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research-article2015

VAWXXX10.1177/1077801215569607Violence Against WomenMoylan et al.

Article

Sexual Assault Response Teams (SARTs): Mapping a Research Agenda That Incorporates an Organizational Perspective

Violence Against Women 2015, Vol. 21(4) 516­–534 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1077801215569607 vaw.sagepub.com

Carrie A. Moylan1, Taryn Lindhorst2, and Emiko A. Tajima2

Abstract Multidisciplinary coordinated Sexual Assault Response Teams (SARTs) are a growing model of providing health, legal, and emotional support services to victims of sexual assault. This article conceptualizes SARTs from an organizational perspective and explores three approaches to researching SARTs that have the potential of increasing our understanding of the benefits and challenges of multidisciplinary service delivery. These approaches attend to several levels of organizational behavior, including the organizational response to external legitimacy pressures, the inter-organizational networks of victim services, and the negotiation of power and disciplinary boundaries. Possible applications to organizational research on SARTs are explored. Keywords rape, service delivery, sexual assault

Every year in the United States, more than 300,000 adult women and almost 93,000 men experience rape; more than 18 million women and 3 million men report having been raped in their lifetime (Tjaden & Thoennes, 2008). It is estimated that sexual violence costs our society approximately US$240,776 per rape (McCollister, French,

1Binghamton 2University

University, Binghamton, NY, USA of Washington, Seattle, USA

Corresponding Author: Carrie A. Moylan, Binghamton University, Department of Social Work, PO Box 6000, Binghamton, NY 13902, USA. Email: [email protected]

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& Fang, 2010) and US$261 billion per year in criminal justice, law enforcement, and social services (Clark, Biddle, & Martin, 2002; Post, Mezey, Maxwell, & Wibert, 2002). Victims of rape can experience a range of detrimental mental and physical health outcomes, including injury, unintended pregnancy, exposure to sexually transmitted diseases, depression, post-traumatic stress disorder (PTSD), anxiety, alcohol and drug abuse, and social and sexual functioning problems (Koss & Harvey, 1991). Responding to the full range of needs of sexual assault victims transcends the boundaries of any one service delivery system. For example, law enforcement investigates sexual assaults according to criminal statutes. Prosecutors authorize criminal charges and try the case in court. Medical professionals provide treatment for injuries, offer emergency contraception, and may also collect forensic evidence as part of the criminal investigation. Rape crisis advocates provide emotional support, crisis intervention, and counseling. No single discipline is positioned to provide all these services, meaning that victims often have to interact with providers from multiple service delivery systems to address the difficult aftermath of sexual assault. Seeking help after an assault can feel disjointed and confusing for victims at a time when they may be particularly vulnerable, especially if there is a lack of coordination and communication across these systems. Communities are increasingly turning to multidisciplinary, coordinated models of service delivery as a means of decreasing the fragmented nature of care for rape victims. Coordination is expected to increase the quality of services provided, lead to higher victim satisfaction with services, and culminate in better outcomes in rape cases (U.S. Department of Justice, 2013). One such approach to coordinating sexual assault response across systems is exemplified by Sexual Assault Response Teams (SARTs). SARTs bring together law enforcement, prosecutors, Sexual Assault Nurse Examiners (SANEs) or other forensic/medical personnel, and rape crisis advocates to respond to victims of sexual assault in a collaborative manner. Typically, SARTs coordinate care during the acute, post-assault period, which may include medical treatment, evidence collection, and initial investigation of a criminal complaint, crisis intervention, and provision of referrals for ongoing support and services. In addition, representatives from each discipline often meet on a regular basis to monitor the community-level coordination of services for rape victims, in a fashion similar to coordinated community responses to domestic violence in some locales (Allen, Watt, & Hess, 2008). A community’s decision to adopt a SART model to guide delivery of sexual assault services is an organizational practice in that it represents a decision at the level of organizations to provide services in a coordinated manner. At its core, SART is an agreement across multiple service organizations, each with a different mission, culture, and set of practices, to work together toward a common goal of improving services for victims through better coordination. When communities implement a SART model of care, agencies serving rape victims must change at the organizational level. For example, organizations may need to commit resources to the SART (e.g., providing staff time for attending SART coordination meetings) or adopt new procedures (e.g., hospitals agreeing to call rape crisis advocates when victims present at the emergency department). To improve the coordination and delivery of services,

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organizational theory and research approaches need to be integrated into research on SARTs. Our purpose is to describe three approaches to investigating organizationallevel factors that could strengthen research on SART functioning, namely, how organizational behavior is shaped by external pressures for legitimacy, the structure of inter-organizational networks, and the inter-disciplinary negotiation of conflict. These three approaches were derived from an evaluation of current research on SARTs from which we identified key organizational concepts that have the potential to help us better understand SART functioning; we present this SART-specific overview first. We then describe each of the three identified approaches to organizational-level research, and end with a discussion of how these theories and methods could generate new understanding of the mechanisms that explain the workings and potential effects of SARTs on psychosocial and legal outcomes for victims.

