WK4CH9SexualAssult

CHAPTER 9:

Sexual Assault The Scope of the Problem Be forewarned:

The statistics in this chapter are some of the most controversial and error prone reported in this book! Given the emotional volatility and cultural artifacts that undergird sexual assault, after reading this chapter we hope you’ll understand why these statistics may be so error prone. The benchmark National Violence Against Women Survey (National Institute of Justice and Centers for Disease Control, 1998) conducted in 1997 in the United States found that 1 in 6 U.S. women and 1 in 33 U.S. men had experienced an attempted or completed rape as a child and/or as an adult, using a definition of rape that includes forced vaginal, oral, and anal sex. Those statistics are probably very conservative, with other studies ranging from 10 to 15 percent of American men and 15 to 33 percent of American women (Lew, 2004; Rowan, 2006). Contrary to popular myth, these acts were not all committed by sexual perverts and deviants lurking in big-city dark alleys and nabbing unsuspecting young schoolgirls as they walked by. In 2002, 3 out of 5 sexual assault victims stated the offender was an intimate, relative, friend, or acquaintance (U.S. Department of Justice, 2003). It should not be surprising, then, that rape, sexual assault, and child sexual abuse demographics tend to mimic domestic violence statistics. In short, it is better-than-even odds that someone who knows you will be the one who sexually assaults you. Further, because most of you reading this book are sitting in a college classroom, be advised that nearly 20 percent of your female classmates will be victims of attempted or actual assault, as will about 6 percent of the men (Krebs et al., 2007). Frazier and her associates (2009) conducted an online survey that examined the incidence of traumatic events among a large and diverse population of college students. When all of the different types of unwanted sexual contact were combined, they ranked second only to unexpected death in frequency of response to trauma. The really interesting fact in all sexual assault reporting is that a great deal of it doesn’t get reported at all, so you can assume that any statistic you see is probably a pretty conservative estimate of what is really happening (Kariane et al., 2005; Weiss, 2010). This chapter will deal mainly with adult males as perpetrators and women or children as their victims. However, no one should labor under the delusion that adult males are not raped (and this excludes the stereotypes of prison sex or gay sex) (Davis, 2002; Gartner, 2005; Isley & Gehrenbeck-Shim, 1997; Mezey & King, 1998; Scarce, 1997), nor should you believe that women are not capable of some of the most heinous sexual and physical abuse imaginable upon their own children, whether boys or girls (Allen, 1991; Elliot, 1994; Gartner, 2005; Holmes, Holmes, & Unholz, 1993; Lew, 2004; Rosencrans, 1997; U.S. Department of Justice, 2000). Although the majority of assaults are perpetrated on children and females under age 25, sexual assault survivors have been identified among males and females from every segment of the population—children, adolescents, adults, and older adults (U.S. Department of Justice, 1998). An estimated 10 to 20 percent of men are sexually assaulted sometime in their lives (U.S. Department of Justice, 2000). Nor does the United States have a corner on either the rape or child abuse markets (Chen, Dunne, & Wang, 2003; Lalor & McElvaney, 2010; Sanday, 1998; Schwartz-Kenney, McCauley, & Epstein, 2001; Tomoko et al., 2002). About 103,000 children are reported as having been sexually abused in the United States out of 903,000 child maltreatment cases. The true figure is estimated to be between 250,000 and 350,000 (U.S. Department of Health and Human Services, 1997), and Finkelhor and his associates (2005) found in their national survey that 1 in 12 children they surveyed had been sexually victimized in the study year alone! Statistics in nations of Asia, Africa, and Latin America are equally grim (Chen, Dunne, & Wang, 2003; Schwartz-Kenney, McCauley, & Epstein, 2001), and in some cases horrifically worse: Children are sold into thralldom as child prostitutes or indentured servants by their poverty-stricken parents (Rowan, 2006). Underreporting The vast majority of crime survey reports do not report sexual abuse of children under the age of 12, yet we certainly see many of those children turnstiling through local child protection centers (Benedict, 1985, pp. 186–192; Brownmiller, 1975, p. 175). The literature consistently estimates that 50 to 90 percent of all rapes or attempted rapes go unreported. Most instances of incest and molestation are never reported. Further, date rapes and even stranger rapes are not reported out of shame, humiliation, guilt, cultural taboos, and the very real fear of secondary victimization at the hands of medical and legal authorities (Cole, 2006; Matsakis, 2003; Weiss, 2010). Beyond the sensationalism of religious cults that practice polygamy with young children (Bottoms et al., 2003) and Catholic priests who sexually abuse young parishioners (McGlone, 2003), it should be very clear that the kinds of sexual assaults this chapter covers are common, are underreported, and the traumatic wake they spread encompasses millions of people. David Lisek has done seminal research in this area (Lisek & Miller, 2002; Lisek & Roth, 1988). Lisek reports that in 1998 there were 1,687 reported rapes and 526 arrests made in metro Boston. If one multiplies the prevalence number from the National Violence Against Women study (Tjaden & Thoennes, 2000), the true rape incidence for the 1.75 million women living in the Boston metro area was 15,225 rapes. This disparity suggests that only 1 in 9 rapes is actually reported. The Unique Situation of Sexual Abuse/Rape Survivors Abundant evidence suggests that crises resulting from sexual abuse and rape are more intense and differ in nature, intensity, and extent from other forms of crisis (Burgess & Holmstrom, 1985; Finkelhor, 1979, 1984, 1987; Gartner, 2005; Lew, 2004; Matsakis, 2003, Rowan, 2006; Williams & Holmes, 1981). In fact, the psychological traumatic wake of rape both in childhood and adulthood marks it as probably second only to prolonged combat in potential for PTSD, and many of the transcrisis rape treatment approaches closely parallel those of standard PTSD treatment (Cloitre & Rosenberg, 2006; Frazier et al., 2001). Defining Rape There are many definitions of rape. Some are based on legal constructs; some are derived from other sources. Brownmiller (1975) distinguishes between most legal definitions and what she refers to as a woman’s definition of rape. She sees the legal definition of rape as “the forcible perpetration of an act of sexual intercourse on the body of a woman not one’s wife” (p. 380) as much too narrow and protective of male supremacy. Brown-miller’s preferred definition from a woman’s perspective is that rape is “a sexual invasion of the body by force, an incursion into the private, personal inner space without consent—in short, an internal assault from one of several avenues and by one of several methods [that] constitutes a deliberate violation of emotional, physical, and rational integrity and is a hostile, degrading act of violence” (p. 376). That definition appears to encompass the whole scope of rape, as well as other forms of sexual abuse/misuse/harassment. For the purposes of this chapter, your authors will use Koss and Achilles’ (2008) definition of rape as an unwanted act of oral, vaginal, or anal penetration committed though the use of force, threat of force, or when incapacitated; sexual assault refers to a broader range of sexual criminal offenses such as sexual battery and sexual coercion up to and including rape (U.S. Department of Education, 2011). The Dynamics of Rape The etiology of rape has roots deeply embedded in the psychosocial and cultural fabric of the particular society in which it occurs (Brownmiller, 1975; Donat & D’Emilio, 1998; Eisler, 1987–1995; Ullman, 1996a, 1996b). According to Brownmiller (1975) and Eisler (1987–1995), the cultural mechanism of male dominance constitutes the driving force in rape in all cultures. The psychosocial, cultural, and personal attitudes and responses of both males and females are important dynamics in considering the phenomenon of rape (Benedict, 1985; Williams & Holmes, 1981). Social/Cultural Factors Baron and Straus (1989) characterize rape as a social phenomenon and theorize four different causes: gender inequality, pornography, social disorganization, and legitimization of violence. Gender inequality refers to the economic, political, and legal status of women in comparison to men. Pornography reduces women to sex objects, promotes male dominance, and encourages or condones sexual violence against women. Social disorganization erodes social control and constraints and undermines freedom of individual behavior and self-determination. Legitimization of violence is the support the culture gives to violence, as portrayed in the mass media (such as television programming), laws permitting corporal punishment in schools, violent sports, military exploits, and video games. The notion of male supremacy has its roots deep in our cultural history, which has always equated the property rights of men with access to and control over the bodies of women, children, and others who are perceived as dependents (Brownmiller, 1975). Indeed, Eisler (1987-1995, pp. 153–154) describes rape and sexual assault as one of several threats widely used to ensure the continued domination and control of women. Historically, the crime of rape has been seen not as a crime against the woman but as a crime against her father or her husband (Donat & D’Emilio, 1998). Brownmiller (1975) and others have documented a part of the history of rape as a psychosocial means by which the victors in wars reward themselves and humiliate their vanquished foes. The wholesale rape and killing of helpless women and children represents the ultimate vulnerability and defeat of a people. It likewise represents the ultimate humiliation and subjugation of a person. Whether it is inflicted on thousands, as reported in war, or on one person, the purpose is quite similar—the use of unrestrained power to force the vanquished into total submission. Personal and Psychological Factors Personal and psychological factors unique to men who perpetrate sexual abuse affect both their decision to assault and the way the assault is carried out (Beech, Ward, & Fisher, 2006; Groth & Birnbaum, 1979; Lisek & Miller, 2002; Lisek & Roth, 1988; Williams & Holmes, 1981). The male offender: 1. Acts in a hostile, aggressive, angry, condescending, and domineering manner, and believes he is strong, courageous, and manly even though he often feels weak, anxious, inadequate, threatened, and dependent and believes women are inherently dangerous. 2. Lacks the interpersonal skills to make his point in society and particularly with women. 3. May need to exercise power to prove to himself and to the victim that he is powerful, omnipotent, and in total control. 4. May show sadistic patterns—the sadistic rapist frequently uses extreme violence and often mutilates or murders the victim in order to attain a feeling of total triumph over the victim. 5. Sees women as primarily sexual objects and has sexual urges that are uncontrollable and all consuming. 6. Holds stereotypical and rigid views of male and female roles with hypermasculine self-views that validate he is a “real man.” 7. Harbors chronic feelings of anger, hostility, and fear toward women and seeks to control them by his sexual “conquests.” Feminists, with good historical reason, have attempted to define rape as basically an exercise in power and control. On that basis most rapists have been cast into one of four categories: anger, power exploitative, power reassurance, and sadistic. McCabe and Wauchope (2005) found evidence to support these typologies in two studies, one of men who had only been charged with sexual assault and the other of men who were convicted, but they also found outliers who did not fit the four categories well. A number of researchers (Lisek & Miller; 2002; Lisek & Roth, 1988; Scully & Marolla, 1998; Sussman & Bordwell, 1981) have interviewed convicted rapists and have vividly demonstrated that each rapist’s reasons for assault are individual. For example: 1. Some men use rape to punish or exact revenge because a specific woman has “done them wrong.” They see all women collectively as responsible for one woman’s supposed transgressions. Some negative precipitating event with an intimate causes them to “take it out” on and “get even” with some woman who is a total stranger to them. It doesn’t make any difference who it is as long as it is a female—a generic symbol of their lost power, virility, and masculinity that they desperately want back. 2. Criminals who commit rape in the perpetration of a crime often see rape as an added bonus. It’s there for the taking, so why not? 3. For some men, rape is attaining the unattainable woman, the woman they would never otherwise have a chance with. In this instance, sex is the motivating factor. 4. For some men, rape is an impersonal experience and preferred over any demonstrated caring or mutual affection. There is no obligation, and the power, control, and sexual tension release are gratifying. 5. Finally, in its most heinous form, gang rapists see rape as recreation, adventure, and proving they are “macho.” These individuals belong to sexually violent subcultures that reflect both the rapist’s views of women and the notion that sexual conquest of as many women as possible is a critical measure of manhood. A gang rape is seen as male bonding at its height. While numerous interviewees stated they regretted their actions and were now sorry for them, the immediate impact on them postrape in regard to what they had done was slight. Ominously, if they felt anything, they generally felt good about what they did. Yet the vast majority of rapes have to do with the power relationships between men and women (Sussman & Bordwell, 1981, p. 12). Somehow the contemporary sociocultural milieu produces some males who feel such absence of power and control in their lives that they develop a need to “take it” (control). These males come to believe that it is their “right” (p. 5) and proceed to rationalize and justify their behavior, even though they have invaded and taken by force another person’s life and body. Myths About Rape One of the most difficult obstacles that human services workers face in dealing with all forms and aspects of rape and sexual abuse is the abundance of debilitating myths in society (Benedict, 1985; Burt, 1998; Ganas et al., 1999; Matsakis, 2003). For example: 1. Rape is just rough sex. The notion that rape equals sex is perhaps the most destructive myth of all. If we believe that rape is sex, then it follows that rape doesn’t hurt (physically or psychologically) any more than sex does. We can even believe that the survivor enjoys and is erotically stimulated by its roughness. Rape is violence, torture, and a life-threatening event. It is utterly humiliating, and the joy of “rough sex” has nothing to do with it. However, research indicates that certain types of rapists are aroused by the use of force and violence against victims, and such arousal may be heightened by aggressive resistance of victims (Drieschner & Lange, 1999; Knight, 1999). 2. Women “cry rape” to gain revenge. Ganas and associates (1999) hypothesize that this myth permeates our society because such myths (a) provide comfort for our social structure (people don’t want to believe that rape really occurred), (b) serve to focus the blame for sexual violence on victims rather than perpetrators, and (c) are easier to believe than the reality of knowing that rape can happen to anyone. As such it is one of the most heated and controversial issues in sexual assault. “Revenge” reports are sometimes heard, and at times the cry of “rape” has been used for secondary gain, such as getting back at a jilted lover, blackmail, job security, or covering up an unwanted pregnancy. A 2 percent rule has been used by the FBI in its training as the percentage of false accusations. Lisek and his associates (2010) found about a 6 percent false accusation rate in their investigation of rape allegations. Yet according to police reports, rapes are no more likely to be falsely reported than other crimes (Lear, 1972). 