Services for victim/survivors of sexual assault
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- Background to service provision: The prevalence of sexual violence, and barriers to reporting and disclosure
- Adverse outcomes of sexual assault experienced by victim/survivors
- Interventions to reduce psychological distress and their effectiveness
- Specialist sexual assault services in Australia: The existing research
- General health service providers working with victim/survivors of sexual assault: Some recommendations
Interventions to reduce psychological distress and their effectiveness
To be meaningful, contemporary sexual assault interventions must respond to survivors' needs and concerns. At the present time, the evidence base on this and other aspects of sexual violence is incomplete. Currently available interventions may not be the most appropriate ones to respond to survivors' needs.
In Australia, the pressing need to deliver services has understandably taken priority over evaluation of those services. As already mentioned, research on existing interventions and different approaches to working with survivors is lacking. Some sexual assault service workers may also have philosophical reservations about psychological research if this is perceived to 'label' and psychopathologise victim/ survivors. A small amount of research exists on service users and their perceptions of sexual assault services. This will be discussed below, but first the largely US research on mental health interventions for survivors will be reported.
Mental health interventions
The main focus of mental health interventions for victim/survivors has been on the treatment of the mental health consequences of sexual violence including guilt, shame, anxiety, depression, hypervigilance, anger, mood swings and social discomfort (Campbell, 2001; Foa, Rothbaum, Riggs, & Murdock, 1991; Trowell et al., 2002; Vaa, Egna, & Sexton, 2002). Some of these consequences equate with symptoms of PTSD (Foa et al., 1991; Lubin, Loris, Burt, & Johnson, 1998). However, as mentioned previously, victims of sexual assault may experience forms of psychological distress that do not meet criteria for the diagnosis of psychological disorders such as intense feelings of shame, existential insecurity and self blame. Alternatively, they may present with symptoms that do meet criteria for disorders such as depression, anxiety and dissociative disorders. These conditions may also co-exist with symptoms of PTSD (Lubin et al., 1998; Nishith, Nixon, & Resick, 2005; Vaa et al., 2002). The literature identifies two main psychotherapeutic approaches in relation to the treatment of victims of sexual assault: cognitive behavioural therapy and feminist (or group) therapy.
Cognitive therapies include cognitive behaviour therapy, rational emotive therapy and cognitive processing therapy. All share the assumption that psychological distress and behavioural dysfunction can be produced by inaccurate and dysfunctional thinking. The goal of therapy therefore, is to change psychological distress by challenging and changing the distorted cognitions which give rise to it. Clients are taught, in a variety of ways to "recognize, observe, and monitor their own thoughts and assumptions, especially their negative automatic thoughts" (Corey, 2005, p. 285).
Cognitive behavioural therapy (CBT). CBT involves a number of different techniques, such as exposure to traumatic memories, cognitive restructuring and eye movement desensitisation and reprocessing (Bradley, Greene, Russ, Duttra, & Westen, 2005).
Prolonged exposure therapy. Under the cognitive behavioural framework, Foa and Rauch (2004) evaluated the outcomes of prolonged exposure therapy on its own as well as the combination of prolonged exposure and cognitive restructuring therapies. Prolonged exposure requires the client to confront traumatic memories repeatedly (through imaginal exposure) as well as confronting trauma related situations which are usually avoided (in vivo exposure) (Foa & Rauch, 2004). The goal of this type of therapy is to present the client with information that invalidates PTSD-related cognitions.
Cognitive restructuring therapy. Cognitive-restructuring targets the negative cognitions associated with a traumatic event. The aim of this therapy is to actively engage the client in challenging negative automatic thoughts in order to alter PTSD related cognitions. Foa and Rauch (2004) found that prolonged exposure therapy was effective in reducing PTSD related symptoms in victims of sexual assault; however the addition of cognitive restructuring did not enhance the outcome of therapy.
Other therapeutic services that address PTSD. Therapeutic services to prevent sexual assault victims from experiencing chronic symptoms of PTSD and depression have also been explored. Resick and Schnicke (1992) used cognitive processing therapy involving education, exposure and cognitive components in a 12-week program using a pre-test post-test design. Women who received the program compared with a wait list (control) group showed significant improvement on measures of PTSD and depression and this improvement was maintained for six months. Foa, Hearst-Ikeda, and Perry (1995) developed a brief cognitive behavioural program for recent victims of sexual assault. The program involved education about common reactions to sexual assault, breathing and relaxation training, prolonged exposure therapy and cognitive restructuring therapy. Immediately following the program, women who received the brief therapy were less likely to meet the criteria for PTSD than those who did not receive the therapy. Five and a half months after the end of treatment, women who had experienced the therapy maintained low levels of PTSD symptomatology and were also significantly less depressed than those who had not.
The efficacy of cognitive-behavioural techniques in comparison to solution-focused counselling was investigated by Foa et al. (1991) for the treatment of PTSD in victims of rape. Participants were assigned to either stress inoculation training, prolonged exposure therapy, supportive counselling or a waiting list group (control group). Stress inoculation training involved education about coping strategies, breathing and relaxation exercises, cognitive restructuring and role playing to prescribe new models of behaviour. Prolonged exposure involved asking the client to imagine the rape event repeatedly within the session, and outside the session to expose herself to feared or avoided situations that were judged by both the client and the therapist to be safe. Supportive counselling was governed by a solution-focused framework in which the client was asked to report and generate strategies to deal with problems in a highly supportive environment.
Each of the therapeutic procedures was effective in reducing PTSD symptoms, immediately after the treatment and at follow up. However, the timing of the effect differed between the two therapeutic approaches. The clients who received stress inoculation training showed more improvement in PTSD symptoms immediately after treatment than those receiving supportive counselling or those on the waiting list. By contrast the clients who received prolonged exposure therapy showed the lowest levels of PTSD symptoms at follow up more than three months later.
