Treatment for survivors of rape: issues and interventions. (Practice).

In this article, treatment issues in counseling survivors of rape are reviewed, including sociocultural influences on a woman's response to rape, a survivor's history of victimization, the specific nature of the assault, and a survivor's experiences with victim-blame. A multimodal treatment approach for women who experience chronic symptoms of posttraumatic stress disorder in the aftermath of rape is also presented. To assist mental health counselors in delivering quality services based upon current standards of care, the model incorporates four empirically supported techniques based upon expert consensus guidelines for treating survivors of trauma.

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Violence against women is a significant social problem, as there is a high probability that any woman will experience some type of violence in her lifetime. According to the National Violence Against Women survey, more than half of all women report an experience of attempted or completed rape and/or physical assault (Tjaden & Thoennes, 1998). While both men and women are victims of rape, women are disproportionately affected by this crime; 1 in 6 women compared with 1 in 33 men report having experienced an attempted or completed rape in their lifetimes. For the purposes of this paper, therefore, the focus will be upon women's experiences and treatment needs following sexual assault and rape.

A significant proportion of women who are sexually assaulted or raped experience symptoms of posttraumatic stress disorder (PTSD) within 2 weeks following the assault (Resnick, Acierno, Holmes, Kilpatrick, & Jager, 1999). The Diagnostic and Statistical Manual of Mental Disorders--Text Revision (DSM-IV-TR; American Psychiatric Association, 2000) groups PTSD symptoms into three clusters:

* Intrusion (re-experiencing of the trauma, including nightmares, flashbacks, recurrent thoughts)

* Avoidance (avoiding trauma-related stimuli, social withdrawal, emotional numbing)

* Hyperarousal (increased emotional arousal, exaggerated startle response, irritability)

While most women experience these symptoms in the immediate aftermath of rape, PTSD continues to persist in survivors at lifetime rates between 30% and 50% (Foa, Hearst-Ikeda, & Perry, 1995; Meadows & Foa, 1998; Resnick et al., 1999).

When symptoms persist for 3 months or longer and meet DSM-IV-TR diagnostic criteria for chronic PTSD, there is a likelihood that survivors will also experience comorbid disorders including anxiety, depression, and substance abuse (Foa, Davidson, & Frances, 1999; Koss & Kilpatrick, 2001; Resnick, Acierno, Holmes, Dammeyer, & Kilpatrick, 2000). Further, they are likely to experience greater physical distress (e.g., chronic pain, sexual dysfunction, headaches, upset stomach, back pains, acne, indigestion) in the year following rape and utilize medical services at higher rates than do women who have not been raped (Clum, Nishith, & Resick, 2001). Women who are particularly at risk for chronic PTSD include those who were injured during the attack, were threatened by the perpetrator that they may be hurt or killed, have a history of prior assault, or have experienced negative interactions with family, peers, or law enforcement systems (Regehr, Cadell, & Jansen, 1999).

Survivors do not typically seek formal mental health services in the year following rape (Kimerling & Calhoun, 1994). Despite their initial hesitancy, survivors may seek counseling eventually when their symptoms become intensified or chronic (Draucker, 1999). Mental health counselors therefore need expertise in providing treatment for survivors whose symptoms are both persistent and severe. Mental health professionals can serve as a primary source of support in a survivor's recovery, yet many practitioners report a lack of training in this area during their programs of study (Campbell, Raja, & Grining, 1999). Campbell and colleagues also found that when training does occur, it takes place through continuing education and does not include information regarding the significant legal and medical issues that can impact a woman's recovery. Mental health counselors' lack of training may become particularly problematic if they are not adequately prepared to assist survivors of rape who are experiencing chronic PTSD symptoms and comorbid disorders.

In sum, significant psychological and physical symptoms can emerge in the aftermath of rape. Furthermore, women are reluctant to seek counseling until their symptoms are chronic, and counselors lack formal training in assisting survivors in their recovery. Given this context, the purpose of this article is two-fold: (a) to provide an overview of treatment considerations for survivors of rape, and (b) to describe a multimodal treatment approach for women who are experiencing chronic PTSD symptoms resulting from rape-related trauma. The model incorporates four empirically supported techniques based upon expert consensus guidelines for treating survivors of trauma: psychoeducation, exposure therapy, cognitive therapy, and anxiety management (Foa et al., 1999).

TREATMENT ISSUES IN COUNSELING SURVIVORS OF RAPE

There are four important issues for mental health counselors to explore when counseling a survivor of rape: (a) sociocultural influences on a woman's response to rape, (b) her history of victimization, (c) the specific nature of her assault, and (d) her experiences with victim-blame. First, mental health counselors who work with survivors of rape should consider a woman's reaction to rape within a sociocultural context. Early feminist scholars (e.g., Brownmiller, 1975) argued that rape is not a crime of sex but should be conceptualized as a crime of power. Brownmiller asserted that rape is a tool of a patriarchal system that serves to perpetuate gender inequality and the devaluation of women. According to this theory, fear of rape limits women's freedom and use of power. This pervasive fear operates to maintain gender inequality, as women's "actions and movements, self-expression, self-presentation, and agency within relationships are constrained by the fear of sexual assault" (Low & Organista, 2000, p. 132).

