RAPE
13.
14.
15. 16. 17.
CRISIS
INTERVENTION
Giacenti TA. Tjaden C: The crime of rape in Denver. Denver, Cob. Denver High Impact Anticrime Council. 1973 (unpublished report) Brodsky SL: Prevention of rape: deterrence by the potential victim. in Sexual Assault: The Victim and the Rapist. Edited by Walker Mi. Brodsky SL. Lexington. Mass. DC Heath and Co. 1976 Burgess AW, Holmstrom LL: Rape trauma syndrome. Am I Psychiatry 131: 981-986. 1974 Holmstrom LL. Burgess AW: Rape: The Victim Goes on Trial. New York. Wiley-lnterscience (in press) Rapoport L: The state of crisis: some theoretical considerations. Social Service Review 36:211-217. 1962
Development Program
of a Medical
BY SHARON AND SUSAN
L. NIW)MBIE, PELL. R.N.
M.S.W..
Center
ELLEN
BASSUK,
,
.
the
is the
United
rape
States: 31,000
(from
Revised
version
the American 1975. authors
ton,
Mass.
tervention chiatry. Bassuk
the to
of a paper Psychiatric
FBI 51,000
psychological rising violent
reported
cases)
a 68% between
presented
at the 128th
Association,
Anaheim,
attack crime in
increase in 1968 and
annual Calif..
meeting May
of 5-9.
Israel Hospital. 330 Brookline Ave., BosMs. McCombie is Director, Rape Crisis InProgram, Drs. Bassuk and Savitz are Assistants in Psyand Ms. Pell is Head Nurse, Inpatient Psychiatric Unit. Drs. and Savitz are also Instructors in Psychiatry. Harvard Medi-
The
cal School, 418
a physical, social, and person. It is the fastest
are with Beth
02215,
Boston,
where
Mass.
Am J Pschiat
/33:4,
April
1976
Parad
HI.
emergency nik HLP. 19.
Resnik care, Ruben
HLP:
JE. Lindemann and Adaptation.
Adams
I. New
York.
20.
Murphy LB: Coping. Ibid. pp 69-100
21.
Burgess ulations.
22.
Hamburg Arch Gen
M.D.,
AW. Lazare Englewood DA. Adams Psychiatry
Crisis
ROBERTA
The
practice
in Emergency HL. Bowie.
Adams Coping
Rape
The Rape Crisis Intervention Program at Beth Israel Hospital utilizes volunteer mnultidisciplina’ counseling teams dra wn from psychiatry social work, psychology, and nursing staffs. The premise of the program is that ear/v crisis intervention can prevent later development ofpsvchological disturbances in victims Counselors accompany victims throughout emergency room procedures:frllow-up begins 48 hours after the initial contact and continues at regular intervalsfor at least a ‘ear. The authors discuss the problems ofimplementation, which include staff resistance,funding questions. and varying levels of counseling sophistication, and describe how these difficulties have been handledin theirprogram. They note that this program is becoming a resource center for the community.
RAPE upon
18.
E: Basic
of
Psychiatric
Md. Charles Coping Edited
with
by
Books,
crisis
intervention
Care. Press,
Edited by Res1975. pp 23-34
long-term
Coelho 1974.
vulnerability
and
A: Community Cliffs. NI.
Mental Prentice-Hall,
IE: A perspective 17:277-284. 1967
G,
pp
resilience
disability,
in
Hamburg
D.
127-138 in childhood.
Health: Target 1976 on
in
coping
Pop-
behavior.
Intervention
SAVITZ.
