GENERAL PAPERS
Psychological Management of Victims of Sexual Assault* REBEKA MOSCARELLO, M.D. I
the criminal justice system. She fears she will not be believed, or she does not conceptualize her unwanted sexual encounter as sexual assault. Canadian federal legislation in January 1983, Bill C-127 (2) moved the crime of rape into the general category of assault, recognizing the violent rather than the sexual nature of sexual assault. This is reflected in the use of the terminology of sexual assault.
Sexual assault, as a crime of violence, induces a life crisis which inflicts major psychological and physiological trauma upon the victim. Lack of mutual consent is present in all sexual assaults. Post-traumatic symptoms occur immediately and for a large percentage of victims this trauma is not integratedfor many years. Symptoms include the classic triad of post-traumatic stress symptoms of haunting, intrusive recollections, numbing or constriction offeelings and focus and lowered threshold of anxious arousal subsequent to experiencing intense fear, terror and loss of control. Long term effects include anxiety, depression, phobic reactions to situations reminiscent of the sexual assault, sexual dysfunction, impaired social adjustment and diminished capacity to enjoy life. Post-traumatic stress responses, symptomatology, psychodynamics and management ofthe victim of recent and nonrecent sexual assault are reviewed.
Post-Traumatic Stress Following Sexual Assault Sexual assault is a life crisis in which the ego is overwhelmed and the balance between internal ego adaptation and the environment is broken. The violation of one human being by another of a fiercely protected, private aspect of oneself, usually results in post-traumatic stress symptomatology. The beliefs most affected by sexual assault are personal invulnerability, the perception of the world as meaningful and the positive view of oneself. The loss of personal invulnerability results in the world no longer being seen as safe and benign, but as unsafe and dangerous. The sexual assault is usually experienced with fear, terror, and helplessness, followed by the classic triad of symptoms of haunting intrusive recollections (thoughts, feelings, images), numbing or constriction of feelings and focus, and increased arousal. A distinct subcategory of post-traumatic symptoms experienced by victims of sexual assault are shame, self-blame, feeling dehumanized, obsessions of vengeance, paradoxical gratitude for the gift of life, feeling dirty and defiled, reduced capacity for intimacy, and second wound through revictimization during the court process (6). The classic triad and the subcategory of symptoms are superimposed upon the psychological, behavioural and cognitive symptoms described within the phases of response which follow sexual assault.
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exual assault has taken place since earliest times (1). The women's movement, changes in the social role of women, their relationship to men, and publications by mental health professionals interested in the effect of the commonly occurring private violation of sexual assault upon women initiated a more humane attitude towards women who have been sexually assaulted. Treatment is offered through rape crisis centres in the community, and the more recent addition of sexual assault care centres in hospitals. Canadian statistics reveal that one in five adult women will be sexually assaulted (sexual assault is defined (2) as "any form of sexual activity with another person without his or her consent, as kissing, fondling, or intercourse), and one in 17 adult women will experience forced sexual intercourse in their lifetime (3, 4). It is estimated that only one or two out of ten sexual assaults are reported (5). In Toronto, Ontario 2,154 sexual assaults were reported in 1988 (personal communication, Metropolitan Toronto Police). If two out often were reported, there were over 10,000 victims in Toronto during 1988. The survivor of sexual assault may choose not to report, to avoid revictimization through the course of medical treatment, involvement with the police and
Phases of Response Phases of the stress response to sexual assault follow the predictable sequences of responses similar to those following other life crises (7-9); that is, an anticipatory or threat phase, impact phase, recoil or immediate phase, and resolution phase. The anticipatory or threat phase, when present, is the recognition of a potentially dangerous situation. There may be mobilization of defenses to avoid the sexual assault or the development of coping strategies to use during the sexual assault. Self-blame and guilt are intensified if this phase is present and is ignored by the victim.
*Manuscript received January 1988; revised September 1989. 'Assistant Professor of Psychiatry, University of Toronto; Psychiatrist, Sexual Assault Care Centre, Women's College Hospital, Toronto, Ontario. Address reprint requests to: Dr. R. Moscarello, Women's College Hospital, 76 Grenville Street, Toronto, Ontario M5S IB2 Can. J. Psychiatry Vol. 35, February 1990
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The impact phase occurs when the sexual assault can no longer be avoided. This phase begins with the attack and lasts for several days to weeks. During the attack emergency problem-solving comes into action. Strategies may include whether to fight back (which may increase the assailant's rage and the risk of being maimed or killed), or whether to surrender one's body and ego-ideal and cooperate to stay alive (increases guilt and self-blame), concentrating on strategies not to cause the assailant to lose his fragile control over his rage (for example, by not screaming, expressing anger, etc.), as well as concentrating on obtaining a description through smell, touch or vision if not blindfolded. The feelings experienced during this phase of impact are initial shock, disbelief and denial, followed by intense fear, terror, and helplessness. The ability to think clearly may be impaired with resulting confusion and disorientation. Victims respond in one of two styles: expressed or controlled (8). The importance of the recognition of the controlled style will be discussed under the section on psychodynamics. During this phase of impact, victims may experience dissociation, during which they feel as if they are outside their body watching the assault. Victims frequently state their fear of going crazy. The direct effect of the physical trauma may be experienced, as well as stress-induced symptoms of general aching, headaches, nausea, abdominal and genital area pain. The emotions of anxiety, anger, guilt, shame, humiliation, helplessness and vulnerability are present. Following the attack, the fear of being alone, and the fear of the assailant returning are paramount. Hypervigilance, hyperalertness, and disordered sleep add to the general feeling of fatigue. There may be reactivation of previous traumatic experiences. Unresolved previous sexual trauma, particularly unresolved sexual violation, intensify the psychologicaltrauma. The recoil, or intermediate phase, begins several days or weeks after the attack and has three components: denial, symptom formation, and anger (10). Denial of the sexual assault, the victim's attempt to regain a sense of control, results in an outward appearance of adjustment, lasting several months or years. When denial fails, symptoms recur which are discussed under the section on long term psychological sequelae. During symptom formation, attempts to gain anonymity result in changing one's telephone number, residence, and on occasion, job. Acknowledging the process of denial and symptom formation, rape crisis and counselling centres share the information regarding the process of denial and symptom formation with their patients on the first or second visit. Anticipating future symptoms, telephone contact is set up. During the final component of the recoil or intermediate phase, anger is experienced at the depth of primitive rage. The anger may be directed at the assailant, at all men, at the therapist, medical and/or legal system. Underlying the anger are feelings of despair, hopelessness and shame. The therapeutic task is to reduce the anger and feeling of devaluation of the self. Prosecution of the assailant provides a focus for working through and channelling the anger, and restoring a sense of control. For some victims, symptoms continue after the sentencing of the assailant. The symptoms function as a defense against a repeat attack.
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The final phase of resolution occurs when the sexual assault becomes part of the past in a meaningful way and can be discussed without undue emotion. The life crisis of sexual assault can be growth-promoting and foster maturation by resulting in positive adaptations (11, 12). This includes becoming more independent, self-reliant, with a more positive view of one's self. The timing of this phase depends on the individual, taking anywhere from six months to two years to a lifetime. It should be noted that rapid recovery may occur in less than 20% of victims (13). Symptoms may become encapsulated in one area, allowing adequate functioning in other spheres of life.