3. Rape is motivated by lust. Eisler (1995) and Scully and Marolla (1998) believe that the motivation for rape is most likely to be domination, power, anger, revenge, control, frustration, or sadism. Benedict (1985, p. 8) and Eisler (1995, pp. 237–239) report that some men may come to associate sex with violence, thereby viewing women not as human beings but as objects of prey and/or domination and viewing sex as an act of power, control, and triumph. However, one counterpoint view, based on studies of the evolutionary theories of rape by Thornhill and Palmer (2000), suggests that the motives of rapists are primarily sexual, with the exercise of power mostly a means to an end. This idea is supported at least in part by Scully and Marolla (1998), who found that some of the rapists they interviewed saw it as the only way to get sexual access to women who were unwilling or “out of their league.” 4. Rapists are weird, psychotic loners. No such contention can be supported by the research. Rapists come from every walk of life. People who rape and commit other forms of sexual abuse/misuse have been identified in every stratum of society—from judges to messenger boys, from weaklings to bodybuilders, from vagrants to corporate executives, from husbands and fathers to strangers, from partners, known friends, and relatives to unknown intruders (Benedict, 1985, pp. 9–10; Burt, 1998). The idea that rapists were mentally ill held sway for a long time (Groth, 1971) and was seen by feminists as a particularly odious way of rationalizing the male-dominated societal power and subjugation motives that undergirded and upheld a repressive, patriarchal society. The sheer number of rapes make it statistically impossible that the typical rapist is “mentally ill,” given the small number of psychopathic men in the population (Scully & Marolla, 1998). 5. Victims or survivors of rape provoked the rape or wanted to be raped, so no harm was done. By acting sexy, wearing sexy clothes or lots of makeup, being at a bar and “coming on” to a man, walking along a road alone at night, or doing laundry or grocery shopping late, somehow or other a woman does something that clearly says “Come rape me!” The bottom line is that through a series of weak inferences and rationalizations, the rapist is able to condone his sexual assault. The rapist is no longer responsible for the way he acted because the woman, by her actions, brought it on herself (Burt, 1998). Although most rapists deny that they are rapists, rationalize that women provoke or want it, or deny that their sexual assaults are rape, there are virtually no documented cases in which women have lured men into raping them. Ganas and associates (1999) and Sussman and Bordwell (1981) have clearly shown that what the survivor does before the rape has little if anything to do with the rapist’s decision to assault. 6. Only bad women are raped. This myth is one of the most blatant examples of a “blame the victim” attitude (Brownmiller, 1975). This myth is taken to mean that if the woman has a “bad” reputation, the rape is justified. The stereotypical “damaged goods” notion means that a woman who has said “Yes” once can no longer legitimately say “No.” She has lost her value (Burt, 1998). For many, the extension of this myth means that prostitutes are so devalued they have no worth at all and therefore cannot be raped (Silbert, 1988). Whether the person is a professional hooker or a minister should make no difference. Neither deserves to be assaulted, and both are entitled to equal protection and treatment. 7. Real rapes happen only in bad parts of town, at night, in abandoned buildings or lonely fields by strangers who have knives or guns and who engage in brutally beating the victims when they resist heroically—even unto death. That’s pretty much rubbish! While there are rapes that happen that way, remember that half or more of the perpetrators are someone who knows the victim. Most rapes do not involve a weapon or sustaining an injury beyond minor bruises or scratches. And most occur in either the victim’s home or the assailant’s (Burt, 1998). 8. If the woman doesn’t resist, she must have wanted it. The old stereotypical notion, which has had some coinage in the courts, is that the woman needs to resist unto death or be so physically drained or hurt that she can’t resist any longer. Resisting may get a woman killed, particularly if the assailant is armed and is more physically powerful. Furthermore, there are many psychological obstacles in the way of resisting that have to do with the historical power differential wherein women do submit. Ominously, Kassing and Prietio (2003) found that both male and female counselors in training thought that male rape victims should fight back. There is no conclusive evidence that fighting back or not fighting back is better for the victim (Matsakis, 2003). It is not easy or simple to eradicate or even to refute the preceding myths in society at large (Ganas et al., 1999). Feminists argue that it is to the advantage of the entire patriarchal society to believe such myths, and it is certainly to the advantage of the rapists (Burt, 1998). Myths about rape and sexual assault are not the sole domain of females. Here are some of the more prevalent myths about males and sexual assault (Male Survivor, 2011). 1. Boys and men can’t be willing victims. Let’s suppose that a 350-pound NFL noseguard decides to have his way with you. What do you think will happen? Boys and adult males are often physically weaker than their attackers or are threatened with weapons. Or the perpetrator may have power and control over the victim though position, influence, knowledge, and prestige. There is essentially no difference between males and females in regard to this myth. 2. Homosexuals are usually the perpetrators of sexual abuse of boys. Pedophiles are pedophiles whether it be boys or girls. They are not gays or lesbians but pedophiles who happen to have different sex and age preferences. 3. Boys are less traumatized than girls. While some studies have found boys to be less negatively affected initially, long-term effects are quite damaging, and when the perpetrators are trusted others (which is often the case, as you will read later in this chapter), they become a psychological abattoir for boys. 4. Boys abused by males will later become homosexual. How and why adult sexual orientation develops is a complex question. While being sexually assaulted by an adult is almost a guarantee for sexual role confusion, it does not mean one automatically becomes gay as a result. In fact, with males, our own experience is that a number of those who have been victimized by males become homophobic or over- compensate by attempting to prove their manhood by having sex with as many females as possible. The bottom line is, though, that at present this is only one variable in a multitude of variables that influence sexual orientation. 5. Vampire/zombie syndrome. The notion is that once you are bitten you become one. This is an especially dangerous myth because it can stereotype victims as perpetrators when the victims desperately need help rather than punishment, ridicule, isolation, and abandonment. Generally, getting psychological help early on is critical to not become a perpetrator later in life. 6. If a boy (or girl) experiences sexual arousal or organism from abuse, this means he enjoys it. We are hardwired for sex. Physical stimulation is likely to happen during sex. That does not mean the child wanted the experience, fully participated in it, or “got off” or “wanted it” as many perpetrators try to rationalize. 