Research on SARTs Two historic and contextual forces have shaped the organizational landscape of services for sexual assault victims and are particularly relevant for understanding the emergence of SARTs. First, acknowledgment of sexual assault as a significant social issue is the result of feminist organizing that began in the 1960s, combining supportive and empowering victim services with advocacy and monitoring of the mainstream service systems that had historically failed to take seriously the issue of sexual assault (Matthews, 1994). The Violence Against Women Act (1994) built on the efforts of feminist advocates to improve the criminal justice system’s response to sexual assault and domestic violence by providing significant funding and legislative mandates encouraging communities to coordinate law enforcement, prosecution, victim advocacy, and other systems. Second, a broader social trend toward teamwork and collaboration has occurred as a means to increase efficiency and reduce redundancy in increasingly complex social settings (Payne, 2000). Business, health care, and many other sectors have taken up teamwork as a major organizing principle particularly when efforts require coordination and collaboration across service sectors or disciplines. Early predecessors of the SART model began to form in the 1970s. These initial projects generally coalesced when individuals strongly committed to improving the formal system response gathered in local communities to meet the needs of victims. Out of these meetings grew creative, grassroots attempts to collaborate across medical, criminal justice, and advocacy fields. It was not until the middle to late part of the 1990s that the concept of SART (as it is known today) received broader recognition (Office for Victims of Crime, 2011). Since the 1990s, the model has grown in popularity (for a more detailed review of SART history, see Office for Victims of Crime, 2011). There is no comprehensive central register of SARTs, so determining the prevalence of this model is complicated. One survey of SARTs reported on 257 unique teams (National Sexual Violence Resource Center, 2011), but this likely underestimates the number of SARTs because of the issues in finding and recruiting SART members to participate in research. Another factor that complicates efforts to quantify

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the number of SARTs is the lack of an agreed on definition of what qualifies as a SART. Many communities coordinate services but do not call themselves a SART. Some of these communities have longer histories of collaboration and a greater degree of coordination than those who adopt the label of SART. In this article, we use the term SART to refer to formal, coordinated, multidisciplinary models of providing care to victims of sexual assault regardless of whether a community uses the term SART (or some other acronym). At times, however, we will draw a distinction between formal SARTs and other kinds of collaboration to focus attention on the need for research that investigates the organizational contexts of service delivery models. Numerous national organizations have expressed their support for the coordinated model of service delivery offered by SARTs, including the U.S. Department of Justice (2013), and the National Sexual Violence Resource Center (2006). The Office for Victims of Crime (2011) published a comprehensive online resource called the SART Toolkit, which is designed to support communities in their efforts to coordinate services. Organizations within the network of available services for rape victims are affected by these and other historical and contemporary factors that encourage multidisciplinary models of service provision. However, we know little about how these external factors shape organizational decisions regarding service provision for victims of rape. Research investigating whether and how these community-level factors influence SART models has the potential to increase our understanding of SARTs and their ability to improve outcomes for victims in varying organizational and community contexts. When a community decides to use a SART or multidisciplinary model of coordination, organizations of service providers alter their pattern of service provision by linking and coordinating those services. Some research has attempted to explore whether more highly coordinated services are linked to better outcomes for rape victims. For example, Campbell (1998) found that the cluster of victims that reported the highest satisfaction with services was associated with communities that had more resources available and in which services were more highly coordinated. In another study, having a rape crisis advocate present when the victim received services from legal and medical systems increased the amount of services a victim received from the other systems, decreased the secondary victimization experienced by victims, and decreased the level of distress and emotional response reported by victims (Campbell, 2006). Two evaluation studies of SARTs found mixed evidence of their effectiveness in improving prosecution-related outcomes (Nugent-Borakove et al., 2006; Wilson & Klein, 2005). However, the research designs used did not sufficiently distinguish between communities that had a SANE program but no SART and those that had a SART (which includes a SANE component). A growing body of research suggests that SANE programs are associated with a range of positive outcomes, including improved evidence collection, higher rates of prosecution, and increased victim satisfaction with services (Campbell, Patterson, Bybee, & Dworkin, 2009; Fehler-Cabral, Campbell, & Patterson, 2011; Plichta, Clements, & Houseman, 2007). However, there is a need for research that differentiates whether a SART approach improves outcomes more than just the provision of SANE services alone. In addition, researchers have not yet