Long Term Psychological Sequelae Difficulties encountered for the researcher documenting the long term psychological sequelae of sexual assault include 1. prospective studies which are limited to one year due to difficulty in maintaining a victim sample for longer periods, and 2. retrospective studies, in which collecting a patient sample is difficult because victims of sexual assault hesitate to seek treatment due to the symptoms of shame, self-blame, and the privacy of the violations. Long term psychological sequelae cluster around the symptoms of the unresolved intermediate phase: anxiety and fear, depression, impaired sexual and social adjustment (family, work, social, interpersonal, and marital) (11-22). Kilpatrick et al (12) found anxiety and fear were experienced by all victims, significantly higher than the control group of nonvictims at six and 12 months post-sexual assault. Initial fears related to cues of the sexual assault become generalized to fears related to vulnerability and repeat attack. Phobic-avoidance reactions include fears associated directly with the attack (man's penis, tough men, anal intercourse); fears precipitated by the sexual assault itself (venereal disease including AIDS, pregnancy, talking with the police, testifying in court); vulnerability to future attack (being alone, being in situations where control feels threatened, when showering alone, on public transit, especially the underground system, in laundry rooms, in crowded supermarkets, strange places, etc.). Altered behaviour patterns include withdrawal, isolation, and increased dependency on others. The latter may be difficult for the victim and her supporters to accept. In Canada, shortened winter daylight hours make going home from work and attending health care facilities arduous and challenging. Depressive symptoms are present, as dysphoria, in 50% of the sample in the study done by Frank and Stewart (18), and 24 % of the total group meet the Research Diagnostic Criteria for depression within the first month after the assault. Others (11,14,19,23) found depressed mood, sadness, inability to experience pleasure, appetite and sleep disturbance, and difficulty in concentration at one to several years postsexual assault. Sexual dysfunction is reported in 25 % to 40 % of victims one to six years post-sexual assault (20, 21). The types of sexual dysfunction experienced by sexual assault victims
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differ from that reported by nonvictims. Symptoms are related to arousal or desire functions; for example, responseinhibiting problems related to perception of sexual stimuli as anxiety-provoking reminiscences of the assault occur three times as frequently as orgasmic or intromission problems. Increased negative feelings about men, increased insecurity concerning sexual attractiveness, and lowered sexual selfesteem have been observed. A study of the impact of sexual assault on a victim's ability to carry out major social roles found victims differed from nonvictims in work functioning for the first eight months, in social and leisure functioning for the first two months, and within the family for one month after the sexual assault (22). Psychological functioning may not return to the presexual assault level of functioning, although social functioning does (13, 15, 16). Factors Influencing the Severity of the Post- Traumatic Stress Response Variables affecting the stress response to sexual assault include characteristics of the sexual assault, personal characteristics, and the response of the social support system. 1. Characteristics ofthe Sexual Assault. Studies examining the variables of sexual assault and post-sexual assault symptomatology are not consistent. The expected positive correlation between sexual assault characteristics and the severity of symptoms, as violent versus nonviolent, dangerous versus safe location, blitz versus confidence sexual assault, stranger versus acquaintance, has not been proved (14, 18). Positive correlation with a more difficult recovery (16) has been found between mock tenderness, multiple assailants, and vaginal penetration. Vaginal penetration symbolizes the ultimate physical domination. A recent paper (24) has reported that blitz sexual assault (sudden surprise attack) versus confidence sexual assault (previous, nonviolent interaction), highlights different symptoms on the spectrum of post-sexual assault symptomatology. The blitz attack evokes intrusive and avoidance symptoms, as well as symptoms of increased arousal (hypervigilance, hyperalertness, exaggerated startle response, etc.). The confidence attack evokes greater feelings of self-blame (loss of confidence in the ability to judge those felt to be trustworthy), shame, guilt, and a sense of not deserving help. 2. Personal Characteristics. Frank and Anderson in 1987 (25) found that one third of the women in their study had some previous contact with mental health professionals, which did not predict a more severe post-traumatic stress response. A direct correlation, with a more severe stress response, was found between previous severe psychiatric symptoms (suicidal attempts, substance abuse, need for psychotropic medication), a history of sexual violation and concurrent life stresses (15). Past psychiatric disorders occur no more frequently among sexual assault victims than among nonvictims (25). The age and stage of development of the victim at the time of the sexual assault modifies the impact of the sexual assault. Notman and Nadelson (9) discuss the relationship between sexual assault and age and stage of development. The effect on the adolescent woman, where the issues are
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of separation and independence, are developmental tasks. The woman with children is concerned about her ability to care for her children, as her self-blame engenders a feeling of personal inadequacy. She is unable to look after herself. Marital conflict may result for the woman with a partner, if victim responses are misunderstood by the partner (in both heterosexual and homosexual relationships). The single woman may feel her credibility is questioned. The elderly woman, whose lifespan is limited, may not appear to suffer as severely initially, but the long term psychological sequelae are more severe and longlasting. Myths maintain that the intensity and severity of the response to sexual assault is directly related to the observable violence (bruises, lacerations, fractures, etc.). A recent study (26) relates subjective distress (as felt or perceived threat) to the intensity of the symptoms of anxiety and fear. This information is important for the victim, significant others and those in the criminal justice system. 3. Social Support System. Social support is the most important single post-sexual assault factor influencing rehabilitation, a powerful predictor over and above the actual stressful life events and the reported symptoms. The social support network provides an atmosphere for feeling loved, valued and esteemed. Supportive individuals must adapt and respond to the changed behaviour and altered moods of the victim following sexual assault (for example, need to be escorted home after dark, moodiness, angry outbursts, phobias, etc.). The victim who is able to integrate and resolve the sexual assault usually has had a strong social support system (11). Diagnosis The psychological reaction to sexual assault was first described in 1974 by Burgess and Holmstrom as the Rape Trauma Syndrome (8). In 1980, the American Psychiatric Association recognized the characteristic common symptoms which follow a psychological traumatic event (war, political terrorism, hostage-taking, natural and man-made disasters, crimes of violence) with the diagnosis of Post-traumatic Stress Disorder in DSM-III and DSM-III-R (27). It also notes that the most severe and longlasting symptoms occur when the stressor is of human design as in sexual assault. (When informed about the diagnosis of Post-traumatic Stress Disorder, many women seen in our facility experienced a decreased sense of isolation, identification with other victims of trauma, and the dispelling of myths regarding sexual assault.) Psychodynamics Psychic Trauma and Symptoms The psychic trauma of sexual assault includes massive environmental assault, the invasion of body boundaries, threat of annihilation, loss of control, narcissistic injury with loss of part of the self, overwhelming of usual ego functions, profound regression, activation of unconscious conflicts and fantasies, including fantasies of revenge and disruption of important relationships (28).
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Dissociation and depersonalization, which protect some ego functions, result from the terror of being killed and the threat of annihilation. The ego being partially overwhelmed results in loss of part of the self which is replaced by a numbed self. "I will never be the same again" is a frequent comment by patients. Primitive drives of rage, anger and aggression are evoked which forms the basis of many symptoms. Women are socialized not to acknowledge and/or express their anger, but to be passive and compliant, adding to the intensity of their anger. Irritability and explosive outbursts of anger may occur. Victims frequently express the feeling of transparency, that everyone knew they had been sexually assaulted. Projection, introjection and denial of rage result in this feeling of being labelled. The public seem to have a morbid curiosity about sexual assault. Fear of return of the assailant includes anger, which is projected onto the assailant, and is a realistic response to the invariable threat by the assailant to return if the victim reports the sexual assault. Guilt, shame and self-blame are universal (9, 29,30). Guilt may result from cooperation with the assailant in order to stay alive (betrayal of the ego ideal). Fantasies of retaliation (murder, dismemberment, castration), when acknowledged and expressed, are followed frequently by the statement, "I am no better than the rapist. " Shame is experienced because the most private spaces and body boundaries are invaded. Humiliation is experienced, if there is loss of control of the autonomic nervous system with vomiting, urination, defecation or physiological sexual arousal and orgasm. The intensity of the loss of self-esteem and self-worth is compounded. Society's focus on the sexual rather than the violent nature of sexual assault adds to the shame. Self-blame serves to control the rage at one's loss of omnipotence, competence, and judgement in others. At the same time, a remaining vestige of self-blame becomes a means of altering behaviour and regaining a sense of invulnerability and control. Memories of childhood threats and punishments for misdeeds evoke the feeling, "I must be bad or this would not have happened to me" (31).