While feminists have examined rape through the lens of gender and power, cultural variables such as ethnicity and class also affect women's responses to and recovery from rape-related trauma. (Low & Organista, 2000). Mental health counselors should remain sensitive to cultural differences in a survivor's access to services, her feelings of safety when reporting crimes, or how disclosures following rape may be received in her community. Further, mental health counselors should consider how cultural factors shape a survivor's view of gender roles, which in turn influence the meaning she imparts to the rape experience. For example, Latina women may be more likely to blame themselves for causing the rape if they subscribe to the cultural belief that women contribute to rape by their behavior and dress and are responsible for controlling male sexuality as well as their own (Low & Organista). It is critical that mental health counselors assess for cultural influences in their conceptualization of a survivor's rape experience and to choose strategies that are appropriate for use with clients from diverse cultural groups (Hansen, Gama, & Harkins, 2002).

Second, mental health counselors providing treatment for survivors of sexual assault and rape should be aware of a client's history of victimization. There is a considerable body of research demonstrating that early sexual abuse and maltreatment are significant risk factors for rape as an adult (Kessler & Bieschke, 1999; Koss & Kilpatrick, 2001; Sanders & Moore, 1999; Tjaden & Thoennes, 1998). One explanation for these findings is that rape in childhood or adolescence can lead to the experience of low self-worth and powerlessness, resulting in poorer general functioning, lack of protection against high-risk situations, and greater risk of multiple victimization (Breitenbecher & Gidycz, 1998). In one study with a national sample of female college students, women who had been raped in adolescence or early in college were more likely to report engaging in high-risk, health-related behaviors (e.g., physical fights, smoking, binge drinking, two or more current sexual partners) than were college women in general; these behaviors may also put them at risk for multiple victimization (Brener, McMahon, Warren, & Douglas, 1999). Women who have a history of abuse or maltreatment will likely have different treatment needs than other survivors, and mental health counselors should assess for prior victimization in an effort to understand these needs. It is important for mental health counselors to reassure survivors that while they are not to blame for the current rape, they can benefit from examining their current patterns of high-risk behavior. As part of this process, survivors can gain insight into how the effects of past victimization experiences are influencing their decisions and actions in the present.

A third treatment issue is related to the specific nature of the assault. As rapes are generally classified as stranger, acquaintance, date, partner, or marital rapes, mental health counselors need to understand a client's response to rape in the context of her prior relationship to the perpetrator. For example, women perceive their risk of being raped by a stranger as much higher than by an acquaintance, date, or partner (Nurius, Norris, Dimeff, & Graham, 1996); yet there is a much greater likelihood of a woman being raped by someone she knows (Tjaden & Thoennes, 1998). Despite the fact that women fear stranger rapes more than acquaintance or date rapes, the effects of both crimes in terms of negative psychological effects are similar (Cowan, 2000; Shapiro & Schwartz, 1998). Women survivors of acquaintance, date, or partner rapes, however, tend to engage in more self-blame and are less likely to label their experiences as rape when compared with those who experienced stranger rapes (Koss & Kilpatrick, 2001). When working with survivors of rape perpetrated by someone they know, mental health counselors can validate clients' fears and reactions, and specifically assist them in challenging their self-blaming tendencies regarding their role in the rape.

Mental health counselors must further consider issues specific to women who were sexually assaulted while under the influence of alcohol or other drugs. Rape is highly associated with alcohol use by both perpetrator and victim. This finding is particularly robust for college students. In a recent national survey of college students conducted by Ullman, Karabatsos, and Koss (1999), half of all women had experienced some type of sexual victimization. During these incidences, 53% of perpetrators and 42% of victims reported using alcohol at the time of the assault. In many alcohol-related cases, women are raped while they are too intoxicated to give consent for sexual activity. In a study by Schwartz and Leggett (1999), women who reported being raped when they were too intoxicated to give consent tended to blame themselves, questioned their role in the assault, and did not label the attack as rape even when the incident clearly met the criteria of a felony crime. Many women who are raped while intoxicated may not be aware that most legal jurisdictions define rape as sexual acts committed without a woman's consent, including when she is incapable of giving consent due to intoxication. Mental health counselors can educate women who are raped while intoxicated regarding the legal definitions of rape so that they can appropriately label their experiences and make informed decisions regarding the initiation of legal proceedings.

Women may also experience intoxication by substances administered to them without their knowledge. Recently, drug-facilitated sexual assaults, including those involving gamma hydroxy-butyrate (GHB), have increased both on college campuses and in rural communities. GHB is preferred by perpetrators due to ease of use, rapid effects (within 10 to 15 minutes), and its ability to produce permanent anterograde amnesia (Donovan, 2000; Shwartz, Milteer, & LeBeau, 2000). Because the GHB liquid is odorless, colorless, and has a low dosage threshold (approximately one teaspoon), the substance is easily poured into a victim's drink without her knowledge. A victim generally awakens spontaneously from a GHB-induced coma after approximately 5 hours and may subsequently realize she was raped, but have no memory of the perpetrator nor of the events surrounding the rape. Women may be hesitant to label the event as rape or to report the crime to the police due to their memory impairments. On the occasions when such rapes are reported, prosecutors may be reluctant to pursue these cases since the legal system requires evidence of a struggle to prove that sexual activity was nonconsensual (Easton, Summers, Tribble, Wallace, & Lock, 1997). It is, therefore, important for mental health counselors to consider the multiple violations that a survivor of drug-facilitated sexual assault has experienced: she was drugged against her will, forced into sexual activity without her consent, has no memory of the rape, may receive skeptical reactions from law enforcement, and may receive limited support from prosecutors in pursuing legal recourse.