M.1).,
1973. and police figures in Boston show a 43.5% increase between 1972 and 1973 (1). Rape has been viewed primarily as a sexual rather than a violent assault. The traditional assumption is that the woman in some way invited the attack. This attitude obscures recognition of the trauma experienced by the victims and interferes with the devebopment of adequate community and institutional resources to treat them. This is reflected in the absence or fragmentation of medical and psychological care for nape victims. In response to this problem, a comprehensive support system for the rape victim has been developed at the Beth Israel Hospital. a metropolitan teaching facility oriented toward community medicine. Particularly in urban areas,, hospital emergency rooms are the typicab health care facility utilized by victims at the time of the rape. Prior to the development of our project, emergency room records showed that an average of one victim a week received medical care during 19721973. The psychiatric service was consulted only if the victim presented a management problem for the emergency room staff. Follow-up was generally inconsistent. Clinicians were impressed, however, by the number of women who appeared at the Psychiatry Clinic months or years later for whom the rape was a major component in the presenting symptomatology. At the time of the assault, these women had not sought psychiatric assistance. Indeed, many had never told anyone about the rape. The Rape Crisis Intervention Program is based on the premise that early intervention can prevent the development of psychological and psychosomatic distur-
MCCOMBIE.
bances. The program’s aim is to integrate and expand available medical services and provide psychiatric crisis counseling (2). This paper will describe some of the problems encountered in implementing such programs in a medical setting.
RAPE
AS
A
LEGITIMATE
HEALTH
ISSUE
There is both community and hospital resistance to recognizing rape as a legitimate health issue requiring medical and psychological services. In the past, the psychiatric community has not participated in providing resources for victims. Throughout the country. most services come from grass roots women’s organizations, which often view psychiatry as a male-dominated , pathology-oriented profession that stigmatizes the victim by labeling her a mental patient. Because hospitals have only recently acknowledged the needs of rape victims, feminist organizations have tended to regard these institutions as part of the prob1cm. These women’s groups have attempted to minimize the victim’s contact with health professionals by establishing alternative facilities. However, there is no way to bypass the necessity for professional gynecological services. The medical, surgical. and psychiatric resources of the emergency room, their 24-hour availability, and the legal requirement for medical evidence bring the victim into the health care system. Because of the multidisciplinary make-up of the general hospitab, it is a potential center for comprehensive treatment of both the physical and emotional needs of the rape victim. Hospital resistance to mobilizing supportive services can be traced to two major sources. First, staff prejudices about rape can jeopardize the respectful, thorough treatment of the victim. Second, staff working in a treatment model geared to respond to medical and surgical emergencies may underestimate the significance of emotional crises. If the woman does not exhibit wounds that testify to her victimization and unambiguously signal her need for medical assistance, her status as a legitimate consumer of health services may be questioned. Regardless of the presence or absence of physical injury, the emotional trauma of forced violation-frequently under threat of deathestablishes the victim’s right to sensitive professional care.
PROGRAM
DESCRIPTION
There have been four major objectives in the implementation of our service for rape victims: I. Providing both immediate and follow-up counseling that is aimed at resolving the psychological crisis. 2. Encouraging emergency room personnel to respond sensitively to the emotional needs of the victim. 3. Developing an understanding of the special needs of this patient population in order to provide expert
BASSUK.
SAVITZ.