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identified the effects of SART models on victims, as compared with less formalized models of collaboration, or communities with little or no collaboration. Although these studies may suggest that collaboration is linked with beneficial outcomes for victims, they lack sufficient information for assessing the direction of any causal links or ascertaining what exactly is responsible for improved outcomes. For instance, communities that choose to collaborate may already be providing services in a way that benefits victims, in which case the coordination itself may reflect other underlying processes that are actually responsible for improved outcomes. Similarly, we do not know why the presence of rape crisis center advocates improves victim outcomes. Is it because of a seamless, coordinated response? Or might it be that advocates serve a monitoring role that keeps other disciplines accountable (Campbell, 2006)? Without looking at the organizational contexts through which communities structure and operate services for sexual assault victims, it is impossible to know how and why a pattern of coordinated services might improve victim outcomes. Further complicating the story of coordination, research on SARTs suggests that there is wide variation in how SART networks are structured and how they go about serving the needs of victims (National Sexual Violence Resource Center, 2006; Office for Victims of Crime, 2011). The National Sexual Violence Resource Center (2006) conducted a needs assessment of SART programs and found that SARTs vary on a number of characteristics including the disciplinary representation of SART membership, funding sources and amounts, leadership structure, meeting frequency and content, and the formality of coordination. Given the variation in SART structures and the range of other kinds of service coordination happening in communities, it is unclear how generalizable studies of one SART will be to others or to communities that choose non-SART ways to coordinate their services. Communities need sufficient evidence to support their decisions about how to structure services to victims, so research that attends to organizational contexts, including how SARTs are structured and operated, is warranted. Often evoked as a benefit of a SART approach is that coordination will streamline service delivery and improve communication between disciplines (U.S. Department of Justice, 2013). Evidence suggests, however, that conflict and tension between disciplines is a common occurrence in SARTs (Cole & Logan, 2010, 2008; Crandall & Helitzer, 2003; Ledray, Faugno, & Speck, 2001; Littel, 2001). Conflicts appear to be twofold. One type includes disputes over role definition, boundaries, turf issues, and differing statutory obligations toward victims (Cole, 2011; Cole & Logan, 2008; Crandall & Helitzer, 2003; Ledray et al., 2001; Littel, 2001). The other type of conflict includes disagreements in professionals’ understandings of rape, victims’ needs, and the desired course of action to be undertaken on behalf of victims (Cole, 2011; Cole & Logan, 2010). SART members reported that these disciplinary conflicts interfered with their ability to coordinate services for sexual assault survivors (Cole & Logan, 2010). Studies in other health and social service contexts similarly suggest that conflict between service providers decreases the team’s ability to meet their goals and negatively affects patient outcomes (Lemieux-Charles & McGuire, 2006; Tekleab, Quigley, & Tesluk, 2009). While these conflicts may be played out between individual

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responders, it is important to recognize that organizational and disciplinary structures shape the actions of those providing services to rape victims (Martin, 2005). The research cited above identifies areas of conflict and tension among SART members, but it does not fully theorize conflict or account for the structural inequality in power, status, and resources between disciplines participating in SARTs. We are left wondering why conflict persists in these teams, what effect conflict has on coordination, and how teams can effectively overcome the challenges posed by conflict. The current literature on SARTs, while a useful start for understanding some of the benefits and limits of this service design, also lacks a strong theoretical focus guiding inquiry into how and why multidisciplinary coordinated services are thought to influence victim outcomes. Existing research also fails to adequately address the organizational contexts, focusing instead on the actions of individual responders. Alternately, research has examined SART as a monolithic concept, lumping together SARTs from several communities without attending to their similarities and differences. Further investigation of SARTs should build on theories capable of providing insight and explanation into the effects of using multidisciplinary coordinated service models to respond to the needs of rape victims. Organizational theories have the potential both to provide new insights about SARTs and to address the lack of adequate attention to organizational characteristics that shape services for rape victims. Based on what is currently known about SARTs, three domains of organizational theory could provide fertile ground for research aimed at better understanding the potential of multidisciplinary coordination to improve outcomes for rape victims. First, the rapid growth of communities adopting SART models and the enthusiasm with which the concept has been embraced combined with sparse empirical literature raises questions about whether communities are facing increasing external pressures to adopt SART to legitimize their operations without sufficient information about how to most effectively design the coordinated response. Second, the variation in structural patterns of coordinated relationships documented in a survey of SARTs (National Sexual Violence Resource Center, 2006) suggests a need for theory and research to help understand whether and how these network variations matter in terms of outcomes for victims. Finally, the documented, and apparently common, experience of conflict within SARTs suggests a need to better understand how disciplines structure responders’ understanding of victims and their needs and, more importantly, how disciplinary differences are negotiated within the context of a coordinated response.