Last, mental health counselors can increase their awareness of the societal tendency towards victim-blame. Many survivors experience negative reactions from others and are often blamed for causing the rape. Termed a secondary victimization (Feldman, Ullman, & Dunkel-Schetter, 1998), the experience of insensitivity and minimization by others can have a considerable effect on a woman's recovery. Victim-blaming and negative social reactions are common for all rape survivors, but are particularly pronounced for women who are raped by someone with whom they have a prior intimate relationship. In comparing social reactions to survivors of the four types of rape, Cowan (2000) found that victim-blame was most likely to occur in cases of partner and date rape. Even though these survivors are similarly affected despite their relationship to the perpetrator (Cowan; Resnick et al., 2000; Schwartz & Leggett, 1999), they receive more blame and less support than survivors of stranger rapes. Women who are survivors of rape committed by someone they know and trust, therefore, may be particularly at risk for negative social, medical, or legal reactions (Feldman et al.).

Women may be significantly affected by the reactions of others, yet these negative effects can be buffered by the availability of social support. Kimerling and Calhoun (1994) reported that survivors who confide in one or more friends or family members after a rape were less likely to experience increased physical symptoms than were those women with no such support. Unfortunately, many survivors never tell anyone about the event or choose to delay disclosures for long periods of time. This is particularly true for survivors of acquaintance or date rape (Ahrens & Campbell, 2000; Dunn, Vail-Smith, & Knight, 1998). In one study of disclosures to friends, survivors of date rape waited an average of 7 months prior to telling a friend about the experience (Ahrens & Campbell).

Because survivors of rape may experience a lack of validation from significant others, it is understandable that they are subsequently reluctant to disclose their experiences to mental health professionals. Mental health counselors who anticipate and explore this hesitancy with clients will be more successful in developing trust and in building working alliances with survivors of rape-related trauma (Marotta, 2000). As noted previously, a mental health counselor's knowledge of the treatment issues related to sociocultural differences, the client's prior abuse history, and the specific nature of the assault will also foster trust in the therapeutic relationship. With these issues and considerations in mind, mental health counselors can more effectively incorporate interventions that target PTSD symptoms commonly experienced following rape.

MULTIMODAL TREATMENT APPROACH FOR RAPE SURVIVORS

The treatment approach described in the paragraphs that follow draws from best practice guidelines for the treatment of PTSD (Foa et al., 1999). The multimodal format for rape survivors encompasses four treatment strategies designed to address specific PTSD symptoms:

* To provide education about commonly experienced PTSD symptoms through psychoeducation,

* To facilitate the client's retelling of the event through exposure-based techniques

* To challenge the client's maladaptive beliefs about her role in the event through cognitive restructuring 

* To enhance her coping skills through anxiety management techniques

Modality One: Psychoeducation

All supported treatments for rape-related trauma include an educational component (Foe et al., 1999; Marotta, 2000). While this approach alone does not reduce symptoms in the long term (Rauch, Hembree, & Foa, 2001), it has been demonstrated to be most effective when combined with exposure-based techniques, cognitive therapy, and anxiety management. Early in treatment, clients can be provided with education about PTSD symptoms. Clients experience relief as they recognize they are not "crazy" but are experiencing manifestations of PTSD, a reaction to trauma experienced by most women who are raped (Rauch et al.). Mental health counselors can also provide clients with written materials outlining rape survivors' commonly experienced thoughts and feelings (e.g., fear, guilt, anger, shame, embarrassment, betrayal, powerlessness, depression) to review as homework.

As clients view their symptoms as a response to trauma rather than as pathology (Bratton, 1999; Lubin & Johnson, 1997), they can strengthen esteem and a sense of self-worth. To this end, mental health counselors can teach the client to separate her PTSD symptoms and reactions from her view of herself as an individual. Through psychoeducation, clients can identify strengths that the trauma did not disrupt, including intellect, perseverance, and coping skills (Lubin & Johnson). Clients may also be empowered through education regarding the impact of sociocultural processes that perpetuate rape. Further, they can discuss and dispel commonly accepted rape myths including the belief that the survivor somehow invited the rape and is responsible for the crime. These psychoeducational segments can be structured in the form of a mini-lecture used to begin and end the session to balance the intensity of each session (Williams & Sommer, 1994).

Modality Two: Exposure Therapy

The goal of this phase of treatment is to assist the survivor in working through painful memories by confronting specific situations, emotions, and thoughts that have become associated with the rape and which currently evoke intense anxiety and fear. As survivors recount thoughts, feelings, and memories surrounding the rape, a highly formalized, structured approach is needed to help them face this emotionally charged material (Johnson & Lubin, 2000). Prolonged exposure (PE) incorporates imaginal and in vivo exposure and is particularly well suited to address the PTSD symptoms of intrusive thoughts, flashbacks, and trauma-related fears (Foa et al., 1999).