7. If the perpetrator is female, the boy just got lucky. This is a widely held and very, very dangerous stereotype. Some of the most disturbed clients we have seen have been children and adolescent boys abused by females in authority positions and consanguine relationships. The conflict, confusion, rage, and other extremely volatile emotions and thinking they display toward women as adults marks them as threats for harm to females. Above all, these boys should receive treatment immediately after discovery of the assault. The problem is that, even among “educated” people, these myths have remarkable staying power. Heppner and associates (1995) found that college students believed many myths about rape. That study identified many differences in men’s and women’s perceptions of rape during and after a session on rape prevention intervention consisting of didactic, video, and question-and-answer discussion. During the intervention, both men’s and women’s attitudes showed decreased belief in rape myths; at a 2-month follow-up, however, men had regained more of their former beliefs than women had. Research by Varelas and Foley (1998) indicated that both black and white college students who strongly believed rape myths were more tolerant of rapists and less tolerant of victims than those who had weaker beliefs. In addition, women with strong beliefs in the myths were less likely to report sexual assaults or to assist in legal actions against rapists. Date and Acquaintance Rape Much of the research reported on date and acquaintance rape deals with sexual assaults on college campuses. Little is known about date rape as it applies to high school students, although at this writing there were 4,000 reported incidents of sexual battery and more than 800 reported rapes and attempted rapes (Robers et al., 2010). According to a 2003 U.S. Department of Justice report, rape is the most common violent crime at U.S. universities. The incidence of rape is 35 per 1,000 female college students per year. However, fewer than 5 percent of these rapes are reported to police. Women may decline to report rape out of shame, self-reproach for drinking too much, or fear of social isolation from the perpetrators and her friends. Ninety percent of the college women who are raped know their assailants, and most rapes occur in a social situation such as partying or studying together in a dorm room (Cole, 2006). Mills and Granoff (1992) found that 28 percent of college women surveyed acknowledged that they had been victims of rape or attempted rape. In a national survey of college men and women, Koss (1998) found that 8.3 percent of the women felt they had been forced to engage in unwanted sex. Conversely, only 3.4 percent of the men felt they had forced a partner to engage in unwanted sex. Few told anyone about the encounters, although those reporting attempted rape were more likely to tell someone than were those who had actually been raped. A number of male respondents admitted to committing what is legally defined as rape and admitted to continuing to make sexual advances even when their dates had told them “No!” One of the bigger myths of rape is: Date rape isn’t really rape. The girl went out with him, didn’t she? He probably spent a good deal of money on her. What if she kissed him back and engaged in heavy petting? Then she turned him off? That’s a “prick tease”! She deserved it and probably even wanted it even though she said no. Even if it was a boyfriend of long standing, and whatever else may have happened before the rape in terms of sexual foreplay, and no matter how much money was spent, “No!” is “No!” and no one has the right or justification to rape a date. Date Rape Risk Date rape survivors in college have been found to be more likely to have experienced stress, maltreatment, and negative home environment/neglect during childhood than were women who reported no date rape experience (Sanders & Moore, 1999). Date rape participants in the Sanders and Moore study were also more likely to have experienced sexual abuse during childhood. Himelein, Vogel, and Wachowiak (1994) suggest that child sexual abuse is an underlying risk factor for both heightened sexual activity and sexual victimization in dating. Shapiro and Chwarz (1997) further suggest that precocious knowledge of sex, confusion about sexual norms, isolation, and neediness might predispose a young abuse survivor to early and frequent sexual activity, which may in turn increase the risk of dating victimization. Alcohol consumption has also been linked to date and acquaintance rape as a risk factor (Cole 2006; Norris & Cubbins, 1992). A study by Abbey, McAuslan, and Ross (1998) found that the mutual effects of college men’s beliefs and experiences with regard to dating, sexuality, and alcohol consumption increased the likelihood that a male would misperceive a female companion’s sexual intentions, and that this misperception might lead to sexual assault. In contrast, the use of a date rape drug (gamma hydroxybutyrate, or GHB) in the commission of a sexual assault constitutes a premeditated and deliberate assault (Boyd, 2000). Ullman, Karabatsos, and Koss (1999) found that both victim’s and offender’s use of alcohol prior to attack was directly associated with more severe victimization of women and that alcohol use played both direct and indirect roles in the outcomes of sexual assaults. Schwartz and Leggett (1999) found that women who were raped while intoxicated were not less emotionally affected and did not blame themselves any more than women who were raped by force while not intoxicated. It is interesting to note that most of these women did not classify their experiences as rape, although all were victims under criminal law. Norris and Cubbins (1992) found that three-fourths of acquaintance rapes involved drinking and that if both members of a dating couple had been consuming alcohol, the rape was not judged as severely as when only the woman had been drinking. In the latter case, the man was likely to be viewed as taking advantage of a vulnerable woman. Preventing Date, Acquaintance, and Other Forms of Rape Mills and Granoff (1992) and Dunn, Vail-Smith, and Knight (1999) suggest that continuing educational and support services (for both men and women) are critically needed to address, in a culturally unbiased manner, the causes and prevention of date and acquaintance rape. Educational programs, especially at the secondary school level, have been recommended as preventive measures in reducing date and acquaintance sexual assaults (Page, 1997). Ullman, Karabatsos, and Koss (1999) recommended that rape and alcohol abuse prevention efforts can benefit from incorporating information about alcohol’s role in different sexual assault contexts. It seems reasonable that such prevention initiatives should also address strategies to avoid assaults connected with the use of date rape drugs. Frazier, Valtinson, and Candell (1994) demonstrated that coeducational and interactive rape prevention programs can succeed in the short run. Their preventive interventions, presented to members of fraternities and sororities, showed that participants endorsed significantly fewer rape-supportive attitudes immediately following the interventions than did control group members. But, like Heppner and colleagues’ (1995) participants, experimental and control group members no longer differed after 1 month. Indeed, most studies of rape education programs indicate they do not hold up over time (Garrity, 2011; Vladutiu, Martin, & Macy, 2011). Hillenbrand-Gunn and her associates (2010) have taken a different approach to rape education. They conducted a program for high school students that focused on social norms theory (Perkins & Berkowitz, 1986), which is based on what one thinks one’s peers do and believe rather than what the peers actually do and believe. Their program was based on a Men as Allies philosophy and combined it with social norms theory as their theoretical framework. Group psychoeducational/discussion sessions were administered to both male and female high school students through a variety of formats that challenged sexist, coercive, and abusive behavior that is a precursor to thinking that sexual assault is acceptable. Pre- to postprogram results indicated that attitudes changed in the experimental group and not in the control group. The results of this methodologically