Role of External Legitimacy Pressures Numerous theories suggest that organizational behavior is driven by factors that come not from inside the organization or local community context, but from the external political, social, and economic environments in which organizations are situated (for a review of these theories, see Hasenfeld, 1992). In the past few decades, a move toward working in teams has coincided with a policy shift encouraging coordination among services for victims of violence. As coordination across service sectors becomes “best

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practice,” communities may face increasing pressures to adopt SART to keep pace with the most current developments in the field. One useful theoretical framework for understanding the effect of external pressures on organizational behavior is called new institutionalism. New institutional theory posits that as an organizational field (a discipline, industry, field of practice, group of similar organizations) matures, it develops a shared set of standards, norms, and values that come to define that field and to which all organizations in the field subscribe (DiMaggio & Powell, 1983). As an example, rape crisis centers tend to have a common set of beliefs (such as that victims deserve non-blaming, empowering support) and practices (such as maintaining 24-hr crisis lines, counseling, and legal advocacy services; Martin, 2005). According to new institutionalism, organizations within the field are seen as legitimate when they comply with these established norms and values. Legitimacy allows organizations access to needed resources like funding and public support, and therefore, organizational behavior is shaped by the need for organizations to legitimize themselves to survive and thrive (Hasenfeld, 1992). Organizations experience a variety of pressures to demonstrate their legitimacy. Coercive pressures include government regulations of an industry and standards set by a funder that must be met to receive funding. Normative pressures are those that involve shared values or norms in the organization field. Mimetic legitimacy pressures demand imitation of organizations perceived to be leaders in the field (DiMaggio & Powell, 1983). These legitimacy pressures lead to isomorphism or the tendency of organizations within the same field to converge or begin to look more similar. As a new idea or organizational form gains legitimacy, organizations face increasing pressure to adopt the innovation to maintain their legitimacy. While motivated to behave in accordance with the established norms, organizations also attempt to maintain their autonomy (Hasenfeld, 1992). This tension between legitimacy and autonomy shapes organizational practices. For example, this tension might lead to decoupling, in which the organization seeks to enhance external legitimacy by adopting a new organizational process while simultaneously insulating the work of the organization from external pressures (Meyer & Rowan, 1977). In decoupling, the organization maintains the appearance of complying with formalized, legitimated structures, while the technical core (e.g., the frontline staff) is still able to respond to daily work situations in ways that are not constrained by that formal structure. A decoupled organizational structure may be characterized by ambiguous goals, de-emphasized or mostly symbolic evaluation measures, and work activities that largely take place out of view of managers (Meyer & Rowan, 1977). An institutional theory perspective draws attention to the conditions that shape community decisions about the use and operation of SART programs. As the concept of SART has grown in popularity, it has come to be seen as a preferred way of structuring services to victims. For example, the U.S. Department of Justice (2013) published guidelines strongly supporting the SART concept. These guidelines, combined with the growing popularity of the SART model, could create pressure for communities to adopt SART as a means of maintaining their legitimacy, appearing to meet norms of practice, or even to comply with mandatory guidelines set by funders or government.

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The literature indicates that rape crisis centers already feel pressure from funders and that the field of rape crisis work has been shaped historically by its relationship with formal, government funding (Maier, 2011; Matthews, 1994). If a community adopts SART primarily in response to similar kinds of legitimacy pressures, the community may be at risk of decoupling, or of using SART on a surface level that increases legitimacy without really changing how the technical core (the police officers, SANEs, and rape crisis advocates) actually conduct their work. The result of decoupling, in this scenario, could be the adoption of SART in name only, without actually changing service delivery in a way that has the potential to improve victim outcomes. An institutional theory perspective suggests, then, that research should examine the extent to which communities adopt SART in response to legitimacy pressures, and the extent to which the adoption of SART redefines the organizational frames that have previously constrained the actions of helping professionals, a process Martin (2005) refers to as the community taking ownership of rape.

Inter-Organizational Networks While decisions about whether and how to adopt a SART model may be shaped in part by external pressures, it is equally important to investigate the structure and content of the inter-organizational networks that are affected by SART coordination efforts. SARTs are teams composed of members who represent an array of community organizations and, as such, whether the network structure of these organizations affects victim outcomes becomes an important question. A network perspective acknowledges that the decision to operate a SART occurs at the level of organizations and communities, not at the level of individuals. Law enforcement departments, hospitals, rape crisis centers, and others must change their organizational patterns and relationships to accommodate a SART model of service delivery. SARTs, then, represent a different way of organizing the network of service delivery systems for victims of sexual assault. Research on service delivery networks focuses on identifying which arrangement of community services is most beneficial to service users. For instance, Pescosolido, Wright, and Sullivan (1995) examined the network properties of different configurations of case management services for chronically mentally ill individuals. She concluded that the most effective case management systems promote a dense web of connections among all the people in the life of a mentally ill person. Similarly, Provan and Milward (1995) examined networks of community services for the mentally ill in several cities and concluded that densely connected organizational networks are most effective in maintaining individuals in community settings. The relationship between victim outcomes and the degree to which networks are driven by a central organization is somewhat less straightforward. Pescosolido et al. (1995) suggests that highly centralized case management systems that funnel all supportive services through a central case manager make clients overly reliant on the case manager instead of connecting them to their own networks of friends, family, and neighbors. Provan and Milward found that some degree of centralization is important in a network of community