Interventions that address victim blaming and feelings of guilt. Victim blaming and feelings of guilt are commonly reported by sexual assault survivors and have become a focus of psychotherapeutic intervention in their own right (Campbell et al., 1999). Trauma-related guilt has been associated with the etiology of depression in victims of sexual assault (Andrews, 1995; Gladstone et al., 2004). Nishith et al. (2005) compared the effectiveness of cognitive processing therapy and prolonged exposure on female rape victims. Cognitive processing therapy was equally effective in treating women with 'pure' PTSD or PTSD together with major depressive disorder and significantly more effective than prolonged exposure in reducing guilt cognitions related to the trauma.
Interventions that address sleep difficulties. As noted earlier, chronic nightmares and other sleep difficulties occur frequently in clients with PTSD but have not been a major focus of treatment to date. Krakow et al. (2001) treated chronic nightmares in female sexual assault victims using imagery rehearsal therapy and cognitive restructuring. This treatment decreased chronic nightmares, improved sleep quality and decreased PTSD symptom severity. Another positive outcome was that the clients' experiences in therapy were generalised to and helpful with other areas of maladaptive functioning such as negative and obsessive thinking.
Eye movement desensitisation and reprocessing therapy. Eye Movement Desensitisation and Reprocessing (EMDR) is another component of cognitive behavioural therapy that has been used quite extensively in traumatised populations (Shapiro, 1989). During EMDR the client is asked to move their eyes rapidly from side to side while imagining an aspect of their trauma experience; such as a visual image, negative cognition, negative emotion or physical sensation (Wilson, Becker, & Tinker, 1995). This process is repeated until the client has altered self-cognitions in a positive manner and has become desensitised to disturbing aspects of their trauma experience. Wilson et al. (1995) found that psychologically traumatised individuals, including sexual assault victims, showed reductions in their trauma related issues and anxiety and increases in positive self-cognitions. These results were maintained at three-month follow-up and EMDR was shown to be effective regardless of type of trauma experienced by the client.
Feminist therapy stresses the importance of considering the social and cultural context, including gender-based oppression, in understanding the causes and nature of women's psychological difficulties. In this way, feminist therapy contrasts with traditional psychotherapies that attribute problematic behaviours and emotions to intrapsychic causes, have a tendency to blame the sufferer for her own distress and ignore the role of sociocultural factors and how women are treated in society in gendering psychological disorder (Astbury, 1996).
There is ample empirical evidence linking material disadvantage, the inferior sociopolitical position of women, the rights violations and exposure to sexual and other forms of gender-based violence women experience to their higher rates of certain psychological disorders including PTSD, depression and eating disorders (for review see Astbury & Cabral, 2000).
The goal of feminist therapy with a victim of sexual violence is to help her understand that such violence is a societal problem not just an individual problem and that sexual violence is reinforced by gender-based differences in privilege and power that play out within interpersonal relationships. Feminist therapies also focus on survivors' difficulties with guilt and self-blame in the long term, not merely the alleviation of psychological symptoms in the short term (Campbell, 2001).
The findings of an early study (Hutchinson & McDaniel, 1986) suggested feminist therapy was, indeed, more successful in reducing survivors' levels of guilt and self blame than traditional counselling. A more recent study (Morgan, 2000) with survivors of childhood sexual abuse also demonstrated that survivors who participated in feminist therapy had greater improvements in depression, social adjustment, self-blame and post traumatic stress than their counterparts in the control group. Most therapeutic services in the United States use a combination of CBT and feminist therapy according to Campbell (2001).
Vaa et al. (2002) used a multimodal group therapy treatment approach with adult survivors of child sexual abuse and recent adult victims of sexual assault. The therapy ran in five phases each with its own specified goal including developing a sense of group identity and social support, re-experiencing and working through trauma, learning assertiveness, experiencing oneself as a victim and regaining control over one's life, evaluating present circumstances and developing future goals. Of the 50 women who participated in the program, 38 were involved in long-term follow-up some four-and-a-half years later. Those who improved immediately after the treatment were likely to retain this improvement at follow up. Women who were older at the time of treatment and initially showed improvement in psychological symptoms were most likely to lose these gains by the time of follow up. Better post-treatment outcome was found in younger women, who had fewer presenting symptoms at the start of the therapeutic program and had received no previous treatment.
Another group model using a feminist approach was evaluated by Lubin et al. (1998) with a female sample of multiply traumatised women. The therapy was psychoeducationally based and was conducted in three phases. The therapy:
- explored the effects of trauma on the sense of self with particular emphasis on feelings of shame, guilt and issues related to feminine identity;
- examined the impact of trauma on interpersonal relationships; and
- focused on existential approaches of generating meaning in one's life despite trauma.
Results indicated that this form of therapy was consistently effective in reducing PTSD symptoms and other forms of psychiatric distress, regardless of the type of trauma experienced. Moreover, these improvements were maintained at six-month follow-up. The researchers suggest that group therapy does not need to be limited by focusing strictly on individualised emotional and interpersonal issues as a more structured, psychoeducational format may contribute to more success in symptom reduction and overall outcome.
Very little literature exists on therapeutic frameworks beyond the cognitive behavioural and feminist approaches. Bowling and Weiland (2002) recently conducted a study utilising a family systems framework in order to test its efficacy in treating victims of sexual assault when compared to traditional individual therapy. The clients receiving family systems therapy showed greater improvement in depressive symptoms than individual therapy clients, however reductions in PTSD symptoms were at the same level for both types of treatment. Family functioning was not affected by either type of therapy.