Imagine hearing that a family responded this way after a sexual assault, “My father and mother said that the way I dressed and friends I chose provoked the incident. They blamed me for the first two months after the incident.”
Or, as another young woman recounted, “[An acquaintance] mentioned that I should never have been talking to him and I should have fought harder—that I should have known what he wanted.”
Just as these quotes from the book Talking about Sexual Assault by professor Sarah E. Ullman, PhD, demonstrate, there is still much stigma and victim blaming for survivors of sexual assault.
It is of upmost importance that your clients do not perceive you as one of those people who does not understand, or worse, blames a rape victim for her perpetrator’s behavior. Nor do you want to be a provider who thinks you don’t have any rape survivors in your practice.
Whether you are aware of it or not, you almost certainly see rape survivors in your office. After all, estimates are that one in six women experiences rape or attempted rape in her lifetime (National Institute of Justice, Extent, Nature, and Consequences of Rape Victimization: Findings from the National Violence Against Women Survey 2006). While most rape victims are female (86% according to the report), sexual assaults are not a problem exclusive to women, and it is estimated that almost three million men in the US have been raped.
The keys to an informed practice are awareness and sensitivity, effective assessment, and the knowledge and skills to treat the mental health problems of sexual assault survivors.
Mental Health Sequelae Following Rape
Now that you know you likely have women in your practice who have experienced rape, you may be wondering how to best assess and treat clients who have experienced sexual assault.
Rape victims are at high risk for developing posttraumatic stress disorder (PTSD), depression, and substance abuse (Kessler RC et al, Arch Gen Psychiatry 1995;52(12):1048–1060).
They may also suffer from panic attacks (Falsetti SA & Resnick HS, J Trauma Stress 1997;10(4):683–689), eating disorders (Laws A & Golding JM, Am J Public Health 1996;86(4):579–582), and sleep problems (Clum GA et al, J Nerv Ment Dis 2001;189(9):618–622), among other disorders.
Assessment of Sexual Assault
A thorough trauma assessment is critical to provide effective treatment for rape victims. The assessment should include a detailed trauma history, such as information about the number and types of trauma experienced, whether the victim knew the perpetrator, and characteristics of the trauma, such as whether the victim’s life was threatened and any injuries that occurred.
Trauma-screening questions need to be direct and behaviorally specific. Some women may not label their experience as rape, even if asked if they have ever been raped. So rather than using labels, use behaviorally specific terms, such as, “Has a man or boy ever made you have sex by using force or threat of force?”
It is also important to assess for PTSD and other common comorbid disorders, including major depression, panic disorder, and substance abuse. Finally, assessing for social support, coping skills, and available resources is helpful in planning treatment.
Treatment for PTSD Related to Sexual Assault
There are several evidence-based treatment options for patients suffering from PTSD. Two of the treatments with the strongest, evidence-based research behind them are prolonged exposure and cognitive processing therapy. Along with those, eye movement desensitization and reprocessing, stress inoculation training, and multiple-channel exposure therapy are treatments that show some effectiveness. Let’s take a more detailed look at these treatments.
Prolonged exposure (PE) is one of the most well-studied treatments for PTSD, although sometimes therapists are uncomfortable with its use because it requires the client to repeatedly confront fearful images and memories of the trauma (Foa EB et al, J Consult Clin Psychol 1991;59(5):715–723).
During PE, a therapist helps a client recount the memory in the safe environment of the therapist’s office. An oral narrative is repeated several times each session and recorded for the patient to listen to in between sessions. Clients are also asked to confront situations that are not dangerous, but that are associated in some way with the trauma and cause fear and anxiety. PE is conducted in 90 minute sessions for nine to 12 weeks.
Cognitive processing therapy (CPT) is based on an information processing model and combines elements of exposure therapy and cognitive restructuring. CPT has been studied extensively and is an effective treatment for PTSD with comorbid depression (Resick PA et al, J Consult Clin Psychol 2002;70(4):867–879:, Resick PA et al, J Consult Clin Psychol 2008;76(2):243–258).
The goal of CPT is to integrate the rape by processing emotions and confronting cognitive distortions and maladaptive beliefs about the rape. Exposure happens through writing detailed accounts of the rape and reading these between sessions.
Writing about the meaning of the rape and cognitive restructuring in the areas of safety, trust, power, esteem, and intimacy, are also part of the treatment.
These strategies assist with accommodating the rape in a healthy manner and help the victim develop and maintain a balanced and realistic view of the world. CPT can be done in groups or individually and can be completed in 12 weekly sessions.
Eye movement desensitization and reprocessing (EMDR) is a psychotherapy that involves exposure to the trauma by imagining the trauma and reciting words about the rape while the therapist moves his/her finger in front of the client, who follows this movement with her eyes (Shapiro F, Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedures. New York: Guilford Press;1995). After anxiety is reduced, the client practices new adaptive beliefs.
EMDR has some support for treating PTSD and depression in rape victims. However, it remains unclear whether the actual eye movements are a necessary component of treatment. Studies of EMDR have reported using five to 10 weekly sessions.
Stress inoculation training (SIT) was developed to treat the fear and anxiety symptoms often experienced by rape victims (Kilpatrick DG et al. Psychological Sequelae to Rape. In: Doleys DM et al eds. Behavioral Medicine: Assessment and Treatment Strategies, New York: Plenum Press;1982:473–497). Several studies have shown SIT to be effective for rape victims (see for example Foa EB et al, J Consult Clin Psychol 1999;67(2):194–200).
SIT consists of three phases: education, skill building, and application. The education phase involves learning how the fear response develops in response to trauma, learning to identify cues that trigger fear (eg, hearing certain noises at night or being alone), and learning progressive muscle relaxation. The skill building phase focuses on reducing fear reactions using thought stopping, mental rehearsal, guided self-talk, and role playing. In the application phase, clients apply the skills they have learned. SIT usually takes 10 to 14 sessions.
Multiple-channel exposure therapy (M-CET) is a treatment adapted from CPT, SIT, and the Mastery of Your Anxiety and Panic treatment manual (Barlow DH & Craske MG. Albany, NY: Graywind Publications Inc;1994).
M-CET targets both PTSD and panic attacks, conditions that often co-occur in rape victims. Because exposure therapy may cause initial high levels of physiological arousal, including panic attacks, clients with panic may avoid exposure-based therapies (Falsetti SA & Resnick HS, J Cogn Psychother 2000;14(3):261–285).
M-CET focuses on panic reduction before trauma exposure work begins. Clients are provided education about panic and trauma, taught diaphragmatic breathing, and learn methods to challenge and restructure negative and distorted thoughts. Clients also intentionally induce panic symptoms to learn that the sensations are not dangerous.
Following successful panic reduction, clients write about their rape, apply other cognitive strategies, and practice in vivo exposure to cues associated with the rape. M-CET is a 12 week treatment and has been shown to reduce PTSD, panic, and depression (Falsetti SA et al, Cogn Behav Ther 2008;37(2):117–130). As with CPT, M-CET can be done in groups or individually.
There are now several effective treatments available for rape victims who suffer from PTSD and other comorbid disorders. For mental health professionals who are unfamiliar with these treatments and who would like to receive further training, there are manuals and workshops available. They include webinars sponsored by the International Society for Traumatic Stress Studies (ISTSS), as well as presentations at the ISTSS annual conferences (www.istss.org). Books such as Effective Treatments for PTSD (Foa EB, et al. New York: The Guilford Press; 2009) and Cognitive Processing Therapy for Rape Victims (Resick PA & Schnicke M. Thousand Oaks, CA: Sage Publications; 1993), as well as treatment manuals for M-CET are also great resources.
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