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services as it provides coordination, oversight, and goal direction to the network. Provan and Milward, however, do caution against too much centralization, which has the potential to become authoritative and lower network effectiveness. Networks organized around specific goals, such as coordinating services to the mentally ill, may require some administrative oversight (or a centralized authority) to set and monitor goals and action plans (Kilduff & Tsai, 2003). This oversight may explain why loosely to moderately centralized networks appeared in these studies to be more successful than those that were highly decentralized. Martin (2005) investigated networks of community services for rape victims; she similarly concluded that denser networks were more effective in fostering a responsive climate for rape victims. Also effective were moderately centralized networks, particularly when the coordinating role was held by rape crisis advocates or law enforcement agents. Martin’s analysis suggests that communities with more coordination foster a pattern of relationships that is better equipped to serve victims, particularly when rape crisis advocates or law enforcement agents provide leadership to keep the community focused on setting and meeting goals. Martin’s analysis did not specifically examine SARTs, though she does suggest that SARTs exemplify the kind of network that is likely to lead to better outcomes for victims and communities. Examinations of network properties like those described above utilize the theory and techniques of network analysis (NA). NA is an approach that examines the pattern and structure of relationships between and among a bounded group of actors that make up a network (Durland & Fredericks, 2005). These actors, often called nodes, can be individual people with the relationships measured on a micro level, or the actors can be organizations with relationships between organizations measured on a macro level. Drawing on principles from mathematical and sociological theories, NA examines the properties of the network structure (Kilduff & Tsai, 2003) and is used to describe, often graphically, the pattern and structure of the relationships that make up a network. NA assumes that the structure of a network shapes the behavior of actors, whether people or organizations. Kilduff and Tsai (2003) describe NA as an attempt to “discern the deeper organizing principles that are assumed to produce and reproduce the structures that shape action” (p. 12). In other words, NA is concerned with understanding and explaining why a network is arranged in a particular way and how the structure of a network shapes action and possibility. Durland and Fredericks (2005) explain that NA is different from team-oriented approaches because it shifts focus from the rational choices of individuals to the more complex, context-driven patterns of relationships and information flows. NA researchers are interested in how networks are structured, what patterns shape the network, how individuals in a network relate to one another, and how information is transferred across the network. Density, as illustrated above, refers to the number of connections observed between nodes out of the total number of connections possible (Durland, 2005). Networks with a higher ratio of connections are thought to be denser. A highly connected, dense network is hypothesized to be more efficient because members of the network can access one another directly, without the use of intermediaries. Centrality refers to the popularity of an actor within the network (Durland, 2005). An

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actor with more connections to other network members would be considered more central than one with fewer connections. Centrality may be used to explore whether certain members of a network are more influential or better situated to control the flow of information within a network. Related to centrality, NA research may also uncover isolates (i.e., nodes with no connections to other network members) and gatekeepers (i.e., nodes who act as go-betweens funneling information from one part of the network to another; Durland & Fredericks, 2005). Network relationship patterns in and of themselves do not have value or meaning. Only when patterns are observed and understood within their context can we begin to consider what they mean. For example, Keating, Ayanian, Cleary, and Marsden (2007) examined discussions among physicians regarding advances in women’s health care and identified patterns in which certain actors were considerably more central than others, an observation that by itself is of limited usefulness. Examination of context revealed that central actors tended to have particular expertise on women’s health or were more accessible to their colleagues. This information allowed the authors to conclude that information about evidence-based women’s health care practices can be most effectively disseminated by targeting doctors with expertise and actors who are seen as accessible to their colleagues. SARTs, and other forms of coordination between service delivery systems, are touted as an improvement over uncoordinated models because they bring together disparate systems to deliver services in a coordinated and collaborative manner. In other words, SARTs represent a different configuration of the network of service providers interacting with victims after a rape. Non-SART communities may have a network configuration consisting of isolated service providers; if connections exist, they may be distant, tenuous, and singular. SARTs, however, may represent a denser, more connected network, one in which service delivery organizations have well-established relationships, work closely with one another, and share information. Other communities may have had informally coordinated services for years and adopt a SART model as a way to formalize and strengthen those network connections. A SART network, in theory, would contain more and closer connections and appear more web-like. Many SARTs aim to streamline service provision for victims by designating a limited number of personnel as responders. We might hypothesize that this kind of service-level streamlining is best supported by dense organizational networks in which a larger group of providers has designated processes to coordinate the flow of information between victims and service organizations. Network analysis, then, can be used to understand the network structures created by SARTs, the role of these structures in outcomes for victims, and whether coordinated organizational configurations like SART are more beneficial or more likely to bring about successful outcomes. NA concepts and techniques could be used to investigate the qualities of raperelated service networks. Are SARTs creating dense or tenuous networks? Does information flow freely? Are there more and better connections in SART models than in pre-SART or non-SART models of care? Does network mapping reveal any network idiosyncrasies that could explain network dysfunction (e.g., isolates)? Beyond description of SART networks, NA could be used to identify differences in SART network