AND
PELL
consultation to community and professional groups. 4. Conducting research on the acute and long-term impact of rape on life adjustment. There are still many unanswered questions about the psychodynamics of nape trauma and the adult victim’s reactions and long-term adaptation (3-5). To provide quality crisis counseling and assessment and to gather sound clinical observations, we needed mental health clinicians on the staff of our program. Because ofthis need and the funding problems we encountered. a volunteer counselor roster was organized. The counseling team is a self-selected group ofvolunteer personnd from psychiatry. social service. psychology. and nursing. This multidisciplinary approach distinguishes our program from the single-discipline model used in other hospitals (6, 7). Training and supervising a multidisciplinary group of volunteers is complicated by the various levels of counseling sophistication that are represented in the team. Individual learning needs are addressed in weekly supervisory sessions based on the model used for teaching psychotherapy. All members of the counseling team are required to attend a series of weekly didactic seminars on crisis intervention lechniques and the special problems ofrape victims. Nurses. gynecologists, and other interested hospital personnel are encouraged to attend these meetings. The volunteer model has proved to be cumbersome, unreliable at times, and difficult to coordinate. However, it has had the advantages of sensitizing a large number of hospital personnel to the emotional needs of the rape victim and of encouraging awareness of psychological issues in the treatment of all general hospital patients. The 24-hour on-call system ensures that a counselor will be available to accompany the victim throughout all emergency room medical procedures. The initial role of the counselor is to provide emotional support and information to the victim. The counselor also meets with friends or relatives who have accompanied the victim to discuss their concerns and mobilize their support. Follow-up begins within 48 hours after the tial emergency room contact. Subsequent contacts are made at regular intervals for at least I year. The frequency and content of the intervention is based on the needs of the victim, as determined by clinical assessment and timing of anticipated periods of exacerbation of symptoms, such as court appearances. The counseling goal is to increase the individual’s adaptive capacity by delineating and working through the crisis-related issues. If the victim has unusual difficulty resuming her precnisis level of functioning, she is referred for psychotherapy.
mi-
ORGANIZATIONAL ISSUES
INTERFACES
AND
Official sanction from the Department was crucial to the implementation Am J P.s’chiatr
/33:4,
POLICY
of Psychiatry of our program. April
/976
419
RAPE
CRISIS
INTERVENTION
Staff time was requested for the recruitment, training, and supervision of the counselor team. Initially, there was hesitation about supporting the program because of the demands on staff time. There was also a tendency to see rape as a social problem rather than as a crisis warranting psychiatric intervention. Since crisis intervention techniques could be taught with rape counseling as a model, the program was consistent with the Psychiatry Department’s commitment to training and its active hospital liaison program, which integrates psychological understanding with patient care (8). At the same time, the growing public awareness of the needs of women helped to offset objections stemming from the controversial nature of our target population. The chiefs of social service, nursing, and medicine were approached to enlist their cooperation in personnd training and coordination of service delivery. This initiated a continuing dialogue with these departments carried on through periodic visits to their staff meetings. In order to establish administrative backing, we had to develop a policy regarding payment for counseling services. Currently, the woman is charged the routine fee for the emergency room visit and is not billed for the counseling services. The cost is absorbed by the hospital as loss of staff hours from the professional vobunteers’ regular duties. There is a continuing debate as to whether the hospitab, the community, or the victim should be responsible for the costs incurred. One argument is that, as in all preventive health care programs, the treatment of rape victims is cost effective in the long run. However, because of the economic recession and the rapidly rising overhead of hospitals, each program must demonstrate its cost effectiveness. A variety of complex factors must be considered before an optimal financial policy can be determined. These include the following: 1 The majority of the victims are young, single women with low incomes, inadequate health insunance, and doubtful ability to pay. 2. Some of the medical procedures are for the collection of evidence for the state’s case against the alleged criminal rather than for the victim’s health care. 3. There is clinical concern about the meaning transmitted to the victims when they are set apart from other consumers of health care who pay for services. .