When survivors are asked to confront their fears, it is understandable that they will be resistant to this strategy. Mental health counselors can express empathy by acknowledging a survivor's fears and conveying positive expectations for her recovery (Draucker, 1999). Mental health counselors also need to spend adequate time in educating clients about the rationale for this phase of treatment. As suggested by Foa, Rothbaum, and Steketee (1993), counselors can explain the use of PE to clients in the following way:

1. Memories, people, places, and activities now associated with the rape make you highly anxious, so you avoid them.

2. Each time you avoid them you do not finish the process of digesting the painful experience, and so it returns in the form of nightmares, flashbacks, and intrusive thoughts.

3. You can begin to digest the experience by gradually exposing yourself to the rape in your imagination and by holding the memory without pushing it away.

4. You will also practice facing those activities, places, and situations that currently evoke fear.

5. Eventually, you will be able to think about the rape and resume your normal activities without experiencing intense fear.

After explaining the rationale for the use of these techniques, counselors can utilize imaginal exposure to assist clients in repeatedly recounting the memories associated with the rape until the thoughts no longer induce intense fear and anxiety (Foa et al., 1999). As clients close their eyes, they are asked to describe the rape as if it were happening in the present, including all details, feelings, thoughts, and behaviors. They are asked to visualize and describe the rape as vividly as possible. As part of this process, mental health counselors will often instruct clients to select a number ranging from 0 to 100 that best represents their current level of anxiety or discomfort. Termed subjective units of distress (SUD), these self-ratings are elicited prior to, during, and after the rape description as a method for assessing progress in reducing anxiety over time (Meadows & Foa, 1998). The rape scenario is repeated several times per session, long enough for the discomfort and anxiety to be experienced and then decreased. Meadows and Foa recommended that these descriptions be audiotaped, as clients may then listen to the tapes as daily homework assignments. Writing about the event in a journal is also recommended (Harris, 1998; Resick & Schnicke, 1993). Through the use of journaling, clients can recount the details and emotions associated with the event, and then read these entries aloud in session. As this exercise is completed over the course of several weeks, clients are asked to increase the level of detail and emotion with each repetition (Harris). Mental health counselors should assist clients in processing their emotions following the use of imaginal exposure to decrease intensity prior to the end of the session. They can also acknowledge the difficulty of this phase of treatment and can reinforce a client's willingness to face and work through her fears. According to Foa et al. (1995), clients are empowered when they recognize their successes in confronting anxiety-producing memories and in tolerating the resulting emotions.

The third component of PE is the use of in vivo exposure. As described by Meadows and Foa (1998), the survivor is asked to focus upon those activities and situations associated with the rape that are now safe but that she currently fears or avoids, thus causing significant disruptions in her daily functioning. Mental health counselors can assist survivors in creating a list of avoided situations and then in hierarchically ordering these items so that they range from least to most distressing. A SUD rating is assigned to each situation. Starting with the situation that causes the least distress, the client remains in that situation for a minimum of 30 minutes. This time period is deemed long enough for her to experience anxiety, challenge and evaluate her ideas about the actual danger present in the situation, and let the anxiety decrease. She is asked to rate her anxiety through SUD ratings and to note reductions in these ratings as she experiences these feared situations and activities. For example, a college student who refuses to attend classes due to her fear of all men who resemble her perpetrator can practice studying in the library with a friend as a step towards resuming class attendance. Over the course of several sessions, she can progress through the hierarchy until she is able to resume her normal activities and routines.

The use of PE is effective for women survivors of rape who have intact memory of the attack, but these techniques need to be modified for use with women who experience memory impairment. A survivor can be reassured that she does not have to access and re-experience the rape in order for recovery to occur, but she does need to recognize the significance and impact of the rape in her life (Williams & Sommer, 1994). Clients who cannot recall the actual rape will not be able to recount or journal about the concrete details surrounding the event. While writing in a journal is a helpful way for clients whose memories are intact to process their experiences, writing is not a recommended strategy for survivors in accessing memories of trauma (Feldman, Johnson, & Ollayos, 1994). However, survivors may benefit from re-experiencing the emotions and thoughts that occurred immediately prior to and following the memory loss. In vivo exposure may also be helpful for clients who avoid feared cues associated with the rape, regardless of their memory impairment of details of the actual event.

If a survivor has no verbal memories of the rape, emotions associated with the event may be accessed through nonverbal means. As suggested by Harris (1998), "the body remembers what the mind forgets" (p. 96). Techniques for use with survivors of drug-facilitated sexual assault or alcohol-induced memory impairment can, therefore, include alternative, experiential approaches drawn from art, music, or dance/movement therapies (see Johnson, 2000, for a review). The use of art has been recommended for survivors of rape as a means to access emotions that have been visually encoded (Backos & Pagon, 1999; Hargrave-Nyakaza, 1994). Art, described as a visual dialogue (Spring, 1994), can give the survivor with no verbal memory something tangible to hold onto during the counseling process and can also represent a survivor's progress in counseling. Further, Stuhlmiller (1994) suggested that survivors with memory impairment may also benefit from movement and activity to rebuild body awareness and access imagery and emotions related to the rape.