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patterns, which can then be used to assess whether certain patterns seem to be more effective than others. It is possible that a network approach would be primarily beneficial for understanding patterns that emerge in communities characterized by numerous and complex organizational structures. However, it may be instructive to examine whether and how network structures vary between SARTs embedded in different community contexts (e.g., rural, suburban, and urban areas). This research would help us better understand the relationship between ideal network structures and the diversity of community contexts in which SARTs operate. Examining the potential network differences among SARTs may help develop theory and answer questions raised earlier in this article about whether the diversity between SARTs’ structural and operational characteristics matters. Such investigations would advance our understanding of SARTs, their promise, and their potential roadblocks, as well as have a broader impact on those seeking to understand the reality of implementing and evaluating multidisciplinary, coordinated, inter-organizational human service networks.

Negotiation of Conflict in SARTs In addition to the influence of external pressures and network structure, SARTs are also shaped by the ways that organizational contexts frame the interactions of the individual responders that together make up the team. We turn now to a discussion of how organizational analysis could help expand our understanding of the inner workings of these multidisciplinary teams. One aspect of SARTs that has received more attention from researchers is the seemingly common experience of conflict between health care workers, criminal justice officers, and rape crisis advocates (Cole, 2011; Cole & Logan, 2008, 2010; Crandall & Helitzer, 2003; Ledray et al., 2001; Littel, 2001). This conflict is typically attributed to either a lack of clarity and agreement about appropriate roles, or to differences in philosophy about rape and victim needs. Suggestions for handling conflict usually center on clarifying roles and increasing understanding of disciplinary standards of practice (Cole & Logan, 2008). These suggestions assume that conflict is a manifestation of misunderstanding and unclear expectations. While expectations may in fact be unclear, we suggest a different reading of conflict, one that sees discord as being the manifestation of a negotiation of power and difference. Cole and Logan (2008) briefly discuss power imbalances, particularly in terms of rape crisis advocates being guests at the hospitals where SARTs do much of their work, without fully exploring what this and other power dynamics mean for SART members or for victims. We propose that an organizational-level analysis can help more deeply analyze the role of power in conflict within SARTs. Power imbalances in SARTs may stem from interpersonal differences, such as demographic characteristics of team members (e.g., age or gender). However, we are interested in the connection between power and the organizational contexts in which individual responders are situated (e.g., disciplinary differences) and how such differences are negotiated. Martin (2005) argues that inadequate treatment of rape victims is not merely the result of misguided individuals but is rooted in the organizational frames adopted by different disciplines that dictate how victims should be treated. We