sound experiment held at a 4-week follow-up for both males and females, suggests that it holds promise as a creative approach focusing on peers, a formidable force for this age group. Clearly, the research indicates that rape prevention programs should be comprehensive and ongoing, rather than programmed as onetime interventions. Finally, studies by Sawyer, Pinciaro, and Jessell (1998) on the effects of coercion and verbal consent on university students’ perception of date rape concluded that, in an act legally defined as rape, male students are generally more prone to deny that a rape occurred unless an assertive or aggressive “No!” is verbalized by the potential victim. The value and effect of profoundly verbalizing “No!” in situations in which women are vulnerable to rape cannot be overestimated. Perhaps even more disheartening, Kassing and Prietio (2003) found that male counselors in training who had no experience working with sexual assault victims were willing to believe myths about male rape victims, and both male and female counselors in training believed that the male victim should have resisted more. The conclusion with regard to training therapists is clearly that they need to be disabused of some myths about sexual assault! Intervention Strategies for Rape and Battery: The Case of Melody Melody Swanson is a 50-year-old teacher. She has been living alone in a small house since the younger of her two children went away to college 2 months ago. Melody was divorced 7 years ago. She had a long weekend off from school and decided to go away to a casino for a mini-vacation. When she returned home from her trip at 9:30 yesterday evening and emerged from her car in her driveway, she was met by a gunman in his middle 20s. She dropped a small bag of groceries and some items from her purse as she was abducted at gunpoint and forced into the gunman’s car, which was parked on the street. Melody was beaten, driven away to an isolated area several miles from her home, raped, beaten again, robbed, and abandoned, bleeding and bruised, with her clothing in shreds. She was weak and dazed, but managed to find her way to the nearest house in the early hours of the morning, where she called for help. It is now 8:30 a.m. and Melody is at the trauma center of a hospital in a large metropolitan city, where she has just been taken by the police. Melody is experiencing physical and emotional trauma. She personifies a traumatized person. She is in shock, shaking and trembling, has both eyes black, numerous contusions, abrasions, and cuts, and is still in the muddy clothes she was abducted in. She is about to meet what will become a very important person in her life—a crisis worker from the local sexual assault and domestic violence center who specializes in rape cases. Immediate Aftermath In most situations the most helpful and appropriate immediate response from a crisis worker is empathy and assurance that the survivor is still alive. Nowhere in crisis intervention is it more important to provide the core facilitative conditions of building trust, displaying unconditional positive regard, using empathic listening and responding, providing concreteness and clarity, and demonstrating patience. The crisis task is predispositioning the client in regard to what she is going to go through, from vaginal examinations to police questioning to the acute stress symptoms that are likely to follow the initial onslaught of emotions she is now experiencing. The worker is going to quickly build what in the psychotherapy trade is called a working alliance. Melody’s rape is a case in point of how this operates in the immediate aftermath of a trauma. Cloitre and her associates (2004) report that building this alliance is as critical as, if not more important than, mastery of any intervention techniques. The impact stage (Matsakis, 2003, pp. 82–90) occurs during the assault and for approximately 2 weeks following it. During this time a kaleidoscope of emotions, thoughts, and behaviors may occur, or conversely the client may be in a state of shock and dissociation, with both physical pain associated with the sexual assault and dissociation, somatic reactions, hypervigilance, nightmares, and startle responses that are symptomatic of the acute stress disorder that often follows. Stability both from a physical and psychological standpoint are critical at this time (Briere & Scott, 2006, pp. 273). It is the crisis worker’s job to do a number of things as soon as the client comes into the hospital or the crisis center. Some sense of control needs to be restored so the client can go through the physical exam and police report. Paramount is restoring a sense of safety and security to a person whose world has just been turned upside down. To do this, the crisis worker must accurately assess the client’s state of mobility and equilibrium and gently but also with assuredness and confidence enter into this upside-down world. The worker needs to gather information while walking a therapeutic tightrope between sensitivity and the need to ask specific behavioral closed-ended questions. Maximum sensitivity means using empathic prefacing statements followed by gathering behavioral information on the assault. To ask for information without voicing sincere concern for the person’s trauma is not only callous and insensitive, it will most likely terminate intervention before it starts (McCart et al., 2009). To that end, it is critical that the crisis worker immediately start the Predisposition task of our crisis intervention model. Courtois and Ford (2009) propose the following capstone statement in regard to treating survivors of prolonged complex trauma, but we believe it also fits well here. Your job at this point is to provide relational conditions that encourage the safety of the attachment between the client and the worker (p. 190), and this may be anything but easy for you or the client. CW: (talking slowly while she gently picks up Melody’s hand in an examining room in the ER) Hi, Melody, I’m Jolee Mabry. I am a counselor from the Metro Sexual Assault Unit. You have been through a terrible experience, that no one should ever go through, but you survived it. I can’t begin to know what it feels like to experience all the feelings and thoughts you are having right now, but I do understand as traumatic as this is you have survived and I am going to be with you while you go through this, if you would like. Melody: (looking fearful and struggling for words) I don’t… I don’t know… what to think, do,… what will happen? Where is he? Who was he ? Why me? Can he get in here? So many things… I… I am so cold and it feels like my heart is about to pound through my chest. Is this a nightmare? But I know it’s real… I think. Where… am… I? I’m so sorry. I… I… I don’t remember your name. Who are you? CW: (Picks up a blanket and gently pulls it around Melody.) I’m Jolee Mabry. I am a nurse and a counselor at the sexual assault center here. You are safe here. You were brought here by the paramedics and the police. You are in the Elvis Presley Trauma Unit. I’m Jolee Mabry, a counselor here in the trauma unit. You were beaten physically by the man who assaulted you and the paramedics brought you here. You were raped and assaulted, that is very real. That’s why you are here to get taken care of, and we do a very good job of taking care of people who have been sexually assaulted. That is my job, to take care of you, steer you through this experience and act as your advocate and just take care of things for you. Do you understand what I just said and know where you are? Melody: Yes. What’s going to happen to me? (Starts to shake.) CW: (Reaches over and slowly strokes the client’s arm with her hand and holds her other hand.) I can’t say it will be pleasant, but the medical staff and police officers who deal with sexual assault here know their business. The nurse who will do the rape kit exam is a specially trained Sexual Assault Nurse Examiner (SANE). She will make it as painless as possible. You will be asked by the police to describe what happened, and there will be a number of medical procedures. As I