Rape Trauma Syndrome

Not surprisingly, but unfortunately, a hearing on Capitol Hill yesterday revealed that, in the last 18 months, there have been 112 rapes reported by servicewomen in the Persian Gulf, and more reported elsewhere. Lack of medical care, incomplete investigations, and retaliation by peers for reporting were some of the complaints. Officials suggest that the number of incidents may be higher, since women may not report every event. So, it seems timely to post a brief paper I wrote on Rape Trauma Syndrome.

Analysis from Four Models of Psychopathology

Rape Trauma Syndrome (RTS) is a relatively recent name given to the suffering experienced by a survivor of sexual assault. It essentially falls within the purview of Posttraumatic Stress Disorder (PTSD). The DSM-IV defines trauma as: a person who has experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others; and that the person’s response involved intense fear, helplessness, or horror. RTS is an anxiety-related disorder resulting in the inability to adequately process the event (Foa & Riggs, 1995). This paper will explore Rape Trauma Syndrome from four models of psychopathology, provide a description of what a person would “look like” if they suffer from it, and explore models for treatment.

The four models of psychopathology present interesting perspectives from which to examine RTS. The physiological model suggests that psychopathology results from a physical aberrance within the brain which impacts cognition, affect, and behavior. In the case of Rape Trauma Syndrome, the physiological model suggests that the survivor may have had a diathesis towards this maladaptation, which the stress of the assault invoked. However, in one study, 86% of individuals who sought treatment in trauma centers had experienced at least one stressor of “high magnitude,” including rape (Foa & Riggs, 1995). Given the prevalence of this syndrome in survivors, this model is weak in its suggestion that it is an individual vulnerability. Or else it suggests that a majority of people carry a predisposition toward this response to trauma. From the perspective of this model, one might try to analyze exactly how the trauma altered the brain so as to result in Rape Trauma Syndrome (which is described below). Once one understands how the neurological responses affect the person, a medication could be prescribed as a means of restoring control to the individual.

The psychodynamic model also presents a challenge in application. Using this perspective, the survivor with RTS could be said to be coping with intrapsychic conflict which has been repressed. Following a rape, the survivor may deal with the fear, horror, and desire for revenge by repressing these. The defenses exhibited in RTS–numbing, avoidance, and increased arousal–are all socially acceptable ways of coping with the intense and potentially destructive emotions from the experience. Additionally, this model would suggest that the recurrent nightmares are a way of processing the event. In a strict Freudian sense, it might also be suggested that a rape can trigger the unresolved sexual conflicts of childhood, and that resulting sexual dysfunction may arise from this. While these theories sound possible, they do not address that fact that RTS results from an external traumatic event. It does not have its origin in childhood experiences (necessarily), and it is not solely an intrapsychic experience. RTS is a direct and intense response to a violent event.

The behavioral model offers more substance for analysis. It suggests that RTS is a learned response to the traumatic event. The survivor experiences the event of rape, which triggers the unconditioned response of anxiety, panic, fear, numbing, and so on. As a result of this event, the survivor becomes hypervigilant to her surroundings, so that all cues (conditioned stimuli) may trigger unconditioned responses. Additionally, a survivor may attempt to cope by becoming numb and avoiding reminders of the trauma.

What is challenging about this model is that some survivors experience flashbacks and nightmares, which are not purposely generated, and they are intrusive. The survivor has no control over these, and as such they do not seem to have a purpose in coping. The behavioral model suggests that learned responses provide a means of coping. However, these behaviors do not assist the survivor in coping, which the learning model would suggest.

The cognitive model is based on the idea that thinking precedes emoting and behavior. In the case of Rape Trauma Syndrome, this model suggests that the survivor’s thinking about the trauma create the symptoms. The activating event of the rape impacts the belief system, perhaps such that the survivor thinks: “I am no longer safe in this world,” which is an appraisal. Or she may also think “I did something to deserve this,” which is an attribution. The subsequent symptoms of RTS result from the powerful hold of these beliefs at the core.

The trauma itself may impact the ability to think, to remember, and to experience emotional responses. One means of coping with the trauma of rape is for the survivor to convince herself that she was responsible. As a result, she suffers shame, depression, and myriad other emotional maladies, but she retains an illusory sense of control. The other option is to acknowledge that this was an event done to her, that she did not deserve, and this would force her to recognize that she cannot control all aspects of her life. Sometimes horrible things happen to good people; to admit this is to allow oneself to experience the trauma, rage, and grief that is associated with it. Survivors who suffer from RTS are not able to do this. Their cognitive process is “jammed,” so to speak.