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similarly highlight the utility of an organizational analysis for investigating how the often stark differences in disciplines’ understandings of rape, victim needs, and best practices for approaching services for victims can compromise the ability of multidisciplinary teams to collaborate successfully. The success of teams hinges not on whether conflict occurs but on whether the team is able to successfully engage all disciplinary perspectives without marginalizing or suppressing any particular discourse (Opie, 2000). In other words, disciplinary conflict can actually represent an opportunity for learning if teams are equipped to engage across disciplines. Such engagement necessarily requires an awareness of and willingness to engage with the structural dynamics of power present in the team. If organizations and their representatives enter into collaboration on unequal footing in terms of access to power and resources and are not actively considering how this unequal power shapes their work together, an important question emerges: In what ways does the process of multidisciplinary negotiation become biased toward those who hold more power? Studies on the negotiation of power within teams have revealed several ways that the idealized view of teamwork masks complex power relationships. For example, within the surgical setting, despite rhetoric about teamwork unifying the disparate medical professions involved in surgery, teamwork actually reinforced structural inequalities in status and material resources available to members of different professions (Finn, 2008). Likewise, Bokhour (2006) examined Alzheimer’s treatment teams and concluded that despite the articulated goal to embrace multidisciplinary perspectives, the actual practice of team meetings prioritized the knowledge of certain professionals and precluded engagement with the different disciplinary accounts of patients and their needs, leaving out crucial information for serving patients. One promising research approach for exploring power and conflict negotiation involves attending to discourse within SARTs. Discourses are sets of ideas, beliefs, or ways of thinking about and understanding a particular issue (Fairclough, 2003; Gee, 2005). There are always multiple discourses of any phenomenon, and these multiple understandings are negotiated through interaction (Gee, 2005). A discourse analysis approach is well-suited to studying SARTs because it allows for explicit attention to both the multidisciplinary nature of these teams and to the role of power in shaping how discourses are produced and reproduced. Discourse analysis focuses on the different discursive representations of victims brought forth by professionals with different disciplinary backgrounds and how these various discourses are managed by the team (Opie, 2000). Four common discourses exist about a person who experiences rape: She may be simultaneously considered a victim, a witness, a patient, and a survivor. Each label not only indicates a distinct understanding of the person and her experience but also demarcates a particular discursive space (set of ideas) that is tied to certain knowledge (theories) and behaviors (skills to be used in the encounter). For example, while a SANE’s primary relationship with a rape victim is through her status as a “patient” needing compassionate care, the SANE also interacts with her as a “witness” whose story needs to be corroborated with other evidence. Furthermore, because of the criminal component of sexual assault, SANEs need to act as an unbiased investigator to

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avoid having the evidence they collect and their expert opinions discredited in the courtroom. The need to negotiate a compassionate care orientation and a neutral investigator orientation may therefore pose discursive challenges for SANEs, especially when interacting with law enforcement, and may unintentionally undermine their intended role (Rees, 2010). Each discipline faces its own internal discursive friction resulting from the philosophical orientation toward rape and the need to negotiate that orientation with other team members. Analysis of communication among SART members can identify patterns of interactions and which discourses are being used and for what purpose. For example, listening to the ways in which each professional describes the circumstances of the sexual assault victim can indicate underlying beliefs that may cause conflicts between team members. However, communication is not only descriptive but also performative; discourses are used to accomplish something (Gee, 2005). Returning to our previous example, when speaking to a police officer, a SANE may draw on the victim-as-witness discourse to build common understanding with the officer or may purposely draw on the victim-as-patient discourse to affirm her role as a medical professional uniquely qualified to perform certain tasks. One of the aims of this analytic approach is to consider not just what discourses are being used but how they are used and what they accomplish. Given that there are multiple discourses and that discourses are performative, discourse analysis is also concerned with understanding how power is enacted in communication by identifying which discourses are prioritized (made “dominant”) in a particular transaction. Several factors may play into determining which ideas about a victim come to be seen as “true.” For instance, the relative power and status of the various team members negotiating their accounts of the victim may shape what discourses are privileged in a given moment. An approach to researching SARTs that attends to issues of discourse and the negotiation of power has the potential to help us understand how teams work with victims and how coordinating services can lead to better outcomes for victims. As Opie (2000) suggests, a key task for multidisciplinary teams is to engage with and negotiate the disciplinary-specific accounts of victims. Understanding how SARTs engage and negotiate across disciplinary boundaries is essential for understanding how (and if) SARTs are successful in leveraging coordinated services into better outcomes for the victims they serve.

A SART Research Agenda Sexual assault victims who reach out for help are too often confronted with a confusing array of professionals in the criminal justice, health care, and victim services systems. These professionals have differing goals in their interactions with the victim, and unfortunately, sometimes these differences result in victims reporting that they feel “revictimized” by the people they have turned to for help (Campbell, Wasco, Ahrens, Sefl, & Barnes, 2001; Madigan & Gamble, 1991; Maier, 2008: Martin, 2005). Although SART is an increasingly popular intervention, little is known about the effectiveness of these programs in improving the response that victims receive