said, I’ll be with you every step of the way, and when they are done I’ll be with you to make arrangements to see that you stay safe and do what’s necessary to get some stability and control back in your life. Melody: Absolutely, please stay. (Grabs Jolee’s hand and grips it.) It was horrible—the rape. I don’t know how I came out alive and without any broken bones. He intended to kill me. Part of the time I was in a daze. I don’t know what came over me. I must have blacked out. He may have thought I was dead. I don’t know how long I lay out there alone after he left me. I certainly didn’t fight back or protest. Look at me, I am so dirty. (Recoils in disgust.) CW: Melody, I’m so proud of you for the way you handled it. You did whatever it took to stay alive. You saved yourself, and that took courage. Whatever you did, whether it was blacking out or offering no protests, was right, because it preserved your life, and that’s the important thing right now. We are going to get those clothes off of you and get you cleaned up, but we need to get some pictures and take some samples first, so hang in there a bit longer. Melody: I feel so damn stupid. Always watchful and just let my guard down. So damn angry at me. I’d kill that bastard if I had a chance. Shoot his nuts off! Lord! Did I just say that! I don’t say things like that, but that scurrilous low life SOB… degrading… How can I go back to face my students… I feel like I’m in a sort of twilight zone. Maybe part of me did die. I’m feeling so alone and vulnerable. It’s like this whole damn thing isn’t real. It couldn’t be happening to me, but I know it is. I know I keep going back to that and all this whirl… I don’t know if I can hold it together. There is no universal response to rape. Melody represents a few of the conflicting emotions that rampage through someone who has been sexually violated. Dissociative responses are a common defense mechanism to try to bring some stability back into the survivor’s life as a whirlwind of emotions blow through survivor’s mind. The laundry list of responses that follows this dialogue represents a good deal of, but not all of the dirty emotions the client is trying to wash out of her mind. The crisis worker’s job is to continuously provide support, safety, and practical assistance. While it may seem to be minimizing and discounting the gravity of the situation to call it psychological first aid (National Child Traumatic Stress Network and National Center for PTSD, 2006; National Institute of Mental Health, 2002), that is exactly what the worker is doing. Psychological first aid comprises three primary tasks of our intervention model: predispositioning/bonding, exploration/assessment, and safety. However, how this usually gets done is anything but stepwise. Crisis workers who ply the trade in the field of sexual assault are indeed engaging in a stand-up act where they have to be quick in changing strategies and responses to meet the kaleidoscope of emotions that may range from catatonic-like shock to unbridled rage. CW: It’s really scary, the thought of losing control with all those thoughts and emotions racing around in your head, Melody, but that is common for sexual assault survivors. It may be hard to imagine, but your mind and body are attempting to get order back into what for the past few hours has been complete chaos. It’s your mind and body’s normal defensive response to a completely abnormal situation. It will pass, and to help move that process along we are going to take this piece by piece, one step at a time, until you get control back. Melody: I don’t know. I guess, but… (Pause, with apprehensive look.) I’m a teacher, I maintain control, but I just can’t seem to get a handle on this… (Starts to breakdown again with muffled sobs.) I’m so sorry, I’m such a mess, and can’t get a grip. CW: You don’t have to be sorry about anything. You are not a mess. Grief is also part of this. You have lost a lot tonight. (Sits patiently while Melody holds on and sobs quietly with her arm around her.) The crisis worker acknowledges her grief, which is a common response to the many losses the client has suffered (Matsakis, 2003, pp. 111–127). She also starts to slowly give her information about the psychological processes occurring within her as a start to developing coping skills and regaining emotional and cognitive control. It is important to start providing basic psychoeducation to clients who are experiencing extreme psychological stress (McCart, 2009). Melody is suffering from what we call peritraumatic stress symptoms. Those are traumalike symptoms that almost all persons would suffer given similar circumstances. Whether these symptoms turn into acute traumatic stress disorder, which we will discuss later in the book, or turns into PTSD will depend a lot on what happens in the next few hours and days. The worker has to be judicious in how much information on psychological coping mechanisms she gives out to avoid cognitive overload. Indeed, engaging in any formal therapeutic intervention or formal assessment in the next few days is not recommended. What is recommended is planning thoroughly for the next few hours and days to keep the client safe, supported, and stabilized. Healing from a rape requires concentration, effort, thought, and time and cannot be rushed (Matsakis, 2003, p. 14). CW: This whole procedure is going to take about three to four hours to complete. We want you thoroughly checked out in regard to not only your sexual assault but the physical assault as well. The police will interview you. Lt. Lenise Balay is going to do the interview. She and I work together a lot on these cases, and I trust her completely. She is one of the most empathic police officers I know. She will ask you some pretty pointed questions, but understand she wants to get this just right so we can catch who did this to you. You are also going to get a pelvic exam and a rape kit done. Andrea Little is a SANE nurse who specializes in doing this. It won’t be pleasant, but again she is a specialist in this business and will be very thorough and gentle. I’ll be with you every step of the way. Okay? This is a brief synopsis of the practical medical and legal information the worker gives the survivor. In rape cases, thoroughly explaining what is going to happen is critical to not secondarily revictimizing the survivor. CW: (after the police lieutenant and SANE nurse are done) Excellent! Dr. Zanzar has gone over all your tests and has okayed your release. You got through that well. Where would you like to go and who would you like to be there with you, someone you really trust? Melody: Well, my brother, Tom. I’d want him there with me. He’s an ex-Marine. Although I don’t know how he’d feel about all this and his stupid sister who he’s always yapping at to be more vigilant and careful. God! I just feel so ashamed to let him know this happened. But I don’t know if I can go back in my driveway or not. That’s ridiculous but it still scares me, just the thought of it… CW: I understand how you could feel that way, and the last thing you want to do is tell him about this. Would you like me to call him and get him down here and talk with him? I have done this before and I think I can help you out with that. Using Support Systems and Stopping Secondary Victimization. In the immediate aftermath of the rape, getting support and safety measures in place is a high priority, as is educating the significant others in the survivor’s life to the foregoing dynamics. A critical component is steering the person through the medical and police procedures that can have a high potential for secondary victimization (Howell, 1999; Ochberg, 1988; Pauwels, 2003). Secondary victim crisis intervention may also be necessary if there are persons in the support system who might either become homicidal or turn on the survivor and blame her (Pauwels, 2003). Particularly husbands, fathers, and boyfriends may need very firm, clear instructions on how they are going to meet the survivor in their first encounter. The difficulty of this initial encounter after the rape cannot be overemphasized. Both from the survivor’s