Modality Three:Cognitive Therapy

Cognitive approaches have demonstrated efficacy in treating survivors of rape (Foa et al., 1993; Meadows & Foa, 1998; Resick & Schnicke, 1993) and are particularly recommended for addressing symptoms of numbing, detachment, loss of interest in activities, irritability, guilt, and shame (Foa et al., 1999). In cognitive therapy, clients are taught to identify the thoughts or beliefs they experience during negative emotional states. The counselor and client then collaboratively evaluate the validity and challenge the helpfulness of these ideas and subsequently replace irrational beliefs with rational or beneficial thoughts (Meadows & Foa). This process can also be incorporated with thought stopping, in which maladaptive beliefs are stopped and replaced with positive thoughts (Muran & DiGiuseppe, 2000). Resick and Schnicke also used cognitive restructuring principles in their Cognitive Processing Therapy (CPT) designed for rape victims. As part of the CPT approach, survivors are assisted in identifying and then challenging maladaptive beliefs and "stuck points" related to five areas: self-blame, power, esteem, trust, and intimacy. In the paragraphs that follow, literature related to these five issues is presented.

Self-blame and guilt. Mental health counselors can play a critical role in assisting survivors in challenging self-blame, even when victim-blame is perpetuated by society and significant others in their lives. In one study of survivors of rape, all women experienced victim-blame from their support systems, but the women who experienced the highest distress following rape were those who incorporated these negative reactions into their views of themselves (Regehr, Marziali, & Jansen, 1999). Of women who blamed themselves for the crime, some survivors assigned blame to their behavior, while others attributed blame to their character (Muran & DiGiuseppe, 2000). Those who attributed blame to their behavior (e.g.," I could have gone home earlier that night") experienced fewer symptoms than those who blamed their character ("I deserved this" or "I am a bad person").

The issue of guilt is often related to self-blame. Trauma-related guilt issues can include perceived responsibility for causing the rape, beliefs that decisions made and actions taken during the rape were not justified, or the belief that one knew what was going to happen and did not do enough to prevent the crime (Kubany, 1998). As clients can examine their decisions at the time of the rape, they can begin to explore the ways in which the perpetrator's actions were not justified, no matter the decisions the woman made at the time. As self-blaming and guilt-related beliefs are reviewed during counseling sessions, these thoughts can be replaced with more logical self-statements that reflect the client's strengths and power (Kubany). For example, she can replace the thought "I made a stupid decision to go to my date's apartment, and since I could have prevented it, I deserved what happened to me" with "I may have made a decision I wouldn't make now, but the rapist is responsible for this crime. I will do everything I can now to regain the power he took away from me." As part of reducing self-blame and guilt, survivors can continue to examine the sociocultural forces that perpetuate victim-blame, and they can use this knowledge in restructuring their beliefs about their role in the rape. This type of cognitive restructuring can also help to assuage the negative effects of victim-blame frequently encountered by survivors of rape.

Power and control. Treatment should be designed to assist survivors in restoring personal power that was temporarily disrupted during the assault. Due to the perpetrator's violent use of power and control, however, women may initially view all issues related to power as negative and may attempt to avoid regaining personal power (Carey, 1998). Through cognitive restructuring, clients' negative views of power and control can be replaced with empowering beliefs that equate power with recovery. While the client was indeed powerless at the time of the rape, she can learn to make the distinction between this temporary lack of control and her ability to make decisions in the present regarding the direction of her recovery. Survivors who develop a sense of agency have more positive treatment outcomes; Regehr, Marziali, et al. (1999) found that rape survivors who were able to view themselves as active agents in determining the results of events in their lives experienced fewer symptoms of PTSD and depression than did women with an external locus of control. As an important part of regaining a sense of power, mental health counselors can encourage clients to take an active role in treatment by providing choices and flexibility regarding counseling goals and in the timing and pacing of sessions. Clients who claim the direction of their treatment are empowered to be the "authors and arbiters of their own recovery" (Draucker, 1999, p. 18).

Self-esteem, intimacy, and trust. It is important to explore the impact of rape on a survivor's self-image. Resick and Schnicke (1993) recommend asking clients to examine their meanings of the rape, and what effect it has had on their view of themselves. Clients' answers to these questions can reveal a pattern of stuck points (e.g., "I am unlovable because this happened to me") that can be challenged and reframed. Survivors' difficulties with self-esteem are interconnected with issues of trust and intimacy. If a survivor questions her judgment, engages in self-blame, and experiences victim-blame following rape, she may experience problems in trusting both herself and others. As rape is a trauma intentionally inflicted upon a woman by another individual; critical issues to explore in counseling will include disruptions in her capacity for intimacy and her ability to trust others (Draucker, 1999).