GYNECOLOGY
AND
EMERGENCY
ROOM
LIAISON
We have emphasized liaison with the gynecology and emergency room staffs. The mechanics of the gynecological examination are usually handled with skill (9). However, anxiety about how to respond to a woman who has just been raped can lead to staff withdrawal or denial of the event. Female staff members are reminded of their own vulnerability. Male staff. members become acutely conscious that they may be 420
Am J Psychiatry
133:4,
April
1976
the first man the victim sees after the rape. The victim’s anger and helplessness are frightening, and there is a tendency to counterattack or to infantilize. The medical examination of the rape victim occurs in the interface between the health and legal professions, since the physician’s findings may become cvidence in a court of law (10). Since the doctor can be required to give testimony, he may hesitate to become involved or may respond by trying to judge for himself whether the case is a “real” rape. The protocol ofthe American College of Obstetricians and Gynecologists for the examination of rape victims is a detailed procedure for the gathering and preservation of specimens for evidence (I I). It has the advantage of providing complete and careful documentation. Nevertheless, in the pressures of the emergency room, it may be regarded as a tedious chore. Other factors a!fecting the physician’s response to the rape victim are his concept of his professional role, his personal feelings about rape, and his attitudes toward the legal and penal systems. Gynecology and nursing meetings have been used as forums to identify and discuss staff concerns. Treating victims of violent sexual assault is openly acknowledged as stressful. Through the use ofvideotaped interviews with victims, role playing, and discussion, personnel are sensitized to the stresses the victim experiences in the emergency room. When a woman who has recently been raped takes on the label ofpatient, she is assuming a role characteristically associated with being damaged and helpless. The victim-as-patient assumes a status that reinforces the helplessness and fears about being damaged that are natural sequelae of the rape experience . Her physicab and emotional pain become tangible reminders of her inability to protect and to defend herself. The confusion and lack of privacy in the emergency room can prolong and compound her discomfort. A pelvic examination done abruptly can be experienced as a repetition ofinternal invasion. The hospital becomes an institutional transference object upon which both negative and positive feelings are focused. The staff must be equipped to deal with the intense affects aroused and to help the victim work through them. The rape crisis counselor is a consultant to medical and nursing staff in the emergency room, and his/her interpretation of the victim’s behavior and empathy with the medical staff’s feelings reduce anxiety and enhance sensitive treatment of the patient. The introduction of a new program staffed by nonemergency-room personnel into the routine emergency room system has presented several unsolved problems. For example, while our counselors relieve the nurses of certain pressures and responsibilities, there is also a mixed message about the nurses’ role and competency. Although we have explicitly invited them to be trained as rape counselors, few are able to do so because of the demands of their regular duties. We have approached this difficulty by including an emergency room nurse as a member of the program’s ad-
MCCOMBIE,
ministnative and planning improved cooperative has supported nurses’ their role.
group; this has resulted in an team effort and, secondarily, continuing efforts to expand
BASSUK,
SAVITZ,
AND
PELL
coming a resource center for the community through consultation and education programs for police, educatons. health professionals. and the public. Our aim is to encourage and assist other community medical facilities in providing a support system for women dealing with this life crisis.
DISCUSSION
Although our program is still in the experimental phase, progress has been made in establishing nape as a legitimate health issue and in including the care of rape victims among the repertoire of services provided within a medical center. The liaison work has been essential in successfully setting up a multidisciplinary program of this kind. The most important interfaces have been with the Departments of Psychiatry. Nursing, and Gynecology. Our continuing dialogues with these departments have emphasized the generalizability of our crisis approach to other patients. As organizational issues are settled, the program will increasingly concentrate its efforts on developing research on the long-range resolution of the rape crisis and will attempt to differentiate the implications for women at various stages in the life cycle. This information is critical for optimally effective service and for evaluation of the preventive impact of early intervention on later adjustment. The didactic series used in teaching our counselors is being refined and compiled into a training manual for use by other hospitals. The Rape Crisis Intervention Program is rapidly be-
REFERENCES I . Federal Bureau of Investigation: Uniform Crime Reports for the United States. Washington. DC. US Government Printing Office. 1973 2. Bassuk E, Savitz R. McCombie S. et al: Organizing a rape crisis program in a general hospital. I Am Med Wom Assoc 30:486490. 1975 3. Burgess A. Holmstrom L: Rape trauma syndrome. Am J Psychiatry 131:981-986. 1974 4. Fox S: Crisis intervention with rape victims. Social Work 17:3442, 1972 Sutherland S. Scherl D: Patterns of response among victims of rape. Am I Orthopsychiatry 40:503-511. 1970 6. Burgess A. Holmstrom L: The rape victim in the emergency ward. Am I Nur.s 73: 1741-1745, 1973 7. Zuspan F. Hayman C. Lewis H. et al: Alleged rape: an invitational symposium. I Reprod Med 12:133-152. 1974 8. Zinberg N (ed): Psychiatry and Medical Practice in a General Hospital. New York, International Universities Press, 1964 9. Halleck S: The physician’s role in the management of victims of sex offenders. IAMA 180:273-278. 1962 10. Evrard I: Rape: The medical. social and legal implications. Am I 5.