and significant others’ standpoint, it may be very easy to affix blame as a way of trying to make sense out of what happened. Secondary victimization must not be allowed to occur, so the crisis worker’s job will be to educate the significant others on how they can best support the client. Therefore, it is extremely important that a counselor from a rape crisis or sexual assault unit be contacted immediately, as in the preceding example. A nationwide nursing service called the Sexual Assault Nurse Examiner (SANE) program provides specially trained nurses for first response medical care and crisis intervention. The SANE program provides comprehensive and consistent postrape medical care, such as emergency contraception and sexually transmitted disease prophylaxis, documents forensic evidence accurately, provides expert testimony, promotes psychological recovery, and coordinates multiple service providers to provide comprehensive care for rape survivors (Campbell, Patterson, & Lichty, 2005). CW: (Meets brother Tom at the center reception desk.) Tom: (excited, agitated, and loud) What’s this all about? What’s going on with my sister? What’s she doing at the Rape Crisis Center? Is she in trouble? Did she get raped? WHAT THE HELL IS HAPPENING AND WHERE IS MY SISTER? CW: Your sister has been beaten and sexually assaulted and… Tom: What the… where did it happen ? CW: In her driveway, about 9:30 last night. She was just coming back from the casino. Tom: Casino! What the hell was she doing at the casino? Jesus Christ, when I get hold of her… CW: (Becoming assertive and using a well-modulated but commanding voice, immediately interrupts his ranting.) I understand that you were in the Marines, so tell me this. Is it the Marine Corps creed if a guy gets wounded to go yell at him and tell him how stupid he has been? Tom: Well no I… um… but this is different. CW: Tell me how so. You took care of your wounded buddies, didn’t you? What was your rank anyway? Tom: Well, uh … Master Sergeant. But, uh … I don’t see what that’s got to do with it. CW: (well-modulated but clearly assertive) I’ll tell you what, Tom. I didn’t get a chance to introduce myself. I am Jolee Mabry, a counselor and nurse with the sexual assault center. I was a nurse in the Gulf War, wore the Eagle, Anchor, and Globe (Marine Corps insignia) myself. First Lieutenant Mabry, USMC retired, at your service. I served in Saudi Arabia and Iraq with mobile surgical units there. If you are as good a marine as I think you are, you retrieved your wounded and did everything possible to keep them alive and safe, did you not? Is that correct, Master Sergeant Swanson? Tom: (sort of snaps to attention and in a rather tentative voice) Yes, ma’am. That is… uh… affirmative, ma’am. CW: Good, so you have a wounded sister. You know about PTSD, right? We don’t want her going out on a date with that now, do we? What she needs is all the care and support you can give her, don’t we now? No blame, no fault finding, don’t you agree? No going out hunting the bad guy because your job is taking care of your troop, and your sister is surely that and more, is she not? A lot of care and understanding, compassion and empathy, for the terrible combat experience she has been through, and make no mistake, it is indeed that. So, Master Sergeant Swanson, can you take this mission on, or do I get somebody else? Tom: Yes, Lieuten… uh, er, ma’am. I can certainly do that. CW: Semper Fi. Now go in there and take care of your sister. Hold her and tell her how much you love her and take her home. Also tell her how brave she was and how smart she was to survive this. You cannot give her too many “way to go’s”! Got it? I’ll be in touch with both you and her. Here’s my card. If you need help, call me. Marines look out for one another. I’ll be back with you two after you spend some time together. Tom: (sheepishly, wringing his baseball cap in his hands) I am sorry for my initial behavior, ma’am. I was pretty wound up. I am squared away now. Thank you for straightening me out, I won’t mess this up. Secondary victimization of a rape victim is always close at hand. It is certainly not uncommon for relatives to become angry and blaming of the victim when they are confronted with news of a rape as they seek to get control over what they perceive as an uncontrollable situation. The crisis worker changes her approach as soon as she detects the brother’s negative attitude and becomes very directive with lots of “I” assertion statements to get the brother’s attention. She lays something of a guilt trip on him to get his attention and change his cognitive sets about what needs to happen. She uses a technique that we would generally be critical of, but works well here. That is, she uses a number of negative interrogative statements (“Don’t you think/agree?”) that ask for agreement with her point of view. By doing so, she shifts focus to positive rather than negative support for this wounded survivor. Although you are probably not a marine nor usually would by chance meet a survivor’s brother who was, the crisis worker manifests the best of creative and adaptive thinking to create a bond and reframe this in terms he can understand. Although he is not now an active sergeant, she knows that once a marine always a marine and that’s why her responses aren’t to “Tom” but “Sergeant Swanson.” That’s an all-star performance which goes to the heart of the adaptability that great crisis workers have. CW: (Reenters the room with Melody and Tom.) You’re going to have a lot of different reactions to this. They are not the same for every person, so don’t be alarmed if you have some and not others. We will talk about all of this when things settled down. People have lots of different ways of coping with this. The main thing is for you to feel as safe and secure as you can. I am going to give you a number that is on call 24 hours a day. Do not feel guilty about calling. I am going to be your main contact from the Center, so don’t be afraid to call me. I will be doing some checking in with you, if that is okay. The crisis worker’s intuition is right when she guesses that the place of safety and comfort for Melody would be her own home but that the frightening part would be getting past the place in her driveway where she was abducted. The crisis worker is also correct in reassuring Melody for her actions, which brought her out alive. Clients will immediately begin second-guessing themselves as to what they should have done and negative emotions of guilt, shame, and embarrassment will start building (Courtois & Ford, 2009, p. 188; Matsakis, 2003, pp.118–119; Weiss, 2010). The crisis worker dispels this notion by clearly and empathically stating that what she did was just right because it got her through the ordeal and out the other side alive. If she is able, the crisis worker immediately starts education in gentle and small doses. Primary education concerns getting the client through the next 24 hours, which are indeed going to be unreal for her. Her brother is a critical support and will need to be given some primary education about rape dynamics. An important issue for rape survivors is control. Whatever will allow Melody to bring some control back in her life is important to do and is a major goal for the crisis worker. That may or may not be attempting to remember details of the assault. She may want to take a long, hot shower, or just sleep. Melody has experienced an emotionally draining loss of control to the attacker, and she needs to be reassured that her loss of control is neither total nor permanent. She did what she had to do to survive, and that took courage. It is important to her for others to recognize her and give her credit. There is no wrong way to survive a rape (Howell, 1999)! Non-judgmentalism and support are critical so that the client immediately starts moving from victim to survivor status (Ganas et al., 1998). Responses. Women may exhibit a wide variety of responses to the rape and the subsequent recovery process (Benedict, 1985; Matsakis, 2003, pp. 81–98; Williams & Holmes, 1981). The female who is assaulted: 1. May respond by exhibiting no emotions—appearing unaffected. 