Practical And Theoretical Considerations In The Treatment Of Sexually Revictimized Women
By Marylene Cloitre, Ph.D.
NCP Clinical Quarterly 4(3/4): Summer/Fall 1994
Over the past 15 years, careful study of rape victims has revealed that the majority of women who have been raped suffer from post stress traumatic disorder symptoms quite like those of war veterans and others exposed to violent interpersonal events. Recognition of the similarity in symptoms experienced by rape victims and war veterans, and the presence of the PTSD diagnosis itself, has been important in producing a conceptual and political shift in understanding rape (1). Rape, once considered primarily a question concerning the moral character of the woman, can now be understood as a violent crime with psychological consequences for women as victims of trauma. A second equally important result is that the understanding of rape as a trauma provided the theoretical basis and impetus for the development of highly effective PTSD-based treatments for rape victims (2,3).
What We Know About Revictimized Women
A more recent issue concerns the role of childhood abuse in the presentation and treatment of the rape survivor. Studies of community and clinical samples have indicated that of women reporting a history of sexual assault, those with both childhood and adult assault, make up the largest group of victims, with relatively smaller numbers reporting only one or the other type of assaults. Despite the fact that revictimized women represent the largest subgroup of sexually assaulted women, little is known about their psychological functioning nor whether the treatments we now have for rape survivors are the most appropriate and effective for them.
Preliminary data at our trauma clinic comparing a small sample of revictimized women (n=24) to those presenting with only adult sexual assault (n=12) indicated that the rates of PTSD were equivalent across both groups with 90% of the revictimized and 100% of the women with only adult sexual assault meeting criteria for PTSD. However, the revictimized women experienced greater frequency and severity of avoidance and arousal symptomatology. Of further importance, the revictimized women presented with much greater dysfunction in the areas of interpersonal and self functioning. They reported significant interpersonal difficulties specifically in the areas of assertiveness, trust, control and responsibility (took too much responsibility for others). In contrast, women with only adult sexual assault showed relatively mild difficulties in these areas compared to normative data. Reports on self-functioning revealed similar patterns with revictimized but not adult rape survivors experiencing clinical levels of dissociation and affective dysregulation. Lastly, revictimized women were more likely to have been raped more than once in adulthood and to have experienced other forms of interpersonal victimization such as assault and robbery.
Treatment Considerations
These differences lead to significant considerations and difficulties for the clinician. The major concern, of course is that revictimized women will become victims yet again and that treatment ought to address this potential problem. The problem is difficult to tackle because it is unclear what patterns of behaviors and symptomatology contribute to vulnerability to revictimization. Furthermore, concern about future victimization is set side by side with the presence of acute PTSD symptomatology. In our clinical work, we have generally taken the approach of first focusing on the PTSD symptoms, using traditional cognitive-behavioral techniques and only later directly focusing on issues, such as patterns of interpersonal functioning that may be related to vulnerability to revictimization.
The course of treatment is not as linear, orderly or as modular as it may appear. First, difficulties with trust, assertiveness and control are not static but are felt and experienced in the client-therapist relationship from the very first meeting. Efforts to engage the client in "homework" or other exercises are useless or will backfire if some time is not spent on directly addressing the client in a discussion about the interpersonal and collaborative nature of the therapy that lies ahead. Requesting and responding to a client's thoughts about an exercise or a general treatment approach is a prerequisite to beginning the work. This intervention has three goals. First, it provides the client with an experience of collaboration in an explicit way and can begin to lay down the foundation of a trusting therapy relationship. Second, it tells you more about the client's interpersonal expectations in the therapy relationship and can guide future interactions towards the goal of maximizing therapeutic benefit.
Thirdly, it can shape an intervention in a way that is "tailor made" for the individual and thus heightens its therapeutic value. For example, a revictimized woman was given the assignment, as the treatment approach required, of writing a narrative about her adult rape. The following week, the woman returned literally trembling in fear and rage at the therapist for having required this assignment. The client then revealed that the severe physical and sexual abuse she experienced by her mother occasionally involved making her write poetry about specified topics. This inadvertent (and at this point) un-therapeutic "reliving" of her traumatic history could have been avoided if the therapist had attempted to elicit the client's reaction to this assignment in the previous session. The therapist and client worked together to identify an alternative way to complete the narrative. The client found tape-recording her narrative feasible and was thus able to use the assignment to her benefit. If the therapist had made an inquiry in the earlier session, this decision could have been made then and avoided a rupture in the early phase of the therapeutic relationship. In general, treatment of revictimized women requires that the therapist be highly sensitive to the client's emotional states and reactions and flexible about shaping the interventions according to the client's abilities. Given these additional concerns, treatment of PTSD symptoms among revictimized women may require more time than that for women assaulted only in adulthood.
The second phase of treatment may begin to focus on identifying risk factors for future victimization. As indicated above, the treatment process is not strictly linear. First, the alleviation of the PTSD symptoms which have been the focus of the earlier part of the treatment may directly contribute to reduced risk of revictimization. PTSD symptoms such as poor concentration, hypervigilence and irritability may impair judgments about and reactions to dangerous environments and individuals. Second, this phase of treatment capitalizes on the interpersonal relationship that has been established between the therapist and client in the preceding sessions. Ideally, both therapist and client have engaged in shifting and complementary assertive and yielding behaviors with good (and measurable) outcome: the client's decreased symptomatology. The client-therapist relationship has hopefully begun to provide an alternative model of how interpersonal relationships may proceed with a positive result. This helps to disconfirm the client's "pathogenic" beliefs about themselves in relationship to others, many of which we believe may put them at risk for revictimization. The goal of this phase of treatment is to clearly identify maladaptive (revictimizing) schemas, formulate alternative schemas and apply the newly hypothesized schemas both within the therapeutic relationship as well as outside of it. In this sense, the second phase of treatment includes an interpersonal/experiential as well as a cognitive therapy component.