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when they seek help. As more communities devote energy and resources to SART models, the need for theoretically grounded research about coordinated service models becomes increasingly urgent. The three approaches to researching domains of organizational behavior reviewed here provide a potential roadmap for SART research. By no means are these the only way to study SARTs from an organizational perspective, but these approaches do build on previous research on SARTs and services for rape victims. A research agenda to improve victim experiences through changing the service delivery system would be comprised of two primary realms of inquiry. First, research should explore how organizational dynamics manifest in the context of SARTs. Second, research should investigate whether and how these organizational dynamics actually improve victims’ experiences of receiving services and their long-term outcomes (e.g., psychological well-being and social functioning). Examples of research questions that would fall under both of these realms of inquiry are described in Table 1. Both quantitative and qualitative research methods could prove fruitful in answering the organizationally framed research questions listed in Table 1. Qualitative research methods, with their focus on exploration and theory building, may be particularly well-suited for exploring how organizational dynamics manifest in SARTs. At the core of many of the research questions suggested in Table 1 is a desire to understand both how these organizational dynamics are shaping SARTs and how the relationship between organizational concepts and their manifestation vary among SARTs. Therefore, researchers may want to consider sampling methods that maximize diversity to access a broad array of perspectives about how SARTs operate. Triangulating data collection methods, such as combining individual interviews with observations of teams in action, might also help facilitate a rich exploration of how these organizational dynamics manifest within SARTs. In addition to understanding how organizational dynamics play out in the context of SARTs, researchers should also investigate how these organizational concepts influence the effectiveness of SARTs. Effectiveness of SARTs can be defined by whether SARTs change functioning on an organizational level (e.g., increase communication between disciplines), but more central and compelling are questions about whether SARTs improve victim outcomes (including health outcomes, prosecution outcomes, long-term healing, and victim satisfaction with services). Quantitative study designs may be most useful for answering effectiveness questions, such as those posed in Table 1, which seek to uncover correlational and causal relationships between organizational dynamics and SART outcomes. Given the need for increased understanding of the differential effects of various organizational-level characteristics, study designs should explicitly investigate organizational-level constructs. Understanding complex organizational processes requires looking beyond simply controlling for possible confounding factors at the organizational level to more sophisticated analytical techniques, such as examining organizational characteristics as moderators and mediators or using multi-level modeling techniques. To understand the influence of coordinated services on victim outcomes, statistical models will also need to adequately account for the complex web of factors that influence victims’

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Table 1.  Examples of Research Questions That Explore Organizational Concepts and Their Impact on SART Efficacy.

Role of external legitimacy pressures

Inter-organizational networks

Negotiation of conflict

Exploratory questions

Efficacy questions

What external pressures are influencing communities’ use of SARTs? As SART increases in popularity, do pressures to adopt SART to maintain legitimacy similarly increase? Is there any evidence of decoupling in communities that adopt SART? Do SARTs represent a different network structure than what we see in communities that are not using SARTs? How do concepts of network analysis explain some of the structural variation seen in SARTs? Are there common patterns of SART networks that can be identified? Does a SART network change the flow of information across disciplines? How might conflict within SARTs be symbolic of deeper tensions around negotiating the power to define and shape the work of serving rape victims? How do issues of unequal power, status, and access to resources shape the coordination across disciplines? Are there different ways that communities negotiate the tensions of multidisciplinary coordination?

Does decoupling negatively affect a SART’s effectiveness? Do state mandates to use a SART model increase the amount of decoupling observed? Are different patterns of network structures associated with better outcomes? Do formally coordinated networks, like SARTs, produce better victim outcomes than other more loosely coordinated networks? Are denser networks always more effective? Are some discursive strategies for engaging with disciplinary differences in power and understanding of rape predictive of less conflict and better victim outcomes?

Note. SART = Sexual Assault Response Team.

post-assault experiences, including individual-level variations (e.g., past history of trauma) and situational factors (e.g., relationship to assailant). Whatever investigational path a researcher chooses to follow, it is important to remember that it is the victims who pay the price of inadequate services, and it is the victims who will benefit most from well-designed, effective services. Research that is organizationally framed and guided by theory is positioned to elicit information that can be used to improve service delivery for victims of sexual assault. This research will undoubtedly help communities navigate the competing demands of different disciplines, create effective service networks, respond effectively to environmental pressures, and evaluate whether variations in SART practice lead to different outcomes for victims.

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Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies Carrie A. Moylan, PhD, is an assistant professor at the Binghamton University. Her current research emphasizes the promotion of effective service delivery for victims of interpersonal violence, increased understanding of the challenges and benefits of coordinating services between disciplines, and improving the community, campus, and organizational responses to victims of violence. To this research, she brings more than 7 years of experience working in sexual assault and domestic violence service organizations. Taryn Lindhorst, PhD, LCSW, is an associate professor of social work at the University of Washington. Her work is informed by 15 years of social work practice experience in public health settings. Her research focuses on organizational practices and policy implementation, especially as this relates to issues of violence against women and health. Her work has been funded by the National Institutes of Health and the National Institute of Justice. Her current

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projects include longitudinal analysis of the long-term impact of domestic violence on economic and mental health outcomes among adolescent mothers, victimization patterns among sexual minority youth, and the use of research information by policy makers. Emiko A. Tajima, PhD, MS, is an associate professor at the University of Washington School of Social Work. She received her doctorate in social work from the Bryn Mawr College Graduate School of Social Work and Social Research. Her scholarly research focuses on the impact of childhood exposure to intimate partner violence, parenting practices, immigrant and refugee populations, and methodological issues in the field of interpersonal violence research.