment to the individual client’s needs (Marmar, Foy, Kagan, & Pynoos, 1993).

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