2. May feel humiliated, demeaned, and degraded. 3. May suffer immediate physical and psychological injury as well as long-term trauma. 4. May experience impaired sexual functioning. 5. May blame herself and feel guilty. 6. May experience difficulty relating to and trusting others—especially men. 7. May experience fantasies, day dreams, and nightmares—vividly reliving the assault or additional encounters with the assailant—or may have mental images of scenes of revenge. 8. Will never be the same, even though most survivors, over time, develop ways to recover, cope, and go on with their lives. 9. May be fearful of going to the police or a rape crisis center. 10. May be reluctant to discuss the assault with members of her family, friends, and others because of the risk of rejection and embarrassment. 11. May become severely depressed and suicidal. 12. May be extremely angry and revenge seeking to the point of becoming lethal. The Following Three Months Rape has high potential for PTSD, depression, suicide, panic attacks, generalized anxiety disorder, social adjustment disorders, sexual dysfunction, eating disorders, dissociation, and more negative worldviews and cognitive distortions. The crisis worker must not let the client regress and retreat into the past. Blaming external factors, self-blaming, and perseverating on why the rape happened are not helpful along with the guilt of “What if-ing?” oneself to death about where one was, what type of clothing one wore, not paying attention to surroundings, and on and on (Frazier et al., 2001; Matsakis, 2003, pp. 81–98;Weiss, 2010). Follow-up, proactive, and continuous supportive therapy is essential and may include any of the following topics (Ganas et al., 1998, 1999; Howell, 1999; Matsakis, 2003; Pauwels, 2003). Critical Needs. During the 3 months following a sexual assault, a survivor such as Melody: 1. May need continuing medical consultation, advice, or treatment; she may experience soreness, pain, itching, nausea, sleeplessness, loss of appetite, and other physical and somatic symptoms. 2. May have difficulty resuming work; the added stress of the sexual assault may create too much stress in the workplace. 3. Needs to have people reach out to her, listen to her, and verbally assure her—not shun her or fear continuing to relate to her. 4. Needs the acceptance and support of family and friends. 5. May have difficulty resuming sexual relations and needs understanding without pressure. 6. May exhibit unusual mood swings and emotional outbursts, which others will need to understand and allow. 7. May experience nightmares, flashbacks, phobias, denial, disbelief, and other unusual effects. 8. May go into depression, which may be accompanied by suicidal ideation or acute traumatic stress disorder. Critical Supports. Support people can be of great help during this phase of recovery. In fact, one of the most important things a crisis counselor can do is getting and coordinating support systems in place. The recovery of survivors of sexual assault is enhanced by the empathic help and understanding of the people close to them. Whether the survivor’s support people are family, friends, associates, medical or legal personnel, crisis workers, or long-term therapists, the important ingredients in the helping relationship are acceptance, genuineness, empathy, caring, and nonjudgmental understanding (Baker, 1995; Benedict, 1985; Howell, 1999; Remer & Ferguson, 1995). These support people can help survivors of sexual assault by: 1. Understanding and accepting the survivor’s changed moods, tantrums, and so on, and allowing her the freedom to act them out. 2. Supporting and being available—but not intruding—while encouraging her to regain control and to recover her life. 3. Ensuring that she doesn’t have to go home alone (without overprotecting her). 4. Realizing that recovery takes a long time and lots of hard work. 5. Allowing her to make her own decisions about reporting the rape and prosecuting the assailant. 6. Leaving it up to her to decide whether she wants to change jobs or place of residence. 7. Responding to her in positive ways, so she does not sense that the support person blames her for “letting it happen” or feels she is not capable of taking care of herself. 8. Allowing her to talk about the assault to whomever she wishes, whenever she wishes, but not disclosing the assault to anyone without her prior consent. 9. Showing empathy, concern, and understanding without dominating her. 10. Recognizing that she will likely suffer from low self-esteem and finding ways to show her that she is genuinely valued and respected. 11. Recognizing that her hurt will not end when the physical scratches and bruises are gone—that her emotional healing will take a long time. 12. Finding ways to help her trust men again—assisting male associates (friends, coworkers, brothers, her father)to show tolerance, understanding, and confidence. 13. Encouraging female coworkers, friends, sisters, and her mother to believe in her and not avoid her or avoid talking with her openly about the rape. 14. Including her children, if she has any, in many of the considerations concerning help toward emotional recovery. 15. Referring her to sexual assault support groups for survivors and family members. 16. Recognizing that her husband, partner, or lover may develop symptoms similar to those of the survivor (nightmares, phobias, rage, guilt, self-blame, self-hate, and such) and may need help similar to that needed by the survivor herself. 17. Encouraging her husband or lover to give her time to recover, free from pressure, before resuming sexual activity and to let her know he/she is still interested in her, still desires her, but that former patterns of sex life will be resumed at the survivor’s own pace. It is important for a husband or lover to talk this out openly with her, to clear the air for both parties. The foregoing is not a grocery list to just be handed to support persons. It is something that the interventionist needs to do as part of a psychoeducation program that lets people know what to expect and works with them as they struggle through what will be a period of transcrisis events and points. PTSD. As previously indicated, rape ranks second only to combat in the potential for PTSD. Because it is a less noxious approach, your authors would first use EMDR as a therapeutic intervention. It is far less intrusive than the cognitive-behavioral approaches generally recommended. If EMDR didn’t work, then we would use a combination of the three recommended cognitive-behavioral treatments (Briere & Scott, 2006; Cloitre & Rosenberg, 2006; Courtois, Ford, & Cloitre, 2009; Foa & Rauch, 2004; Frazier et al., 2001): 1. Exposure treatment, which calls for repeated emotional recounting of the traumatic memory 2. Affect regulation, which focuses on teaching clients skills to reduce painful internal emotional states 3. Cognitive therapy, to replace dysfunctional cognitions with new, more adaptive thoughts These procedures will be demonstrated shortly in this chapter in the case of Heather, an adult survivor of childhood sexual abuse. Two supplementary therapy issues that are specific to rape need to be mentioned. First, there is the fact of opening up the old wound of the rape. Confronting the rape may be painful, but it is absolutely necessary, and the client needs to clearly understand what is going to happen. However, opening this wound, whether it be the recent rape of Melody or the old ones of Heather’s adolescent abuse, needs to be done in a carefully gauged manner. To start exposure therapy means pushing away defenses that are in place to keep the client stabilized, although that stability may be anything but healthy (Courtois, Ford, & Cloitre, 2009). However, because these defense systems are being rent asunder, sexual assault survivors have a tendency to go rather blindly in harm’s way. While therapy is occurring, they are almost a sure bet to experience transcrisis points as they form new defensive systems and coping mechanisms. As a result, it is not just the psychological safety but the physical safety