Psychodynamics of the Controlled Style Two emotional styles of presentation following major psychological trauma have been described, the expressed style and the controlled style (8, 32). In the expressed style, the individual is anxious, agitated, angry, emotionally labile and disorganized in behaviour. This is the expected and accepted reaction to sexual assault. In all other instances of psychic trauma, such as hostage-taking or natural disasters, the expressed style is acceptable but viewed as hysterical. The controlled style is one of being calm, cool, collected, somewhat detached, organized, and events are related clearly and coherently. In sexual assault, this presentation results in disbelief on the part of others. "If you were sexually assaulted, you have to be hysterical," it is said. In most other life crises, being calm, cool, organized, controlled, is characteristic of the leader or the obedient follower; for example, the pilot and passengers of a hijacked jet are calm, obedient, do as they are told. They do not become angry or fight back. This
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behaviour is applauded by observers and society in general. The psychodynamics of the controlled style have been welldocumented (33). Terror of death leads to massive regression, which results in psychologic infantilism and automatonlike behaviour which presents as the calm, cool, cooperative, organized, controlled style. Approximately 50% of victims present in each style during the impact phase, and again during contact with the police and during the court process. Prejudgment and disbelief by the police and health care workers, whom the victim of sexual assault first encounters, have a long term devastating effect.
The Rapist The psychodynamics of the rapist and the impact upon the victim must be considered. The source of the trauma to the victim, a human being, acting intentionally to inflict trauma is central to the response. The etiology of the assailant's behaviour is multidetermined and complex but involves the issues of power (control) and anger (hostility) more than passion (sexuality) (34). The hierarchy, interrelationships and the intensity of these three factors vary from one assailant to another. The assailant's psychopathology is part of the victim's psychic trauma and response. The intimate experience of the assailant's anger may result in identification with the aggressor, as the victim expresses concern for the assailant. "He must be sick. I feel sorry for him. " The assailant may view the victim as participant in the sexual assault, as part of her own aggressive or sexual fantasy. The more she resists, the more she wants to be raped. Countertransference Countertransference is defined broadly here as the unconscious response of others to the victim, the assailant, and the assault. Countertransference plays an important role in the victim'S psychological sequelae, sense of self-esteem and self-worth. Symonds (33) notes the basic need of all individuals to find an explanation for a violent and brutal crime. The feeling of vulnerability engendered in others is defended against by blaming and accusing the victim of lack of judgment, stating what should have been done (35). Fathers and husbands threaten to kill the assailant. Partners may find hints of doubt linger (36). Frightened of being assaulted themselves, members of the public will project blame onto the victim with statements such as, "she asked for it; she deserved it." Professionals, too, may defend against their vulnerability by blaming the victims. Through millennia, women have been the property of their fathers, then their husbands. Following sexual assault a woman is devalued and considered damaged goods. In some societies the victim is executed with the assailant (1). Further education of the police, criminal justice system, health care workers. family, friends and society in general is required. Management of Victims of Sexual Assault Prior to discussing the management of victims of sexual assault. the gender of the therapist will be discussed. Silverman (37) found men overanxious to please, to be gentle, monitoring their physical contact and space as well as their
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nonverbal communication for seductiveness. Most women who have personally confronted their own feelings of vulnerability and powerlessness and may more easily convey empathy to the victim, assist her in experiencing, containing, and tolerating her feelings. Both women and men must be vigilant about making assumptions concerning the victim's feelings and needs. For example, the therapist's feeling of anger against the' assailant may exceed the patient's anger. The management of the victim of recent and nonrecent sexual assault differs. The victim of a recent sexual assault requires crisis intervention. The victim of a nonrecent or nondisclosed sexual assault may seek help months or years following the sexual assault. She may have hoped for spontaneous recovery or did not conceptualize herself as a victim of sexual assault. The victim of a past sexual assault may require crisis intervention following disclosure of the sexual assault, in addition to more intensive psychotherapeutic interventions. The recent victim of sexual assault may present at the emergency of a general hospital, the office of a general practitioner, gynecologist or community health agency. Immediate care includes assessment of both the physical and psychological trauma. Physical examination and gathering of forensic evidence has been well described (36, 38, 39). Recognition of the psychological trauma modifies the manner of the physical examination. Each aspect of the physical examination is explained to the patient and permission obtained to proceed with the next step, returning control to the patient through decision-making. The nonjudgemental, empathic attitude of the medical staff modifies the long term psychological consequences. Legal judgement of the sexual assault is in the domain of the criminal justice system. The patient who is involved with the police might benefit from referral to the local rape crisis centre, or hospital-based sexual assault care centre, where support is given during the court process. Immediate follow-up, based on crisis intervention, may be limited to one session. During the phase of denial, followup appointments may not be kept. Insistence on further therapy may be perceived as a second assault. Goals for the initial session should include establishing a nonjudgemental, supportive relationship, becoming the patient's advocate; handling immediate needs, such as reassuring the patient she is safe and not alone; notifying family, friends and/or colleagues upon request; educating the patient and significant others about needs; dealing with myths and anticipated future symptoms; making application for criminal injuries compensation; offering telephone follow-up and future treatment when requested. Evaluation of psychotherapeutic techniques which facilitate recovery from sexual assault are in the beginning stages (40). Cognitive Behaviour Therapy and Systematic Desensitization offered as a 14 session treatment program for both recent and nonrecent victims of sexual assault (41) was effective in modification of depressive and phobic systems with general improvement in post-traumatic stress symptomatology. Isolated accounts of psychoanalytic psychotherapy are reported (28, 42). Group psychotherapy, including both
a short term psychoeducational (43) and a long term (44) format have been described. However, many women do not continue in treatment. In one study (45), at three months postrape, less than one half of the women judged to need treatment agreed to accept psychotherapy. In another study (46), only a quarter of the victims who entered an immediate postsexual assault program completed the 14 hour course of therapy. At this time, the modality of treatment chosen is a clinical decision, as is the availability of community resources. Summary Sexual assault is a crime of violence in which the rapist's anger and need for power are served through a sexual act. The psychodynamics of the assailant become interwoven with the psychodynamics of the victim's stress response. The victim experiences a breakdown of the existential denial of environmental threat and the belief that the world is benign. Terror of being killed results in intense fear, helplessness and psychological regression, and symptoms of posttraumatic stress. There is loss of the integrity of body boundaries as personal space is invaded, particularly those areas directly connected to sexuality. Previously unresolved anxieties and conflicts may be evoked. The victim must resolve the psychic trauma, rework the body image and body boundaries to regain a sense of autonomy over one's body and a valued sense of self. When a woman is the victim of sexual assault, she must come to terms with the relationship with the men in her life. Lastly, by working through the feelings of powerlessness and vulnerability, a sense of safety, together with the existential denial of environmental threat is restored. The goal of treatment has been well-stated by Bassuk (47): "to regain a sense of safety, a valued sense of self and reestablish sharing altruistic, mutually satisfying relationships with men, women and society, where sexual assault remains a threat." Acknowledgements The author wishes to thank Dr. Howard Book and the staff of the Sexual Assault Care Centre for their comments.