ObstetGyneeol I I.
American cal
Bulletin
111:197-199. College Number
1971
of Obstetricians 14. Chicago.
A,n J Psychiatry
and
Gynecologists:
ACOG,
1970
/33:4,
April
1976
Techni-
421
13.
14.
15. 16. 17.
CRISIS
INTERVENTION
Giacenti TA. Tjaden C: The crime of rape in Denver. Denver, Cob. Denver High Impact Anticrime Council. 1973 (unpublished report) Brodsky SL: Prevention of rape: deterrence by the potential victim. in Sexual Assault: The Victim and the Rapist. Edited by Walker Mi. Brodsky SL. Lexington. Mass. DC Heath and Co. 1976 Burgess AW, Holmstrom LL: Rape trauma syndrome. Am I Psychiatry 131: 981-986. 1974 Holmstrom LL. Burgess AW: Rape: The Victim Goes on Trial. New York. Wiley-lnterscience (in press) Rapoport L: The state of crisis: some theoretical considerations. Social Service Review 36:211-217. 1962
Development Program
of a Medical
BY SHARON AND SUSAN
L. NIW)MBIE, PELL. R.N.
M.S.W..
Center
ELLEN
BASSUK,
,
.
the
is the
United
rape
States: 31,000
(from
Revised
version
the American 1975. authors
ton,
Mass.
tervention chiatry. Bassuk
the to
of a paper Psychiatric
FBI 51,000
psychological rising violent
reported
cases)
a 68% between
presented
at the 128th
Association,
Anaheim,
attack crime in
increase in 1968 and
annual Calif..
meeting May
of 5-9.
Israel Hospital. 330 Brookline Ave., BosMs. McCombie is Director, Rape Crisis InProgram, Drs. Bassuk and Savitz are Assistants in Psyand Ms. Pell is Head Nurse, Inpatient Psychiatric Unit. Drs. and Savitz are also Instructors in Psychiatry. Harvard Medi-
The
cal School, 418
a physical, social, and person. It is the fastest
are with Beth
02215,
Boston,
where
Mass.
Am J Pschiat
/33:4,
April
1976
Parad
HI.
emergency nik HLP. 19.
Resnik care, Ruben
HLP:
JE. Lindemann and Adaptation.
Adams
I. New
York.
20.
Murphy LB: Coping. Ibid. pp 69-100
21.
Burgess ulations.
22.
Hamburg Arch Gen
M.D.,
AW. Lazare Englewood DA. Adams Psychiatry
Crisis
ROBERTA
The
practice
in Emergency HL. Bowie.
Adams Coping
Rape
The Rape Crisis Intervention Program at Beth Israel Hospital utilizes volunteer mnultidisciplina’ counseling teams dra wn from psychiatry social work, psychology, and nursing staffs. The premise of the program is that ear/v crisis intervention can prevent later development ofpsvchological disturbances in victims Counselors accompany victims throughout emergency room procedures:frllow-up begins 48 hours after the initial contact and continues at regular intervalsfor at least a ‘ear. The authors discuss the problems ofimplementation, which include staff resistance,funding questions. and varying levels of counseling sophistication, and describe how these difficulties have been handledin theirprogram. They note that this program is becoming a resource center for the community.
RAPE upon
18.
E: Basic
of
Psychiatric
Md. Charles Coping Edited
with
by
Books,
crisis
intervention
Care. Press,
Edited by Res1975. pp 23-34
long-term
Coelho 1974.
vulnerability
and
A: Community Cliffs. NI.
