TREATMENT STRATEGIES FOR

SEXUAL ASSAULT SURVIVORS

Nancy Newport RN, LPC,

Licensed Professional Counselor

Consultant to Peace Corps

Fairfax, Virginia

(703) 352-9005

• Prevalence of rape in this country is estimated to be between 5% to 22% of all adult women

• Some 40% to 80% of college women report being assaulted by dates or friends (not necessarily raped)

• In the United States, 12.1 million adult women have been forcibly raped during their lifetime. Of these, 39% have been raped more than once

• One in four females experience rape sometime in their lifetime

• Every six minutes, a woman is raped in the United States

• 31% of all rape victims develop rape-related Post-Traumatic Stress Disorder (PTSD) in their lifetime

• Rape victims may constitute the largest single group of PTSD sufferers

• Traumatic events lead to PTSD in less than 25% of victims; 80% of rape victims experience symptoms of PTSD

• The degree of violence experienced during the rape affects the severity of the PTSD symptoms; if life-threatening and physical injury occurs, 80% developed PTSD

• Victims who had developed PTSD 3 months following the rape were significantly more likely to have had a prior history of sexual aggravated assault

• The majority of rape victims are raped by family members and acquaintances:

• Half of all rapes of women over 30 are partner rapes

• The majority of rapes happen in childhood and the perpetrators are known to the victims:

• Approximately 500,000 high school girls will be raped before they graduate

• 1 in 12 college women will be a victim of rape or attempted rape each year

• Only 8% of college students report such rape incidents

• Only 1% of rapes are ultimately resolved by arrest or conviction of the offender. The average time served in State prisons for a rape conviction is 29 months

· sleep disturbance

· nightmares

· flashbacks

· overeating

· loss of appetite

· anxiety

· fear

· phobic avoidance of reminders and thoughts of the assault

· exaggerated startle response

· hypervigilance

· powerlessness, helplessness

· sense of detachment

· denial

· blunted affect

· impaired memory

· lack of concentration, confusion

· guilt

· shame

· hostility

· interpersonal difficulties

· sexual difficulties

· physical illness/symptoms

III. Rape Trauma--Stages of Emotional Reaction

The Acute Stage: (Shock and Chaos) This stage occurs immediately after the assault. It may last a few days to several weeks. During this stage the person may:

· seem agitated or hysterical or s/he may appear totally calm and be in shock

· have crying spells and anxiety attacks

· have difficulty concentrating, making decisions, and performing simple, everyday tasks · show little emotion, act as though numb or stunned

· have poor recall of the rape or other memories

NOTE: Any apparently calm demeanor should not be mistaken for evidence that the rape did not occur or that she is unaffected by it

The Outward Adjustment Stage: During this stage the person resumes what appears to be from the outside her/his "normal" life. She tries to put the rape in the past and may not want to talk about it. This closure is premature. Inside, there is considerable turmoil which can manifest itself by any of the following behaviors:

· continuing anxiety

· sense of helplessness

· persistent fear and/or depression

· severe mood swings ( e.g. happy to angry, etc.) · vivid dreams, recurrent nightmares, insomnia · physical aliments

· appetite disturbances (e.g. nausea, vomiting, compulsive eating, lack of appetite) · efforts to deny the assault ever took place and/or to

· minimize its impact

· withdrawal from friends and/or relatives

· preoccupation with personal safety

· reluctance to leave the house and/or to go places which remind the person of the rape · hesitation about forming new relationships with men and/or distrustful of existing relationship

· sexual difficulties

· disruption of normal everyday routines (e.g. high absenteeism at work suddenly or, conversely, working longer than usual hours; traveling different routes; going out only at certain times)

The Resolution Stage: This stage can begin within a month or years after the attack. During this stage the rape is no longer the central focus in the person's life. The person begins to recognize that while s/he will never forget the assault, the pain and memories associated with it are lessening. S/he has accepted the rape as a part of her/his life experience and is choosing to move on from there. Some of the behaviors of the second stage may flare up at times but they do so less frequently and with less intensity. In this fashion the person who has survived has moved from being a "victim" to a "survivor."