References 1. Brownmiller S. Against our will: men, women and rape. New York: Simon and Schuster, 1975. 2. Bill C-127. Communication and Public Affairs. Ottawa, Canada: Department of Justice, 1983. 3. Sexual offenses against children in Canada. Ottawa, Canada: Canadian Government Publishing Centre, 1984. 4. Canadian Advisory Council on the Status of Women. Ottawa, Canada: Box 1541, Station B, 1985. 5. Mackinnon C. Feminism unmodified. Cambridge: Harvard University Press, 1987. 6. Ochberg FM. Post-traumatic therapy and victims of violence. In: Ochberg FM, ed. Post-traumatic therapy and victims of violence. New York: Brunner/Mazel, 1988. 7. Lindemann E. Symptomatology and management of acute grief. Am J Psychiatry 1944; 101: 141-145. 8. Burgess AW, Holmstrom LL. Rape trauma syndrome. Am J Psychiatry 1974; 131: 981-986.
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9. Notman MT, Nadelson CC. The rape victim: psychodynamic consideration. Am J Psychiatry 1976; 133: 408-413. 10. Forman B. Psychotherapy with rape victims. Psychotherapy: Theory, Research and Practice 1980; 17: 304-311. II. Nadelson S, Notman M, Zackson H, et al, A follow-up study of rape victims. Am J Psychiatry 1982; 139: 1266-1270. 12. Kilpatrick D, Veronen L, Resick P. Effects of a rape experience a longitudinalstudy. Journal of Social Issues 1981; 37: 105-122. 13. Forman B. Treating victims of rape. Psychotherapy: Theory, Research and Practice 1983; 20: 515-519. 14. Ellis EM, Atkeson BM, Calhoun KS. An assessment of longterm reaction to rape. J Abnorm Psychol 1981; 90: 263-266. 15. Ruch LO, Leon JJ. Sexual assault and trauma change. Women Health 1983; 8: 5-21. 16. Sales E, Baum M, Shore B. Victim readjustment following assault. Journal of Social Issues 1984: 40: 117-136. 17. Feldman-Summers S, Gordon P, Meagher J. The impact of rape on sexual satisfaction. J Abnorm Psychol 1979; 88: 101-105. 18. Frank E, Stewart BD. Treatment of depressed victims an approach to stress-induced symptomatology. In: Clayton PJ, Barrett J, eds. Treatment of depression: old controversies and new approaches. New York: Raven Press, 1983. 19. Atkeson B, Calhoun KS, Resick PA, et al. Victims of rape: repeat assessment of depressive symptoms. J Consult Clin Psychol 1982; 50: 96-102. 20. Becker JV, Skinner LJ. Assessment and treatment of raperelated sexual dysfunction. Clinical Psychologist 1983; 36: 102-105. 21. Burgess AW, Holmstrom LL. Rape: sexual disruption and recovery from rape. Am J Orthopsychiatry 1979; 49: 648-656. 22. Resick PA, Calhoun KS, Ellis EM. Social adjustment in victims of sexual assault. J Consult Clin Psychol 1981; 49: 705-712. 23. Frank E, Anderson BP. Psychiatric disorders in rape victims past history and current symptomatology. Compr Psychiatry 1987; 28: 77-82. 24. Silverman DC, Kalick SM, Bowie SI, et al. Blitz rape and confidence rape: a typology applied to 1,000 consecutive cases. Am J Psychiatry 1988; 145: 1438-1441. 25. Frank E, Turner SM, Duffy BD. Depressive symptoms in rape victims. J Affective Disord 1979; 8: 101-105. 26. Girelli SA, Resick PA, Marhoeffer-Dvorak S, et al. Subjective distress and violence during rape their effect on long term fear. Victims and Violence 1986; I: 35-46. 27. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, third edition, revised. Washington, DC: American Psychiatric Association Press, 1987. 28. Rose D. Worse than death: psychodynamics of rape victims and the need for psychotherapy. Am J Psychiatry 1986; 143: 817-824. 29. Binder RL. Why women do not report sexual assault. J Clin Psychiatry 1981; 42: 437-438. 30. Libow J, Doty D. An exploratory approach to self-blame and self-degradation by rape victims. Am J Orthopsychiatry 1979; 49: 670-679. 31. Janis I. Psychological stress. New York: Wiley, 1958. 32. Symonds M. The rape victim: psychological patterns of response. Am J Psychoanal 1976; 36: 27-34. 33. Symonds M. Victims of violence: psychological effects and after-effects. Am J Psychoanal 1975; 35: 19-26. 34. Groth AN, Burgess AW, Holmstrom LL. Rape: power, anger and sexuality. Am J Psychiatry 1977; 134: 1239-1243.
35. Field HS. Attitudes toward rape: a comparative analysis of police, rapists, crisis counsellors and citizens. J Pers Soc Psychol 1978; 36: 156-179. 36. Whynot E. Principles of the sexual assault exam. Diagnosis 1987; 4: 41-50. 37. Silverman D. First do no harm: female rape victims and the male counsellor. Am J Orthopsychiatry 1977; 47: 91-96. 38. Hargot L. The sexual assault examination. Can Fam Physician 1985; 31: 775-780. 39. Cabaniss ML, Scott SE, Copeland L. Gathering evidence for rape cases. Contemporary Ob/Gyn 1985; 25: 160-178. 40. Ellis EM. A review of empirical rape research victim: reactions and response to treatment. Clinical Psychology Review 1983; 3: 473-490. 41. Frank E, Anderson B, Stewart BD, et al. Immediate and delayed treatment of rape victims. NY Acad Sci 1988; 528: 296-309. 42. Shuker E. Psychodynamics and treatment of sexual assault victims. J Am Acad Psychoanal 1979; 4: 553-573. 43. Frank E, Anderson B, Hughes C, et al. Psychoeducational intervention therapy manual. University of Pittsburgh School of Medicine and Magee-Women's Hospital. Personal communication 1988. 44. Roth S, Dye E, Lebowitz L. Group therapy for sexual assault victims. Psychotherapy: Theory, Research, Practice Training 1988; 25: 82-93. 45. Veronen L, Kilpatrick D. Stress management for rape victims. In: Michenbaum D, Jaremko ME, eds. Stress reduction and prevention. New York: Plenum Press, 1983: 341-374. 46. Frank E, Stewart BD. Treating depression in rape victims. Clinical Psychologist 1983; 36: 95-98. 47. Bassuk EL. Crisis theory perspective on rape. In: McCombie SL, ed. The rape crisis intervention handbook. New York: Plenum Press, 1980.
Resume Comme il s 'agit d'un acte de violence, I'agression sexuelle declenche chez la victime une crise vitale qui s 'accompagne de traumatismes psychologiques et physiologiques importants. Toutes les agressions sexuelles se caracterisent par I'absence de consentement mutuel. Des sympt6mes posttraumatiques apparaissent immediatement et, chez un grand nombre de victimes, it faut de nombreuses annees pour que I'integration du traumatisme s 'accomplisse. On observe la triade classique de sympt6mes de stress post-traumatique qui apparait apres une peur intense, la terreur et une perte de controle, savoir " des visions obsedantes, des souvenirs indesirables, et I'engourdissement ou le refoulement des sentiments accompagne d'un manque de concentration et d'une plus grande disposition a l'anxiete. A long terme, les effets du traumatisme se traduisent par l'anxiete, la depression, des reactions phobiques dans les situations qui rappellent I'agression sexuelle, Ie dysfonctionnement sexuel ainsi qu 'une diminution de I'adaptation sociale et de I'aptitude jouir de la vie. On passe en revue les reactions de stress posttraumatique, la symptomatologie, la psychodynamique et Ie traitement des victimes d 'agression sexuelle recente et ancienne.