As clients challenge maladaptive beliefs in recovery, they can eventually learn to view the rape and its aftermath as a traumatic but growth-enhancing experience (Williams & Sommer, 1994) that provides them with a more flexible worldview (Koss & Kilpatrick, 2001). According to Frazier and Burnett (1994), 57% of adult rape survivors in their sample cited positive changes that resulted from their rape experience (e.g., improved interpersonal relationships, enhanced self-awareness, and spiritual growth). Studies in resilience theory demonstrate that resilient individuals are those who grow and develop as a result of trauma. Rather than being stunted by life difficulties, they recover from traumatic events with an increased sense of empathy, enhanced coping skills, and greater capacity for intimacy (Young-Eisendrath, 1996). Regehr, Cadell, et al. (1999) found similar qualities in a study of survivors of sexual assault who displayed the most resilience in recovery. These women possessed a sense of safety and trust, a positive view of self, a sense of power, positive relationships, the ability to employ cognitive reframing, and a refusal to engage in self-blame. Survivors who strengthen these qualities and skills in recovery will also develop the ability to cope more effectively with future life demands. Further, they may become empowered to engage in advocacy and activism in working to reduce the prevalence of sexual violence (Robinson & Howard-Hamilton, 2000).

[b] Modality Four: Anxiety Management

While there are a variety of anxiety management techniques, Stress Inoculation Training (SIT) is one of the most researched and comprehensive anxiety management programs for survivors of sexual assault and rape (Meadows & Foa, 1998). The goal of SIT is to promote a set of coping skills that help to reduce general anxiety, hypervigilance, hyperarousal, sleep disturbances, and difficulty in concentration (Foa et al., 1999). These coping skills include muscle relaxation training, controlled breathing exercises, role playing, covert modeling, positive thinking and self-talk, assertiveness training, guided self-imagery and dialogue, and thought stopping.

Krakow et al. (2001) recently examined the use of an anxiety management technique in reducing PTSD-related sleep disturbance and nightmares. In a randomized, controlled study of women survivors of sexual assault who experienced nightmares and insomnia, participants were asked to consider their nightmares as learned habits that are influenced by what they think about during the day. Through the use of imagery rehearsal, women were asked to select one of their disturbing dreams, to change the dream, and to describe the new dream in writing. Over the course of three sessions, survivors were asked to describe the new dream using self-imagery, and to rehearse the new dream throughout the week for at least 5 to 20 minutes. According to Krakow and colleagues, the survivors in the treatment group experienced a significant decrease in overall PTSD symptoms when compared with survivors in the control group. Further, as the survivors who learned to use self-imagery gained a greater sense of control over their nightmares, they also implemented these techniques as a successful method for coping with other problems in their lives. Clients are empowered as they develop these and other anxiety management techniques to facilitate recovery from rape-related trauma.

CONCLUSIONS

Mental health counselors who wish to deliver quality services for women who experience rape-related trauma should be knowledgeable of best-practice guidelines based upon expert consensus and controlled outcome studies. The multimodal approach described in this article incorporates the use of four empirically supported treatment modalities specifically designed for the reduction of PTSD symptoms commonly experienced by survivors of rape. Awareness of these guidelines is particularly important in an era of accountability in which counselors are challenged to stay abreast of current mental health trends and standards of care (Marotta, 2000).

While the recommended strategies and methods described in this model are straightforward, the actual process of recovery from rape-related trauma is long and difficult (Koss & Kilpatrick, 2001). Survivors are vulnerable to victim-blame, self-blame, unwillingness to disclose the rape to others, and an overall lack of support in addition to PTSD symptoms and other significant negative psychological and physiological outcomes. Survivors of rape need validation as they attempt to recover in the aftermath of rape, but they frequently receive inadequate support and even skepticism from those systems designated to provide services to victims of trauma. It is, therefore, understandable that survivors may experience disruptions in trust and be reluctant to seek mental health services until PTSD symptoms are chronic or compounded. Unfortunately, many mental health professionals report a lack of formal training in working with survivors of rape (Campbell et al., 1999), and this inadequate preparation likely perpetuates survivors' reluctance to seek or continue treatment. With education and enhanced awareness, however, it is possible for mental health counselors to serve an important role in assisting survivors of rape, as mental health counselors' developmental, prevention-focused approaches to treatment are particularly well-suited to working with survivors of rape-related trauma (Marotta, 2000).

There are several areas for future research in rape-related treatment issues and interventions. First, studies can examine necessary modifications for practice guidelines that account for memory impairment and other important treatment differences related to the specific nature of an assault. Further, future research is needed to examine women's treatment needs in the context of sociocultural variables such as ethnicity and class. Last, mental health counselor educators can examine the ways in which they can effectively incorporate information into their programs regarding best-practice guidelines and salient treatment issues reviewed in this article.

In conclusion, mental health counselors can provide sensitive treatment for survivors of rape by balancing their focus on PTSD symptom reduction with support, validation, and client empowerment (Draucker, 1999). By integrating the support that survivors need with a structured treatment approach for rape-related trauma symptoms, mental health counselors can best assist survivors of rape in their journey towards recovery.

REFERENCES

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Ahrens, C. E., & Campbell, R. (2000). Assisting rape victims as they recover from rape: The impact on friends. Journal of Interpersonal Violence, 15, 959-986.