Mental Prentice-Hall,
IE: A perspective 17:277-284. 1967
G,
pp
resilience
disability,
in
Hamburg
D.
127-138 in childhood.
Health: Target 1976 on
in
coping
Pop-
behavior.
Intervention
SAVITZ.
M.1).,
1973. and police figures in Boston show a 43.5% increase between 1972 and 1973 (1). Rape has been viewed primarily as a sexual rather than a violent assault. The traditional assumption is that the woman in some way invited the attack. This attitude obscures recognition of the trauma experienced by the victims and interferes with the devebopment of adequate community and institutional resources to treat them. This is reflected in the absence or fragmentation of medical and psychological care for nape victims. In response to this problem, a comprehensive support system for the rape victim has been developed at the Beth Israel Hospital. a metropolitan teaching facility oriented toward community medicine. Particularly in urban areas,, hospital emergency rooms are the typicab health care facility utilized by victims at the time of the rape. Prior to the development of our project, emergency room records showed that an average of one victim a week received medical care during 19721973. The psychiatric service was consulted only if the victim presented a management problem for the emergency room staff. Follow-up was generally inconsistent. Clinicians were impressed, however, by the number of women who appeared at the Psychiatry Clinic months or years later for whom the rape was a major component in the presenting symptomatology. At the time of the assault, these women had not sought psychiatric assistance. Indeed, many had never told anyone about the rape. The Rape Crisis Intervention Program is based on the premise that early intervention can prevent the development of psychological and psychosomatic distur-
MCCOMBIE.
bances. The program’s aim is to integrate and expand available medical services and provide psychiatric crisis counseling (2). This paper will describe some of the problems encountered in implementing such programs in a medical setting.
RAPE
AS
A
LEGITIMATE
HEALTH
ISSUE
There is both community and hospital resistance to recognizing rape as a legitimate health issue requiring medical and psychological services. In the past, the psychiatric community has not participated in providing resources for victims. Throughout the country. most services come from grass roots women’s organizations, which often view psychiatry as a male-dominated , pathology-oriented profession that stigmatizes the victim by labeling her a mental patient. Because hospitals have only recently acknowledged the needs of rape victims, feminist organizations have tended to regard these institutions as part of the prob1cm. These women’s groups have attempted to minimize the victim’s contact with health professionals by establishing alternative facilities. However, there is no way to bypass the necessity for professional gynecological services. The medical, surgical. and psychiatric resources of the emergency room, their 24-hour availability, and the legal requirement for medical evidence bring the victim into the health care system. Because of the multidisciplinary make-up of the general hospitab, it is a potential center for comprehensive treatment of both the physical and emotional needs of the rape victim. Hospital resistance to mobilizing supportive services can be traced to two major sources. First, staff prejudices about rape can jeopardize the respectful, thorough treatment of the victim. Second, staff working in a treatment model geared to respond to medical and surgical emergencies may underestimate the significance of emotional crises. If the woman does not exhibit wounds that testify to her victimization and unambiguously signal her need for medical assistance, her status as a legitimate consumer of health services may be questioned. Regardless of the presence or absence of physical injury, the emotional trauma of forced violation-frequently under threat of deathestablishes the victim’s right to sensitive professional care.
PROGRAM
DESCRIPTION
There have been four major objectives in the implementation of our service for rape victims: I. Providing both immediate and follow-up counseling that is aimed at resolving the psychological crisis. 2. Encouraging emergency room personnel to respond sensitively to the emotional needs of the victim. 3. Developing an understanding of the special needs of this patient population in order to provide expert
BASSUK.
SAVITZ.