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Psychological Management of Victims of Sexual Assault* REBEKA MOSCARELLO, M.D. I
the criminal justice system. She fears she will not be believed, or she does not conceptualize her unwanted sexual encounter as sexual assault. Canadian federal legislation in January 1983, Bill C-127 (2) moved the crime of rape into the general category of assault, recognizing the violent rather than the sexual nature of sexual assault. This is reflected in the use of the terminology of sexual assault.
Sexual assault, as a crime of violence, induces a life crisis which inflicts major psychological and physiological trauma upon the victim. Lack of mutual consent is present in all sexual assaults. Post-traumatic symptoms occur immediately and for a large percentage of victims this trauma is not integratedfor many years. Symptoms include the classic triad of post-traumatic stress symptoms of haunting, intrusive recollections, numbing or constriction offeelings and focus and lowered threshold of anxious arousal subsequent to experiencing intense fear, terror and loss of control. Long term effects include anxiety, depression, phobic reactions to situations reminiscent of the sexual assault, sexual dysfunction, impaired social adjustment and diminished capacity to enjoy life. Post-traumatic stress responses, symptomatology, psychodynamics and management ofthe victim of recent and nonrecent sexual assault are reviewed.
Post-Traumatic Stress Following Sexual Assault Sexual assault is a life crisis in which the ego is overwhelmed and the balance between internal ego adaptation and the environment is broken. The violation of one human being by another of a fiercely protected, private aspect of oneself, usually results in post-traumatic stress symptomatology. The beliefs most affected by sexual assault are personal invulnerability, the perception of the world as meaningful and the positive view of oneself. The loss of personal invulnerability results in the world no longer being seen as safe and benign, but as unsafe and dangerous. The sexual assault is usually experienced with fear, terror, and helplessness, followed by the classic triad of symptoms of haunting intrusive recollections (thoughts, feelings, images), numbing or constriction of feelings and focus, and increased arousal. A distinct subcategory of post-traumatic symptoms experienced by victims of sexual assault are shame, self-blame, feeling dehumanized, obsessions of vengeance, paradoxical gratitude for the gift of life, feeling dirty and defiled, reduced capacity for intimacy, and second wound through revictimization during the court process (6). The classic triad and the subcategory of symptoms are superimposed upon the psychological, behavioural and cognitive symptoms described within the phases of response which follow sexual assault.
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exual assault has taken place since earliest times (1). The women's movement, changes in the social role of women, their relationship to men, and publications by mental health professionals interested in the effect of the commonly occurring private violation of sexual assault upon women initiated a more humane attitude towards women who have been sexually assaulted. Treatment is offered through rape crisis centres in the community, and the more recent addition of sexual assault care centres in hospitals. Canadian statistics reveal that one in five adult women will be sexually assaulted (sexual assault is defined (2) as "any form of sexual activity with another person without his or her consent, as kissing, fondling, or intercourse), and one in 17 adult women will experience forced sexual intercourse in their lifetime (3, 4). It is estimated that only one or two out of ten sexual assaults are reported (5). In Toronto, Ontario 2,154 sexual assaults were reported in 1988 (personal communication, Metropolitan Toronto Police). If two out often were reported, there were over 10,000 victims in Toronto during 1988. The survivor of sexual assault may choose not to report, to avoid revictimization through the course of medical treatment, involvement with the police and
Phases of Response Phases of the stress response to sexual assault follow the predictable sequences of responses similar to those following other life crises (7-9); that is, an anticipatory or threat phase, impact phase, recoil or immediate phase, and resolution phase. The anticipatory or threat phase, when present, is the recognition of a potentially dangerous situation. There may be mobilization of defenses to avoid the sexual assault or the development of coping strategies to use during the sexual assault. Self-blame and guilt are intensified if this phase is present and is ignored by the victim.
*Manuscript received January 1988; revised September 1989. 'Assistant Professor of Psychiatry, University of Toronto; Psychiatrist, Sexual Assault Care Centre, Women's College Hospital, Toronto, Ontario. Address reprint requests to: Dr. R. Moscarello, Women's College Hospital, 76 Grenville Street, Toronto, Ontario M5S IB2 Can. J. Psychiatry Vol. 35, February 1990
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The impact phase occurs when the sexual assault can no longer be avoided. This phase begins with the attack and lasts for several days to weeks. During the attack emergency problem-solving comes into action. Strategies may include whether to fight back (which may increase the assailant's rage and the risk of being maimed or killed), or whether to surrender one's body and ego-ideal and cooperate to stay alive (increases guilt and self-blame), concentrating on strategies not to cause the assailant to lose his fragile control over his rage (for example, by not screaming, expressing anger, etc.), as well as concentrating on obtaining a description through smell, touch or vision if not blindfolded. The feelings experienced during this phase of impact are initial shock, disbelief and denial, followed by intense fear, terror, and helplessness. The ability to think clearly may be impaired with resulting confusion and disorientation. Victims respond in one of two styles: expressed or controlled (8). The importance of the recognition of the controlled style will be discussed under the section on psychodynamics. During this phase of impact, victims may experience dissociation, during which they feel as if they are outside their body watching the assault. Victims frequently state their fear of going crazy. The direct effect of the physical trauma may be experienced, as well as stress-induced symptoms of general aching, headaches, nausea, abdominal and genital area pain. The emotions of anxiety, anger, guilt, shame, humiliation, helplessness and vulnerability are present. Following the attack, the fear of being alone, and the fear of the assailant returning are paramount. Hypervigilance, hyperalertness, and disordered sleep add to the general feeling of fatigue. There may be reactivation of previous traumatic experiences. Unresolved previous sexual trauma, particularly unresolved sexual violation, intensify the psychologicaltrauma. The recoil, or intermediate phase, begins several days or weeks after the attack and has three components: denial, symptom formation, and anger (10). Denial of the sexual assault, the victim's attempt to regain a sense of control, results in an outward appearance of adjustment, lasting several months or years. When denial fails, symptoms recur which are discussed under the section on long term psychological sequelae. During symptom formation, attempts to gain anonymity result in changing one's telephone number, residence, and on occasion, job. Acknowledging the process of denial and symptom formation, rape crisis and counselling centres share the information regarding the process of denial and symptom formation with their patients on the first or second visit. Anticipating future symptoms, telephone contact is set up. During the final component of the recoil or intermediate phase, anger is experienced at the depth of primitive rage. The anger may be directed at the assailant, at all men, at the therapist, medical and/or legal system. Underlying the anger are feelings of despair, hopelessness and shame. The therapeutic task is to reduce the anger and feeling of devaluation of the self. Prosecution of the assailant provides a focus for working through and channelling the anger, and restoring a sense of control. For some victims, symptoms continue after the sentencing of the assailant. The symptoms function as a defense against a repeat attack.
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The final phase of resolution occurs when the sexual assault becomes part of the past in a meaningful way and can be discussed without undue emotion. The life crisis of sexual assault can be growth-promoting and foster maturation by resulting in positive adaptations (11, 12). This includes becoming more independent, self-reliant, with a more positive view of one's self. The timing of this phase depends on the individual, taking anywhere from six months to two years to a lifetime. It should be noted that rapid recovery may occur in less than 20% of victims (13). Symptoms may become encapsulated in one area, allowing adequate functioning in other spheres of life.