Backos, A. K., & Pagon, B. E. (1999). Finding a voice: Art therapy with female adolescent sexual abuse survivors. Art Therapy: Journal of the American Art Therapy Association, 16, 126-132.

Bratton, M. (1999). From surviving to thriving. New York: Hawthorn Maltreatment and Trauma Press.

Breitenbecher, H. B., & Gidycz, C. A. (1998). An empirical evaluation of a program designed to reduce the risk of multiple sexual victimization. Journal of Interpersonal Violence, 13, 472-489.

Brener, N. D., McMahon, P.M., Warren, C. W., & Douglas, K. A. (1999). Forced sexual intercourse and associated health-risk behaviors among female college students in the United States. Journal of Consulting and Clinical Psychology, 67, 252-259.

Brownmiller, S. (1975). Against our will: Men, women, and rape. New York: Bantam.

Campbell, R., Raja, S., & Grining, P. L. (1999). Training mental health professionals on violence against women. Journal of Interpersonal Violence, 14, 1002-1013.

Carey, L. A. (1998). Illuminating the process of a rape survivors' support group. Social Work with Groups, 21, 103-116.

Clum, G. A., Nishith, P., & Resick, P. A. (2001). Trauma-related sleep disturbance and self-reported physical health symptoms in treatment-seeking female rape victims. Journal of Nervous and Mental Disease, 189, 618-622.

Cowan, G. (2000, May). Beliefs about the causes of four types of rape. Sex Roles: A Journal of Research, 807-824.

Donovan, J. W. (2000). Gamma-hydroxybutyrate, Gamma-Butyrolactone, and Butanediol: Abuse and effects. Journal of Toxicology: Clinical Toxicology, 38(2), 184.

Draucker, C. B. (1999). The psychotherapeutic needs of women who have been sexually assaulted. Perspectives in Psychiatric Care, 35, 18-29.

Dunn, P. C., Vail-Smith, K., & Knight, S. M. (1998). What date/acquaintance rape victims tell others: A study of college student recipients of disclosure. Journal of American College Health, 47, 213-220.

Easton, A., Summers, J., Tribble, J., Wallace, P. B., & Lock, R. S. (1997). College women's perceptions regarding resistance to sexual assault. Journal of American College Health, 46, 127-132.

Feldman, P. J., Ullman, J. B., & Dunkel-Schetter, C. (1998). Women's reactions to rape victims: Motivational processes associated with blame and social support. Journal of Applied Social Psychology, 28, 469-503.

Feldman, S. C., Johnson, D. R., & Ollayos, M. (1994). The use of writing in the treatment of PTSD. In M. B. Williams & J. F. Sommer (Eds.), Handbook of post-traumatic therapy (pp. 366-385). Westport, CT: Greenwood.

Foa, E. B., Davidson, J. R. T., & Frances, A. (1999). Expert consensus guideline series: Treatment of posttraumatic stress disorder. The Journal of Clinical Psychiatry, 60 (Suppl.16), 1-31.

Foa, E. B., Hearst-Ikeda, D., & Perry, K. J. (1995). Evaluation of a brief cognitive-behavioral program for the prevention of chronic PTSD in recent assault victims. Journal of Consulting and Clinical Psychology, 63, 948-955.

Foa, E. B., Rothbaum, B. O., & Steketee, G. S. (1993). Treatment of rape victims. Journal of Interpersonal Violence, 8, 256-276.

Frazier, P. A., & Burnett, J. W. (1994). Immediate coping strategies among rape victims. Journal of Counseling and Development, 72, 633-639.

Hansen, L. S., Gama, E. M. P., & Harkins, A. K. (2002). Revisiting gender issues in multicultural counseling. In P. B. Pedersen, J. G. Draguns, W. J. Lonner, & J. E. Trimble (Eds.), Counseling across cultures (5th ed., pp. 163-184). Thousand Oaks, CA: Sage.

Hargrave-Nyakaza, K. (1994). An application of art therapy to the trauma of rape. Art therapy: A Journal of the American Art Therapy Association, 11, 53-57.

Harris, M. (1998). Trauma recovery and empowerment: A clinician's guide for working with women in groups. New York: Free Press.

Johnson, D. R. (2000). Creative therapies. In E. B. Foa et al. (Eds.), Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (pp. 302-314). New York: Guilford.

Johnson, D. R., & Lubin, H. (2000). Group psychotherapy for symptoms of PTSD. In R. H. Klein & V. Schermer (Eds.), Group psychotherapy for psychological trauma (pp. 141-169). New York: Guilford.

Kessler, B. L., & Bieschke, K. J. (1999). A retrospective analysis of shame, dissociation, and adult victimization in survivors of childhood sexual abuse. Journal of Counseling Psychology, 46, 335-341.

Kimerling, R., & Calhoun, K. S. (1994). Somatic symptoms, social support, and treatment seeking among sexual assault victims. Journal of Consulting and Clinical Psychology, 62, 333-340.

Koss, M. P., & Kilpatrick, D. G. (2001). Rape and sexual assault. In E. Gerrity, T. Keane, & F. Tuma (Eds.), Mental health consequences of torture (pp. 177-193). New York: Plenum.