Description of Syndrome

It is important to differentiate between different levels of RTS following an assault. People respond to stress and trauma differently. However, most rape survivors experience definable stages of response, which can vary in length of time: acute trauma, denial/outward adjustment, and resolution. If the duration of symptoms is less than three months, the case of RTS is specified as acute. If the symptoms remain after three months, it is considered chronic. RTS can also have a delayed onset, in which at least six months have passed between the event and the onset of symptoms (DSM-IV, 1994).

General literature suggests that immediately following a rape, a survivor may: seem agitated or hysterical or may appear totally calm; have crying spells and anxiety attacks; experience difficulty concentrating, making decisions, and doing simple, everyday tasks; show little emotion and act numb or stunned; and have poor recall of the rape or other memories. As the survivor progresses into the outward adjustment stage, she may resume what appears to be a “normal” life. However, she may experience considerable turmoil, which manifests itself in the following ways: continuing anxiety; sense of helplessness, persistent fear and/or depression; severe mood swings; vivid dreams, recurrent nightmares, insomnia; physical ailments; appetite disturbances; efforts to deny the event took place or to minimize its impact; withdrawal from friends and/or relatives; preoccupation with personal safety.

Additionally, there may be: a reluctance to leave the house or go to places which remind the victim of the rape; a hesitation in forming new relationships with men or emergence of distrust with a current relationship; sexual dysfunction; and disruption of everyday normal routines, such as high absenteeism at work, dropping out of school, etc. (O’Gorman & Sandler, 1987; Scherer, 1992). However, while a survivor may experience some, all, or none of these responses, the criteria for diagnosis are more specifically defined.

With regard to RTS itself, many of the criteria used to diagnose the syndrome are similar. Following the rape, there are four categories in which symptoms must be present to make a diagnosis: reexperiencing the event; avoidance/numbing, increased arousal, and duration of symptoms. A survivor must persistently reexperience the traumatic event in one of the following ways: recurrent and intrusive recollections of the event; recurrent distressing dreams of the event; acting or feeling as if the traumatic event were recurring; intense psychological distress at exposure to cues (internal and external) that resemble an aspect of the event; and physiological reactivity upon exposure to such cues (DSM-IV, 1994).

Furthermore, the survivor coping with RTS may also persistently avoid stimuli associated with the trauma and experience numbing of general responsiveness. This can occur in the following ways (three or more must be present): efforts to avoid thoughts, feelings, or conversations about the trauma; efforts to avoid activities, places, or people that arouse recollections; inability to recall an important aspect of the trauma; markedly diminished interest/participation in significant activities; feeling of detachment/estrangement from others; restricted range of affect; and a sense of a foreshortened future (DSM-IV, 1994). Symptoms of increased arousal must be present, as indicated by two or more of the following: difficulty falling or staying asleep; irritability or outbursts of anger; difficulty concentrating; hypervigilance; and an exaggerated startle response. Lastly, the duration of the disturbance must be more than one month and must cause clinically significant distress or impairment in social, occupational, or other important functional areas (DSM-IV, 1994).

Treatment

It is difficult to restrict the categorization of RTS to one category, because in the case of this exceptionality, both cognitive and behavioral models interact. Following a rape, a survivor is traumatized both by cognitions about the event, the perpetrator, herself, and both antecedent and post-event decisions and actions. Furthermore, the event creates, in essence, a learning experience which can profoundly affect behavior. The unconditioned stimulus of the rape engages the unconditioned response of fear and anxiety, such that almost every situation can feel dangerous and become a conditioned stimulus which engages the conditioned response of RTS symptoms. In the case of RTS, a cognitive-behavioral model is the best fit. With regard to RTS, processing of the event, which involves organizing and streamlining memories, does not occur; sufferers retain disjointed memories (Foa, Molnar, & Cashman, 1995). Additionally, poor concentration and high distractibility can result in poorly organized memory records, thus interfering event processing (Foa, Molnar, & Cashman, 1995).