Long Term Psychological Sequelae Difficulties encountered for the researcher documenting the long term psychological sequelae of sexual assault include 1. prospective studies which are limited to one year due to difficulty in maintaining a victim sample for longer periods, and 2. retrospective studies, in which collecting a patient sample is difficult because victims of sexual assault hesitate to seek treatment due to the symptoms of shame, self-blame, and the privacy of the violations. Long term psychological sequelae cluster around the symptoms of the unresolved intermediate phase: anxiety and fear, depression, impaired sexual and social adjustment (family, work, social, interpersonal, and marital) (11-22). Kilpatrick et al (12) found anxiety and fear were experienced by all victims, significantly higher than the control group of nonvictims at six and 12 months post-sexual assault. Initial fears related to cues of the sexual assault become generalized to fears related to vulnerability and repeat attack. Phobic-avoidance reactions include fears associated directly with the attack (man's penis, tough men, anal intercourse); fears precipitated by the sexual assault itself (venereal disease including AIDS, pregnancy, talking with the police, testifying in court); vulnerability to future attack (being alone, being in situations where control feels threatened, when showering alone, on public transit, especially the underground system, in laundry rooms, in crowded supermarkets, strange places, etc.). Altered behaviour patterns include withdrawal, isolation, and increased dependency on others. The latter may be difficult for the victim and her supporters to accept. In Canada, shortened winter daylight hours make going home from work and attending health care facilities arduous and challenging. Depressive symptoms are present, as dysphoria, in 50% of the sample in the study done by Frank and Stewart (18), and 24 % of the total group meet the Research Diagnostic Criteria for depression within the first month after the assault. Others (11,14,19,23) found depressed mood, sadness, inability to experience pleasure, appetite and sleep disturbance, and difficulty in concentration at one to several years postsexual assault. Sexual dysfunction is reported in 25 % to 40 % of victims one to six years post-sexual assault (20, 21). The types of sexual dysfunction experienced by sexual assault victims
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differ from that reported by nonvictims. Symptoms are related to arousal or desire functions; for example, responseinhibiting problems related to perception of sexual stimuli as anxiety-provoking reminiscences of the assault occur three times as frequently as orgasmic or intromission problems. Increased negative feelings about men, increased insecurity concerning sexual attractiveness, and lowered sexual selfesteem have been observed. A study of the impact of sexual assault on a victim's ability to carry out major social roles found victims differed from nonvictims in work functioning for the first eight months, in social and leisure functioning for the first two months, and within the family for one month after the sexual assault (22). Psychological functioning may not return to the presexual assault level of functioning, although social functioning does (13, 15, 16). Factors Influencing the Severity of the Post- Traumatic Stress Response Variables affecting the stress response to sexual assault include characteristics of the sexual assault, personal characteristics, and the response of the social support system. 1. Characteristics ofthe Sexual Assault. Studies examining the variables of sexual assault and post-sexual assault symptomatology are not consistent. The expected positive correlation between sexual assault characteristics and the severity of symptoms, as violent versus nonviolent, dangerous versus safe location, blitz versus confidence sexual assault, stranger versus acquaintance, has not been proved (14, 18). Positive correlation with a more difficult recovery (16) has been found between mock tenderness, multiple assailants, and vaginal penetration. Vaginal penetration symbolizes the ultimate physical domination. A recent paper (24) has reported that blitz sexual assault (sudden surprise attack) versus confidence sexual assault (previous, nonviolent interaction), highlights different symptoms on the spectrum of post-sexual assault symptomatology. The blitz attack evokes intrusive and avoidance symptoms, as well as symptoms of increased arousal (hypervigilance, hyperalertness, exaggerated startle response, etc.). The confidence attack evokes greater feelings of self-blame (loss of confidence in the ability to judge those felt to be trustworthy), shame, guilt, and a sense of not deserving help. 2. Personal Characteristics. Frank and Anderson in 1987 (25) found that one third of the women in their study had some previous contact with mental health professionals, which did not predict a more severe post-traumatic stress response. A direct correlation, with a more severe stress response, was found between previous severe psychiatric symptoms (suicidal attempts, substance abuse, need for psychotropic medication), a history of sexual violation and concurrent life stresses (15). Past psychiatric disorders occur no more frequently among sexual assault victims than among nonvictims (25). The age and stage of development of the victim at the time of the sexual assault modifies the impact of the sexual assault. Notman and Nadelson (9) discuss the relationship between sexual assault and age and stage of development. The effect on the adolescent woman, where the issues are
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of separation and independence, are developmental tasks. The woman with children is concerned about her ability to care for her children, as her self-blame engenders a feeling of personal inadequacy. She is unable to look after herself. Marital conflict may result for the woman with a partner, if victim responses are misunderstood by the partner (in both heterosexual and homosexual relationships). The single woman may feel her credibility is questioned. The elderly woman, whose lifespan is limited, may not appear to suffer as severely initially, but the long term psychological sequelae are more severe and longlasting. Myths maintain that the intensity and severity of the response to sexual assault is directly related to the observable violence (bruises, lacerations, fractures, etc.). A recent study (26) relates subjective distress (as felt or perceived threat) to the intensity of the symptoms of anxiety and fear. This information is important for the victim, significant others and those in the criminal justice system. 3. Social Support System. Social support is the most important single post-sexual assault factor influencing rehabilitation, a powerful predictor over and above the actual stressful life events and the reported symptoms. The social support network provides an atmosphere for feeling loved, valued and esteemed. Supportive individuals must adapt and respond to the changed behaviour and altered moods of the victim following sexual assault (for example, need to be escorted home after dark, moodiness, angry outbursts, phobias, etc.). The victim who is able to integrate and resolve the sexual assault usually has had a strong social support system (11). Diagnosis The psychological reaction to sexual assault was first described in 1974 by Burgess and Holmstrom as the Rape Trauma Syndrome (8). In 1980, the American Psychiatric Association recognized the characteristic common symptoms which follow a psychological traumatic event (war, political terrorism, hostage-taking, natural and man-made disasters, crimes of violence) with the diagnosis of Post-traumatic Stress Disorder in DSM-III and DSM-III-R (27). It also notes that the most severe and longlasting symptoms occur when the stressor is of human design as in sexual assault. (When informed about the diagnosis of Post-traumatic Stress Disorder, many women seen in our facility experienced a decreased sense of isolation, identification with other victims of trauma, and the dispelling of myths regarding sexual assault.) Psychodynamics Psychic Trauma and Symptoms The psychic trauma of sexual assault includes massive environmental assault, the invasion of body boundaries, threat of annihilation, loss of control, narcissistic injury with loss of part of the self, overwhelming of usual ego functions, profound regression, activation of unconscious conflicts and fantasies, including fantasies of revenge and disruption of important relationships (28).
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Dissociation and depersonalization, which protect some ego functions, result from the terror of being killed and the threat of annihilation. The ego being partially overwhelmed results in loss of part of the self which is replaced by a numbed self. "I will never be the same again" is a frequent comment by patients. Primitive drives of rage, anger and aggression are evoked which forms the basis of many symptoms. Women are socialized not to acknowledge and/or express their anger, but to be passive and compliant, adding to the intensity of their anger. Irritability and explosive outbursts of anger may occur. Victims frequently express the feeling of transparency, that everyone knew they had been sexually assaulted. Projection, introjection and denial of rage result in this feeling of being labelled. The public seem to have a morbid curiosity about sexual assault. Fear of return of the assailant includes anger, which is projected onto the assailant, and is a realistic response to the invariable threat by the assailant to return if the victim reports the sexual assault. Guilt, shame and self-blame are universal (9, 29,30). Guilt may result from cooperation with the assailant in order to stay alive (betrayal of the ego ideal). Fantasies of retaliation (murder, dismemberment, castration), when acknowledged and expressed, are followed frequently by the statement, "I am no better than the rapist. " Shame is experienced because the most private spaces and body boundaries are invaded. Humiliation is experienced, if there is loss of control of the autonomic nervous system with vomiting, urination, defecation or physiological sexual arousal and orgasm. The intensity of the loss of self-esteem and self-worth is compounded. Society's focus on the sexual rather than the violent nature of sexual assault adds to the shame. Self-blame serves to control the rage at one's loss of omnipotence, competence, and judgement in others. At the same time, a remaining vestige of self-blame becomes a means of altering behaviour and regaining a sense of invulnerability and control. Memories of childhood threats and punishments for misdeeds evoke the feeling, "I must be bad or this would not have happened to me" (31).