I feel dirty, humiliated; feel everyone can tell by looking at me

of my own ability to make judgments; of men/people in general

• Strengthen support system
• Surround with safety (may not want to stay home, if site of rape) · Access resources
• Create trust

Self-care

• Doctor's exam for injury & STDs
• Eating nutritious foods/drinking water
• Avoiding alcohol, caffeine, sugar
• Sleeping, resting
• Exercise
• Resume normal activity as soon as possible

Stress Management

• Decrease work load
• Decrease stressful activities
• Keep a notebook
• Avoid disturbing stimuli (TV, movies, reading material or horror or violence)
• Increase relaxing activities (reading, writing, drawing, music, talking, exercise)

• throwing glass bottles into a recycling bin
• throwing rocks into the river
• playing tennis/racquetball
• hitting pillows
• hitting plastic bottles together
• tearing old clothes
• chopping wood
• kneading dough
• running
• drawing/painting

• writing
• making a collage of feelings
• journaling writing prose/poetry
• writing letters
• talking to friends
• crying
• talking to self in mirror

To be most helpful to victims of sexual assault, it is imperative to understand the dynamics that occur before, during and after the attack.

When a person is about to be attacked, the ability to react depends on the amount of time between the threat of attack and the actual attack. Initially, the victim may use verbal or physical tactics or may be overwhelmed with fear and not resist at all.

Once the assault occurs, internal defense mechanisms kick in to cope psychologically with the fear and horror of the violation. Survival becomes the goal despite the demands being made which can include oral, vaginal and/or anal penetration.

These defense mechanisms serve to provide some "mental distance" from the reality of what is happening. It is important for Peace Corps staff not trained in such matters to understand how these defense mechanisms work so as not to misunderstand the extent of the trauma when they hear the victim talk about how she felt during the attack.

Typical internal defense mechanisms used:

There are physiological responses to rape that can include some involuntary choking, gagging, nausea, vomiting, pain, urinating, hyperventilating (rapid shallow breathing) and losing consciousness.

After the attack is finished, the stressful situation is not over. The victim must alert others to her distress, escape, get help, and endure peoples' reactions to her story.

Possible responses after the assault:

During the acute stage immediately after the assault, the victim may have varying reactions. She may:

· Have difficulty concentrating, making decisions, and performing simple, everyday tasks

The most important role that Peace Corps staff can play after a Volunteer has been raped is to get to her as soon as possible and begin creating an environment where she can feel safe.

Allow her to be in as much control of herself and of her situation as is possible, even in small ways. Don't decide everything for her. For example - "Do you want to talk to the police now or in a few hours?"; "Do you want to drink a soda or have some water?"; "Where or with whom would you feel safe spending the night tonight?"

There are three basic messages she needs to hear verbally and behaviorally from everyone who is in a supportive role with her:

At this stage, it is NOT helpful to point out ways that the victim used poor judgement or placed herself at risk. Avoid all statements or attitudes that would imply blame, criticism or judgement. Remember that no matter what the victim did or did not do, she did not ask to be attacked. She was vulnerable perhaps through her actions, but not to blame for being raped. The rapist is to blame for the rape.

The Volunteer needs to be accompanied by a responsible staff member to the police station or to any legal proceeding. Never leave her alone there. Be her advocate and protect her from further abuse. If possible, allow the Volunteer to have input into who will be accompanying her.

Except for those who "need to know" (see Rape Notification Protocol), respect her need for privacy. Do not tell others that she has been raped unless you have her permission.

It is strongly recommended that all rape victims have access to counseling. If the person is medevac'd to Washington, she will receive counseling right away and be followed very closely. Counseling will continue three times a week for support and to assist her in resolving the trauma. Sometimes Volunteers are reluctant to leave country and their friends to go to Washington. Yet they do not feel safe in country. It can be helpful to validate that concern and point out to the Volunteer that others have felt the same way at first. Tell the Volunteer that those who have gone to Washington have been very glad they allowed themselves to benefit from the care they received there. It also gives the victim an opportunity to talk to and perhaps see friends and family for additional support and sense of safety. One of the most important factors in creating a healthy recovery from assault is to establish a consistent environment of safety and support, something that is almost impossible to do in country where there are so many reminders of the trauma.

4. HOW ARE YOU DOING? (a note to Country Staff)

It is very stressful to care for someone who has been raped. Hearing her story can cause a secondary trauma for you. Please make sure you are caring well for yourself and your own needs so that you can be at your best for the victim. That may include getting enough rest, taking turns being with the victim, having someone you can talk to about the feelings you are experiencing, and recognizing your limits.

You may feel:

All of these feelings are understandable in the face of trauma. The more honest you are with yourself about your own responses, the more likely you will work through them.

Nancy Newport, RN, LPC Licensed Professional Counselor Consultant to Peace Corps October, 1997

Ledray, L. E., (1994) Recovering from Rape, H. Holt and Company, N.Y.

Post-Traumatic Stress Disorder (1996) The Harvard Mental Health Letter, June/July.