AND
PELL
consultation to community and professional groups. 4. Conducting research on the acute and long-term impact of rape on life adjustment. There are still many unanswered questions about the psychodynamics of nape trauma and the adult victim’s reactions and long-term adaptation (3-5). To provide quality crisis counseling and assessment and to gather sound clinical observations, we needed mental health clinicians on the staff of our program. Because ofthis need and the funding problems we encountered. a volunteer counselor roster was organized. The counseling team is a self-selected group ofvolunteer personnd from psychiatry. social service. psychology. and nursing. This multidisciplinary approach distinguishes our program from the single-discipline model used in other hospitals (6, 7). Training and supervising a multidisciplinary group of volunteers is complicated by the various levels of counseling sophistication that are represented in the team. Individual learning needs are addressed in weekly supervisory sessions based on the model used for teaching psychotherapy. All members of the counseling team are required to attend a series of weekly didactic seminars on crisis intervention lechniques and the special problems ofrape victims. Nurses. gynecologists, and other interested hospital personnel are encouraged to attend these meetings. The volunteer model has proved to be cumbersome, unreliable at times, and difficult to coordinate. However, it has had the advantages of sensitizing a large number of hospital personnel to the emotional needs of the rape victim and of encouraging awareness of psychological issues in the treatment of all general hospital patients. The 24-hour on-call system ensures that a counselor will be available to accompany the victim throughout all emergency room medical procedures. The initial role of the counselor is to provide emotional support and information to the victim. The counselor also meets with friends or relatives who have accompanied the victim to discuss their concerns and mobilize their support. Follow-up begins within 48 hours after the tial emergency room contact. Subsequent contacts are made at regular intervals for at least I year. The frequency and content of the intervention is based on the needs of the victim, as determined by clinical assessment and timing of anticipated periods of exacerbation of symptoms, such as court appearances. The counseling goal is to increase the individual’s adaptive capacity by delineating and working through the crisis-related issues. If the victim has unusual difficulty resuming her precnisis level of functioning, she is referred for psychotherapy.
mi-
ORGANIZATIONAL ISSUES
INTERFACES
AND
Official sanction from the Department was crucial to the implementation Am J P.s’chiatr
/33:4,
POLICY
of Psychiatry of our program. April
/976
419
RAPE
CRISIS
INTERVENTION
Staff time was requested for the recruitment, training, and supervision of the counselor team. Initially, there was hesitation about supporting the program because of the demands on staff time. There was also a tendency to see rape as a social problem rather than as a crisis warranting psychiatric intervention. Since crisis intervention techniques could be taught with rape counseling as a model, the program was consistent with the Psychiatry Department’s commitment to training and its active hospital liaison program, which integrates psychological understanding with patient care (8). At the same time, the growing public awareness of the needs of women helped to offset objections stemming from the controversial nature of our target population. The chiefs of social service, nursing, and medicine were approached to enlist their cooperation in personnd training and coordination of service delivery. This initiated a continuing dialogue with these departments carried on through periodic visits to their staff meetings. In order to establish administrative backing, we had to develop a policy regarding payment for counseling services. Currently, the woman is charged the routine fee for the emergency room visit and is not billed for the counseling services. The cost is absorbed by the hospital as loss of staff hours from the professional vobunteers’ regular duties. There is a continuing debate as to whether the hospitab, the community, or the victim should be responsible for the costs incurred. One argument is that, as in all preventive health care programs, the treatment of rape victims is cost effective in the long run. However, because of the economic recession and the rapidly rising overhead of hospitals, each program must demonstrate its cost effectiveness. A variety of complex factors must be considered before an optimal financial policy can be determined. These include the following: 1 The majority of the victims are young, single women with low incomes, inadequate health insunance, and doubtful ability to pay. 2. Some of the medical procedures are for the collection of evidence for the state’s case against the alleged criminal rather than for the victim’s health care. 3. There is clinical concern about the meaning transmitted to the victims when they are set apart from other consumers of health care who pay for services. .