Psychodynamics of the Controlled Style Two emotional styles of presentation following major psychological trauma have been described, the expressed style and the controlled style (8, 32). In the expressed style, the individual is anxious, agitated, angry, emotionally labile and disorganized in behaviour. This is the expected and accepted reaction to sexual assault. In all other instances of psychic trauma, such as hostage-taking or natural disasters, the expressed style is acceptable but viewed as hysterical. The controlled style is one of being calm, cool, collected, somewhat detached, organized, and events are related clearly and coherently. In sexual assault, this presentation results in disbelief on the part of others. "If you were sexually assaulted, you have to be hysterical," it is said. In most other life crises, being calm, cool, organized, controlled, is characteristic of the leader or the obedient follower; for example, the pilot and passengers of a hijacked jet are calm, obedient, do as they are told. They do not become angry or fight back. This
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behaviour is applauded by observers and society in general. The psychodynamics of the controlled style have been welldocumented (33). Terror of death leads to massive regression, which results in psychologic infantilism and automatonlike behaviour which presents as the calm, cool, cooperative, organized, controlled style. Approximately 50% of victims present in each style during the impact phase, and again during contact with the police and during the court process. Prejudgment and disbelief by the police and health care workers, whom the victim of sexual assault first encounters, have a long term devastating effect.
The Rapist The psychodynamics of the rapist and the impact upon the victim must be considered. The source of the trauma to the victim, a human being, acting intentionally to inflict trauma is central to the response. The etiology of the assailant's behaviour is multidetermined and complex but involves the issues of power (control) and anger (hostility) more than passion (sexuality) (34). The hierarchy, interrelationships and the intensity of these three factors vary from one assailant to another. The assailant's psychopathology is part of the victim's psychic trauma and response. The intimate experience of the assailant's anger may result in identification with the aggressor, as the victim expresses concern for the assailant. "He must be sick. I feel sorry for him. " The assailant may view the victim as participant in the sexual assault, as part of her own aggressive or sexual fantasy. The more she resists, the more she wants to be raped. Countertransference Countertransference is defined broadly here as the unconscious response of others to the victim, the assailant, and the assault. Countertransference plays an important role in the victim'S psychological sequelae, sense of self-esteem and self-worth. Symonds (33) notes the basic need of all individuals to find an explanation for a violent and brutal crime. The feeling of vulnerability engendered in others is defended against by blaming and accusing the victim of lack of judgment, stating what should have been done (35). Fathers and husbands threaten to kill the assailant. Partners may find hints of doubt linger (36). Frightened of being assaulted themselves, members of the public will project blame onto the victim with statements such as, "she asked for it; she deserved it." Professionals, too, may defend against their vulnerability by blaming the victims. Through millennia, women have been the property of their fathers, then their husbands. Following sexual assault a woman is devalued and considered damaged goods. In some societies the victim is executed with the assailant (1). Further education of the police, criminal justice system, health care workers. family, friends and society in general is required. Management of Victims of Sexual Assault Prior to discussing the management of victims of sexual assault. the gender of the therapist will be discussed. Silverman (37) found men overanxious to please, to be gentle, monitoring their physical contact and space as well as their
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nonverbal communication for seductiveness. Most women who have personally confronted their own feelings of vulnerability and powerlessness and may more easily convey empathy to the victim, assist her in experiencing, containing, and tolerating her feelings. Both women and men must be vigilant about making assumptions concerning the victim's feelings and needs. For example, the therapist's feeling of anger against the' assailant may exceed the patient's anger. The management of the victim of recent and nonrecent sexual assault differs. The victim of a recent sexual assault requires crisis intervention. The victim of a nonrecent or nondisclosed sexual assault may seek help months or years following the sexual assault. She may have hoped for spontaneous recovery or did not conceptualize herself as a victim of sexual assault. The victim of a past sexual assault may require crisis intervention following disclosure of the sexual assault, in addition to more intensive psychotherapeutic interventions. The recent victim of sexual assault may present at the emergency of a general hospital, the office of a general practitioner, gynecologist or community health agency. Immediate care includes assessment of both the physical and psychological trauma. Physical examination and gathering of forensic evidence has been well described (36, 38, 39). Recognition of the psychological trauma modifies the manner of the physical examination. Each aspect of the physical examination is explained to the patient and permission obtained to proceed with the next step, returning control to the patient through decision-making. The nonjudgemental, empathic attitude of the medical staff modifies the long term psychological consequences. Legal judgement of the sexual assault is in the domain of the criminal justice system. The patient who is involved with the police might benefit from referral to the local rape crisis centre, or hospital-based sexual assault care centre, where support is given during the court process. Immediate follow-up, based on crisis intervention, may be limited to one session. During the phase of denial, followup appointments may not be kept. Insistence on further therapy may be perceived as a second assault. Goals for the initial session should include establishing a nonjudgemental, supportive relationship, becoming the patient's advocate; handling immediate needs, such as reassuring the patient she is safe and not alone; notifying family, friends and/or colleagues upon request; educating the patient and significant others about needs; dealing with myths and anticipated future symptoms; making application for criminal injuries compensation; offering telephone follow-up and future treatment when requested. Evaluation of psychotherapeutic techniques which facilitate recovery from sexual assault are in the beginning stages (40). Cognitive Behaviour Therapy and Systematic Desensitization offered as a 14 session treatment program for both recent and nonrecent victims of sexual assault (41) was effective in modification of depressive and phobic systems with general improvement in post-traumatic stress symptomatology. Isolated accounts of psychoanalytic psychotherapy are reported (28, 42). Group psychotherapy, including both
a short term psychoeducational (43) and a long term (44) format have been described. However, many women do not continue in treatment. In one study (45), at three months postrape, less than one half of the women judged to need treatment agreed to accept psychotherapy. In another study (46), only a quarter of the victims who entered an immediate postsexual assault program completed the 14 hour course of therapy. At this time, the modality of treatment chosen is a clinical decision, as is the availability of community resources. Summary Sexual assault is a crime of violence in which the rapist's anger and need for power are served through a sexual act. The psychodynamics of the assailant become interwoven with the psychodynamics of the victim's stress response. The victim experiences a breakdown of the existential denial of environmental threat and the belief that the world is benign. Terror of being killed results in intense fear, helplessness and psychological regression, and symptoms of posttraumatic stress. There is loss of the integrity of body boundaries as personal space is invaded, particularly those areas directly connected to sexuality. Previously unresolved anxieties and conflicts may be evoked. The victim must resolve the psychic trauma, rework the body image and body boundaries to regain a sense of autonomy over one's body and a valued sense of self. When a woman is the victim of sexual assault, she must come to terms with the relationship with the men in her life. Lastly, by working through the feelings of powerlessness and vulnerability, a sense of safety, together with the existential denial of environmental threat is restored. The goal of treatment has been well-stated by Bassuk (47): "to regain a sense of safety, a valued sense of self and reestablish sharing altruistic, mutually satisfying relationships with men, women and society, where sexual assault remains a threat." Acknowledgements The author wishes to thank Dr. Howard Book and the staff of the Sexual Assault Care Centre for their comments.