Studies have suggested that the disorder reflects an impairment in the mechanisms that underlie the natural decline of emotional disturbance following a traumatic event (Foa & Riggs, 1995). Specifically, the survivor’s efforts to become numb to the event, to avoid talking about it, and to dissociate from self and others generally impede emotional processing (Foa, Molnar, & Cashman, 1995; Foa & Riggs, 1995). Treatments that have been effective involved exposure. In this, the survivor is guided through a process in which she repeatedly describes the experience and relives it through her imagination. In the course of treatment, studies have shown that the narratives become longer, which may reflect the survivor’s willingness or ability to engage in the processing of the trauma as anxiety decreases (Foa, Molnar, & Cashman, 1995). Additionally, during the course of treatment the percent of thoughts and feelings increase, while the percentage of actions and dialogue decrease (Foa, Molnar, & Cashman, 1995). This suggests that as the memory becomes less threatening, there is a shift toward processing emotions and meaning and a reduction in details about the assault itself. The process of exposure can assist the survivor in overcoming the numbing, effortful avoidance, and dissociation resulting from the event. It may also involve, in due time, a visit to the scene of the assault.

Having personal experience with sexual assault, I view the treatment of survivors from an “inside-out” perspective. The first step I would take in working with someone suffering from RTS would be to establish rapport. It is vital to let the survivor know that she is now safe, that this was not her fault, and that she is believed. In this culture, people continue to view the stories of rape survivors with skepticism, which compounds the effect of Rape Trauma Syndrome. When society essentially tells her, “We don’t want to hear it and we don’t believe it anyway,” a survivor has no safe retreat in which to deal with her experience. She has no invitation not to remain shut down.

Someone coping with the aftermath of rape needs this invitation and needs to know someone will witness her pain. I would listen without judgment and be patient; healing comes on the survivor’s terms alone. I would, however, gently persist and encourage her to talk about her experience: to me, to friends, to family. In the telling, the power of the violation does retreat. It is as if one says to the perpetrator, “I will not allow you to victimize me twice.”

Following a rape, no matter the circumstance (but especially in acquaintance situations), it is easy for a survivor to accept responsibility and blame for the event. In the course of treatment, the survivor must come to a solid understanding that she did not deserve to be violated. Period. This is challenge enough. Yet Rape Trauma Syndrome compounds this, because it is as if one’s body is not one’s own. The trauma of the violation penetrates deeply. It is not uncommon to feel “normal” one day and to awake the next feeling unable to move or incapable of deciding what to wear, eat, or do next. Or to have nightmares, or flashbacks, or crying spells. The survivor does not even know when this will occur. I would expect treatment to progress unevenly.

Another part of the treatment would involve physical and sexual reintegration when she is prepared. For instance, treatment may involve receiving massages from a licensed massage therapist as a means of receiving nurturing touch from another person in a safe environment. Depending on the survivor, treatment may also involve counseling about sexuality. It is not uncommon for sexual dysfunction and body image problems to arise from the aftermath of an assault. RTS tends to create a sense of dissociation from self and others, and there literally needs to be a reconnecting of the body, mind, and spirit.

The survivor has the task of reintegrating a shattered self. The life-changing impact of such an event does not easily allow for puzzle-piece assembly. Moreover, one must come to realize that this event will revisit one in different ways for the rest of her life. I am not affected by the immediate events any longer; time and healing have created a distance. Yet I will not be surprised if some aspect of the assault emerges in the future. Healing is a gradual process, especially from an event that wields such a profound physical and psychological impact.

References

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, D.C.: American Psychiatric Association.

Foa, E. B., Molnar, C., & Cashman, L. (1995). Change in rape narratives during exposure therapy for posttraumatic stress disorder. Journal of Traumatic Stress, 8, (4), 675-691.

Foa, E. B., & Riggs, D. S. (1995). Posttraumatic stress disorder following assault: Theoretical considerations and empirical findings. Current Directions in Psychological Science, 4, (2), 61-65.

O’Gorman Hughes, J., & Sandler, B.R. (1987). ‘Friends’ Raping Friends–Could It Happen to You?. Project on the Status and Education of Women, Association of American Colleges [On-line]. Available: http://danenet.wicip.org/dcccrsa/saissues/daterape.html

Scherer, Migael. (1992). Still loved by the sun: A rape survivor’s journal. New York: Simon & Schuster.

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