GYNECOLOGY
AND
EMERGENCY
ROOM
LIAISON
We have emphasized liaison with the gynecology and emergency room staffs. The mechanics of the gynecological examination are usually handled with skill (9). However, anxiety about how to respond to a woman who has just been raped can lead to staff withdrawal or denial of the event. Female staff members are reminded of their own vulnerability. Male staff. members become acutely conscious that they may be 420
Am J Psychiatry
133:4,
April
1976
the first man the victim sees after the rape. The victim’s anger and helplessness are frightening, and there is a tendency to counterattack or to infantilize. The medical examination of the rape victim occurs in the interface between the health and legal professions, since the physician’s findings may become cvidence in a court of law (10). Since the doctor can be required to give testimony, he may hesitate to become involved or may respond by trying to judge for himself whether the case is a “real” rape. The protocol ofthe American College of Obstetricians and Gynecologists for the examination of rape victims is a detailed procedure for the gathering and preservation of specimens for evidence (I I). It has the advantage of providing complete and careful documentation. Nevertheless, in the pressures of the emergency room, it may be regarded as a tedious chore. Other factors a!fecting the physician’s response to the rape victim are his concept of his professional role, his personal feelings about rape, and his attitudes toward the legal and penal systems. Gynecology and nursing meetings have been used as forums to identify and discuss staff concerns. Treating victims of violent sexual assault is openly acknowledged as stressful. Through the use ofvideotaped interviews with victims, role playing, and discussion, personnel are sensitized to the stresses the victim experiences in the emergency room. When a woman who has recently been raped takes on the label ofpatient, she is assuming a role characteristically associated with being damaged and helpless. The victim-as-patient assumes a status that reinforces the helplessness and fears about being damaged that are natural sequelae of the rape experience . Her physicab and emotional pain become tangible reminders of her inability to protect and to defend herself. The confusion and lack of privacy in the emergency room can prolong and compound her discomfort. A pelvic examination done abruptly can be experienced as a repetition ofinternal invasion. The hospital becomes an institutional transference object upon which both negative and positive feelings are focused. The staff must be equipped to deal with the intense affects aroused and to help the victim work through them. The rape crisis counselor is a consultant to medical and nursing staff in the emergency room, and his/her interpretation of the victim’s behavior and empathy with the medical staff’s feelings reduce anxiety and enhance sensitive treatment of the patient. The introduction of a new program staffed by nonemergency-room personnel into the routine emergency room system has presented several unsolved problems. For example, while our counselors relieve the nurses of certain pressures and responsibilities, there is also a mixed message about the nurses’ role and competency. Although we have explicitly invited them to be trained as rape counselors, few are able to do so because of the demands of their regular duties. We have approached this difficulty by including an emergency room nurse as a member of the program’s ad-
MCCOMBIE,
ministnative and planning improved cooperative has supported nurses’ their role.
group; this has resulted in an team effort and, secondarily, continuing efforts to expand
BASSUK,
SAVITZ,
AND
PELL
coming a resource center for the community through consultation and education programs for police, educatons. health professionals. and the public. Our aim is to encourage and assist other community medical facilities in providing a support system for women dealing with this life crisis.
DISCUSSION
Although our program is still in the experimental phase, progress has been made in establishing nape as a legitimate health issue and in including the care of rape victims among the repertoire of services provided within a medical center. The liaison work has been essential in successfully setting up a multidisciplinary program of this kind. The most important interfaces have been with the Departments of Psychiatry. Nursing, and Gynecology. Our continuing dialogues with these departments have emphasized the generalizability of our crisis approach to other patients. As organizational issues are settled, the program will increasingly concentrate its efforts on developing research on the long-range resolution of the rape crisis and will attempt to differentiate the implications for women at various stages in the life cycle. This information is critical for optimally effective service and for evaluation of the preventive impact of early intervention on later adjustment. The didactic series used in teaching our counselors is being refined and compiled into a training manual for use by other hospitals. The Rape Crisis Intervention Program is rapidly be-
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