Krakow, B., Hollifield, M., Johnston, L., Koss, M., Schrader, R., Warner, T. D., et al. (2001). Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: A randomized controlled trial. The Journal of the American Medical Association, 286, 537-545.

Kubany, E. S. (1998). Cognitive therapy for trauma related guilt. In V. Follette, I. Ruzek, & F. Abueg (Eds.), Cognitive-behavioral therapies for trauma (pp. 124-161). New York: Guilford.

Low, G., & Organista, K. C. (2000), Latinas and sexual assault: Towards culturally sensitive assessment and intervention. Journal of Multicultural Social Work, 8, 131-157.

Lubin, H., & Johnson, D. R. (1997). Interactive psychoeducational group therapy for traumatized women. International Journal of Group Psychotherapy, 47, 271-288.

Marotta, S. A. (2000). Best practices for counselors who treat posttraumatic stress disorder. Journal of Counseling and Development, 78, 492-495.

Meadows, E. A., & Foa, E. B. (1998). Intrusion, arousal, and avoidance: Sexual trauma survivors. In V. Follette, I. Ruzek, & F. Abueg (Eds.), Cognitive-behavioral therapies for trauma (pp. 100-123). New York: Guilford.

Muran, E., & DiGiuseppe, R. (2000). Rape trauma. In F. M. Dattilio & A. Freeman (Eds.), Cognitive behavioral strategies in crisis intervention (2nd ed., pp. 150-165). New York: Guilford.

Nurius, P. S., Norris, J., Dimeff, L. A., & Graham, T. L. (1996). Expectations regarding acquaintance sexual aggression among sorority and fraternity members. Sex roles: A Journal of Research, 35, 427-445.

Rauch, S. A. M., Hembree, E. A., & Foa, E. B. (2001). Acute psychosocial preventive interventions for post-traumatic stress disorder. Advances in Mind-Body Medicine, 17, 160-196.

Regehr, C., Cadell, S., & Jansen, K. (1999). Perceptions of control and long term recovery from rape. American Journal of Orthopsychiatrty, 69, 110-114.

Regehr, C., Marziali, E., & Jansen, K. (1999). A qualitative analysis of strengths and vulnerabilities in sexually assaulted women. Clinical Social Work Journal, 27, 171-184.

Resick, P. A., & Schnicke, M. K. (1993). Cognitive processing therapy for rape victims:A treatment manual. Newbury Park, CA: Sage.

Resnick, H., Acierno, R., Holmes, M., Dammeyer, M., & Kilpatrick, D. (2000). Emergency evaluation and intervention with female victims of rape and other violence. Journal of Clinical Psychology, 56, 1317-1333.

Resnick, H., Acierno, R., Holmes, M., Kilpatrick, D., & Jager, N. (1999). Prevention of post-rape psychopathology: Preliminary findings of a controlled acute rape treatment study. Journal of Anxiety Disorders, 13, 359-370.

Robinson, T., & Howard-Hamilton, M. (2000). Convergence of race, ethnicity, and gender: Multiple identities in counseling. Upper Saddle River, NJ: Prentice-Hall.

Sanders, B., & Moore, D. L. (1999). Childhood maltreatment and date rape. Journal of Interpersonal Violence, 14, 115-124.

Schwartz, M. D., & Leggett, M. S. (1999). Bad dates or emotional trauma? The aftermath of campus sexual assault. Violence Against Women, 5, 251-271.

Shapiro, B. L., & Schwartz, C. (1998). Date rape: Its relationship to trauma symptoms and sexual self-esteem. Journal of Interpersonal Violence, 12, 407-420.

Shwartz, R. H., Milteer, R., & LeBeau, M. A. (2000). Drug-facilitated sexual assault. Southern Medical Journal, 93, 558-561.

Spring, D. (1994). Art therapy as a visual dialogue. In M. B. Williams & J. F. Sommer (Eds.), Handbook of post-traumatic therapy (pp. 337-351). Westport, CT: Greenwood.

Stuhlmiller, C. M. (1994). Action-based therapy for PTSD. In M. B. Williams & J. F. Sommer (Eds.), Handbook of post-traumatic therapy (pp. 386-400). Westport, CT: Greenwood.

Tjaden, P., & Thoennes, N. (1998). Prevalence, incidence, and consequences of violence against women: Findings from the national violence against women survey. Atlanta, GA: Center for Disease Control and Prevention, Center for Injury Prevention and Control.

Ullman, S. E., Karabatsos, G., & Koss, M. P. (1999). Alcohol and sexual assault in a national sample of college women. Journal of Interpersonal Violence, 14, 603-625.

Williams, M. B., & Sommer, J. F. (1994). Toward the development of a generic model of PTSD treatment. In M. B. Williams & J. F. Sommer (Eds.), Handbook of post-traumatic therapy (pp. 551-565). Westport, CT: Greenwood Press.

Young-Eisendrath, P. (1996). The resilient spirit: Transforming suffering into meaning and purpose. Cambridge, MA: Perseus.

Laura G. Hensley, Ed.D., is an assistant professor in the Department of Educational Leadership, Research, and Counseling at Louisiana State University in Baton Rouge. E-mail: [e-mail] The author acknowledges Laura Laggren for her suggestions and contributions to this article.