References 1. Brownmiller S. Against our will: men, women and rape. New York: Simon and Schuster, 1975. 2. Bill C-127. Communication and Public Affairs. Ottawa, Canada: Department of Justice, 1983. 3. Sexual offenses against children in Canada. Ottawa, Canada: Canadian Government Publishing Centre, 1984. 4. Canadian Advisory Council on the Status of Women. Ottawa, Canada: Box 1541, Station B, 1985. 5. Mackinnon C. Feminism unmodified. Cambridge: Harvard University Press, 1987. 6. Ochberg FM. Post-traumatic therapy and victims of violence. In: Ochberg FM, ed. Post-traumatic therapy and victims of violence. New York: Brunner/Mazel, 1988. 7. Lindemann E. Symptomatology and management of acute grief. Am J Psychiatry 1944; 101: 141-145. 8. Burgess AW, Holmstrom LL. Rape trauma syndrome. Am J Psychiatry 1974; 131: 981-986.
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9. Notman MT, Nadelson CC. The rape victim: psychodynamic consideration. Am J Psychiatry 1976; 133: 408-413. 10. Forman B. Psychotherapy with rape victims. Psychotherapy: Theory, Research and Practice 1980; 17: 304-311. II. Nadelson S, Notman M, Zackson H, et al, A follow-up study of rape victims. Am J Psychiatry 1982; 139: 1266-1270. 12. Kilpatrick D, Veronen L, Resick P. Effects of a rape experience a longitudinalstudy. Journal of Social Issues 1981; 37: 105-122. 13. Forman B. Treating victims of rape. Psychotherapy: Theory, Research and Practice 1983; 20: 515-519. 14. Ellis EM, Atkeson BM, Calhoun KS. An assessment of longterm reaction to rape. J Abnorm Psychol 1981; 90: 263-266. 15. Ruch LO, Leon JJ. Sexual assault and trauma change. Women Health 1983; 8: 5-21. 16. Sales E, Baum M, Shore B. Victim readjustment following assault. Journal of Social Issues 1984: 40: 117-136. 17. Feldman-Summers S, Gordon P, Meagher J. The impact of rape on sexual satisfaction. J Abnorm Psychol 1979; 88: 101-105. 18. Frank E, Stewart BD. Treatment of depressed victims an approach to stress-induced symptomatology. In: Clayton PJ, Barrett J, eds. Treatment of depression: old controversies and new approaches. New York: Raven Press, 1983. 19. Atkeson B, Calhoun KS, Resick PA, et al. Victims of rape: repeat assessment of depressive symptoms. J Consult Clin Psychol 1982; 50: 96-102. 20. Becker JV, Skinner LJ. Assessment and treatment of raperelated sexual dysfunction. Clinical Psychologist 1983; 36: 102-105. 21. Burgess AW, Holmstrom LL. Rape: sexual disruption and recovery from rape. Am J Orthopsychiatry 1979; 49: 648-656. 22. Resick PA, Calhoun KS, Ellis EM. Social adjustment in victims of sexual assault. J Consult Clin Psychol 1981; 49: 705-712. 23. Frank E, Anderson BP. Psychiatric disorders in rape victims past history and current symptomatology. Compr Psychiatry 1987; 28: 77-82. 24. Silverman DC, Kalick SM, Bowie SI, et al. Blitz rape and confidence rape: a typology applied to 1,000 consecutive cases. Am J Psychiatry 1988; 145: 1438-1441. 25. Frank E, Turner SM, Duffy BD. Depressive symptoms in rape victims. J Affective Disord 1979; 8: 101-105. 26. Girelli SA, Resick PA, Marhoeffer-Dvorak S, et al. Subjective distress and violence during rape their effect on long term fear. Victims and Violence 1986; I: 35-46. 27. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, third edition, revised. Washington, DC: American Psychiatric Association Press, 1987. 28. Rose D. Worse than death: psychodynamics of rape victims and the need for psychotherapy. Am J Psychiatry 1986; 143: 817-824. 29. Binder RL. Why women do not report sexual assault. J Clin Psychiatry 1981; 42: 437-438. 30. Libow J, Doty D. An exploratory approach to self-blame and self-degradation by rape victims. Am J Orthopsychiatry 1979; 49: 670-679. 31. Janis I. Psychological stress. New York: Wiley, 1958. 32. Symonds M. The rape victim: psychological patterns of response. Am J Psychoanal 1976; 36: 27-34. 33. Symonds M. Victims of violence: psychological effects and after-effects. Am J Psychoanal 1975; 35: 19-26. 34. Groth AN, Burgess AW, Holmstrom LL. Rape: power, anger and sexuality. Am J Psychiatry 1977; 134: 1239-1243.
35. Field HS. Attitudes toward rape: a comparative analysis of police, rapists, crisis counsellors and citizens. J Pers Soc Psychol 1978; 36: 156-179. 36. Whynot E. Principles of the sexual assault exam. Diagnosis 1987; 4: 41-50. 37. Silverman D. First do no harm: female rape victims and the male counsellor. Am J Orthopsychiatry 1977; 47: 91-96. 38. Hargot L. The sexual assault examination. Can Fam Physician 1985; 31: 775-780. 39. Cabaniss ML, Scott SE, Copeland L. Gathering evidence for rape cases. Contemporary Ob/Gyn 1985; 25: 160-178. 40. Ellis EM. A review of empirical rape research victim: reactions and response to treatment. Clinical Psychology Review 1983; 3: 473-490. 41. Frank E, Anderson B, Stewart BD, et al. Immediate and delayed treatment of rape victims. NY Acad Sci 1988; 528: 296-309. 42. Shuker E. Psychodynamics and treatment of sexual assault victims. J Am Acad Psychoanal 1979; 4: 553-573. 43. Frank E, Anderson B, Hughes C, et al. Psychoeducational intervention therapy manual. University of Pittsburgh School of Medicine and Magee-Women's Hospital. Personal communication 1988. 44. Roth S, Dye E, Lebowitz L. Group therapy for sexual assault victims. Psychotherapy: Theory, Research, Practice Training 1988; 25: 82-93. 45. Veronen L, Kilpatrick D. Stress management for rape victims. In: Michenbaum D, Jaremko ME, eds. Stress reduction and prevention. New York: Plenum Press, 1983: 341-374. 46. Frank E, Stewart BD. Treating depression in rape victims. Clinical Psychologist 1983; 36: 95-98. 47. Bassuk EL. Crisis theory perspective on rape. In: McCombie SL, ed. The rape crisis intervention handbook. New York: Plenum Press, 1980.
Resume Comme il s 'agit d'un acte de violence, I'agression sexuelle declenche chez la victime une crise vitale qui s 'accompagne de traumatismes psychologiques et physiologiques importants. Toutes les agressions sexuelles se caracterisent par I'absence de consentement mutuel. Des sympt6mes posttraumatiques apparaissent immediatement et, chez un grand nombre de victimes, it faut de nombreuses annees pour que I'integration du traumatisme s 'accomplisse. On observe la triade classique de sympt6mes de stress post-traumatique qui apparait apres une peur intense, la terreur et une perte de controle, savoir " des visions obsedantes, des souvenirs indesirables, et I'engourdissement ou le refoulement des sentiments accompagne d'un manque de concentration et d'une plus grande disposition a l'anxiete. A long terme, les effets du traumatisme se traduisent par l'anxiete, la depression, des reactions phobiques dans les situations qui rappellent I'agression sexuelle, Ie dysfonctionnement sexuel ainsi qu 'une diminution de I'adaptation sociale et de I'aptitude jouir de la vie. On passe en revue les reactions de stress posttraumatique, la symptomatologie, la psychodynamique et Ie traitement des victimes d 'agression sexuelle recente et ancienne.
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