How Does Revictimization Happen?: An Interpersonal Schema Approach
Our attempts to understand revictimization are, thus far, a blend of the systematic information we have obtain from revictimized women, the results of our preliminary treatment work and the theoretical contents of interpersonal schema theory (4) which has its origins in the work of the John Bowlby (5). The theory has allowed us to make predictions about the constellation of symptoms we expect to find in revictimized women and to provide an explanation for their behaviors. We hope that this will ultimately serve to expand our repertoire of clinical interventions and to identify the most effective interventions possible for this large and as yet under-served population.
Bowlby and others have assumed that a child has a biologically-based need to establish an attachment with a carefigure to satisfy basic survival needs (e.g., safety, nurturance). One way in which attachment is maintained is through interpersonal schemas which represent the various interactions the child has experienced with a caretaker. In their most sophisticated formulation, these schemas can been understood as contingency statements used to guide future interactions with the caretaker that will maximize satisfaction of survival needs primarily by ensuring the love of the carefigure(s) (e.g., "If I do well in my chores, I will be loved"). When the caretaker is also an abuser, the schemas are inevitably shaped by this reality (e.g., "When daddy touches/hurts me, he is happy with and loves me). The abused child views being abused as a contingency for being cared for and loved.
Because schemas are relatively stable over time, the belief systems learnt in and adaptive to an abusive environment are automatically applied to other environments. This may create risk for revictimization. The expectation that abuse is inevitably linked to and elicits caring is likely to lead to acceptance of abusing relationships and difficulty in forming non-abusive relationships. Furthermore, there is some indication that incestuous homes are highly rigid and limited in the types of interpersonal interactions that occur, thus the abuse survivor may not only have negative schemas to work from as an adult but also have a world view which suggests to her that there are only few ways to interact with people. Treatment of the revictimized women means not only identifying and reformulating maladaptive schemas but expanding their repertoire of interpersonal beliefs, expectations and behaviors. Because revictimized women may have relatively impoverished interpersonal histories, the interpersonal/experiential aspect of the treatment may be key in having them go beyond mere survival to a capacity for enduring warm and loving relationships.
The above analysis provides an explanation for the risk of revictimization among acquaintances. The explanation for the increased presence of assaults by strangers taps into a different aspect of interpersonal schema theory. Many developmental psychologists have noted that the caretaking relationship is the context for the development of a sense of self, including both bodily and emotional integrity. Chronic physical and or sexual abuse can negatively impact on a sense of self-integration and may lead to symptoms such as dissociation, alexythymia and poor body language. We view these three symptoms as the cognitive, affective and behavioral constellation which comprises the childhood abuse survivor's self-(dis)organization and believe that such symptoms can lead the revictimized woman into situations of risk or danger to which they are ill-prepared to respond.
The symptom constellation described above is based on the systematic data we have collected but the connection of these symptoms to adult assault is based on the experiences clients have reported. Revictimized women have reported, for example, dissociating and finding themselves in unfamiliar and threatening environments. They have also provided narratives of rapes in which they met an unknown man in a social setting (e.g. bar or party) who displayed overly aggressive behaviors but to whom they did not react with fear, or at least could not label their reaction as such (alexythymia). Many revictimized women seem to have little ability to rely on feeling states, especially that of fear to help them identify a potentially threatening situation. Overall, they appear to have a dysregulation of emotional responses: they report either not experiencing fear when warranted and/or overreacting to situations with little realistic risk. Lastly, clinical observation indicates that the body language of these women tends to be uncoordinated and without a good sense of integrity, all of which may quite accurately convey their feelings of vulnerability. Some literature on the victim selection by perpetrators indicate that the latter are highly sensitive to body language which expresses lack of assertiveness and target their victims accordingly.
Thus the interpersonal schema theory organizes two potential sources of vulnerability to revictimization. One source is the presence of negative (abusive) and rigid interpersonal schema which creates risk for acquaintance rape and other assaults (e.g. battering relationships). The other source is the presence of cognitive, affective and behavioral self-dysregulation or self-disorganization which places the women at risk for assaults from strangers. Because the interpersonal relationship is believed to underlie both sets of problems, the larger context of recovery may best be viewed as an interpersonal process. This of course is inevitable as therapy is an interpersonal experience. For example, even if an intervention is focused on improving the client's body language, the setting of the goals, and assessment about achievement of the goals is completed between the client and therapist. Nevertheless, greater sensitivity to and use of this dimension of treatment may lead to more positive and enduring treatment outcomes.
References
1. Herman, J. (1992). Trauma and Recovery. New York: Basic Books.
2. Foa, E.B., Rothbaum, B.O., Riggs, D., & Murdock, T. (1991). Treatment of post-traumatic stress disorder in rape victims: A comparison between cognitive-behavioral procedures and counseling. Journal of Consulting and Clinical Psychology, 59,715-723.
3. Resick, P.A., & Schnicke M.K. (1992). Cognitive processing therapy for sexual assault victims. Journal of Consulting and Clinical Psychology, 60, 748-756.
4. Safran, J. & Segal, Z. (1990). Interpersonal Process in Cognitive Therapy. New York: Basic Books.
5. Bowlby, J. (1969). Attachment. New York: Basic Books.
Marylene Cloitre is an Assistant Professor of Psychology in the Department of Psychiatry at New York Hospital-Cornell University Medical College and Director of the Trauma Recovery Study at the Payne Whitney Clinic in New York. Marylene specializes in the assessment and treatment of sexually revictimized women.
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