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CHAPTER 10
Posttraumatic Stress Disorder: Rape Trauma
Jocelyn Rowley, a 20-year-old single woman, was a sophomore at a midwestern university. She had always been a good student, but her grades had fallen recently, and she was having trouble studying. Her academic difficulties, coupled with some problems with relationships and with sleeping, had finally led Jocelyn to see a therapist for the first time. Although she was afraid of being alone, she had no interest in her current friends or boyfriend. She told the therapist that when she was doing everyday things like reading a book, she sometimes was overcome by vivid images of violent events in which she was the victim of a mugging or an assault. These symptoms had begun rather suddenly, and together they made her afraid that she was losing her mind.
Most of Jocelyn’s symptoms had begun about 2 months before she visited the university’s counseling service. Since then she had been having nightmares almost every night about unfamiliar men in dark clothing trying to harm her. She was not having trouble falling asleep, but she was trying to stay awake to avoid the nightmares. During the day, if someone walked up behind her and tapped her unexpectedly on the shoulder, she would be extremely startled, to the point that her friends became offended by her reactions. When she was studying, especially if she was reading her English textbook, images of physical brutality would intrude on her thoughts and distract her. She had a great deal of difficulty concentrating on her schoolwork.
Jocelyn also reported problems with interpersonal relationships. She and her boyfriend had argued frequently in recent weeks, even though she could not iden- tify any specific problems in their relationship. “I just get so angry at him,” she told the therapist. Her boyfriend had complained that she was not emotionally invested in the relationship. He had also accused her of cheating on him, which she denied. These problems were understandably causing her boyfriend to distance himself from her. Unfortunately, his reaction made Jocelyn feel abandoned.
Jocelyn was afraid to walk alone to the library at night. She could not bring herself to ask anyone to walk with her because she didn’t know if she could feel
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safe with anyone. Her inability to study in the library intensified her academic problems. Jocelyn’s roommates had begun to complain that she was unusually sensitive to their teasing. They noticed that she cried frequently and at unexpected times.
In the course of the first few therapy sessions, the psychologist asked a number of questions about Jocelyn’s life just prior to entering therapy. Because the symp- toms had such a rapid onset, the therapist was looking for a specific stressful event that might have caused her symptoms. During these first few sessions, Jocelyn reported that she had begun to feel more and more dissociated from herself. She would catch a glimpse of herself in the mirror and think, “Is that me?” She would walk around in the winter weather with no gloves on and be relieved when her hands hurt from the cold, because “at least it’s an indication that I’m alive.”
After several sessions, Jocelyn mentioned to her therapist that she had been raped by the teaching assistant in her English literature course. The rape occurred 2 months before she entered therapy. Jocelyn seemed surprised when the thera- pist was interested in the event, saying “Oh, well, that’s already taken care of. It didn’t really affect me much at all.” The therapist explained that serious trauma such as rape is rarely resolved by itself, and especially not quickly.When it became apparent that Jocelyn had not previously reported the rape to anyone else, her ther- apist strongly advised her to contact the police. She refused, citing a number of reasons, ranging from her conviction that no one would believe her (especially 2 months after the incident) to the fear of facing cross-examination and further humiliation. Without Jocelyn’s consent, the therapist could not report the rape because the information she had obtained from Jocelyn was protected by confi- dentiality (the ethical obligation not to reveal private communications, in this case between psychologist and client). There are some rare exceptions to this ethical principle. State laws require mental health professionals to break confidentiality and report cases of child abuse. Psychologists are also required to report clients who are imminently dangerous to themselves or others. These exceptions did not apply to Jocelyn’s situation.
Jocelyn gradually revealed the story of the rape over the next few sessions. She had needed help writing an English paper, and her T.A. had invited her to his house one night so that he could tutor her.When she arrived at the house, which he shared with several male graduate students, he was busy working. He left her alone in his room to study her English textbook. When he returned, he approached her from behind while she was reading and grabbed her. The T.A. forced her onto his bed and raped her. Jocelyn said that she had not struggled or fought physically because she was terrified and stunned at what was happening to her. She had protested verbally, saying, “No!” and, “Don’t do this to me!” several times, but he ignored her earnest objections. She had been afraid to yell loudly because there were only other men in the house, and she was not sure whether or not they would help her.
After the rape, the T.A. walked Jocelyn back to her dorm and warned her not to tell anyone. She agreed at the time, thinking that if she never told anyone what had happened, she could effectively erase the event and prevent it from having a
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negative effect on her life. She went up to her dorm room and took an hour-long hot shower, trying to scrub away the effects of the rape. While describing these events to the therapist, Jocelyn shook and her voice was breathy. She kept saying, “You believe me, don’t you?”
For several days after the rape occurred, Jocelyn believed that she had been able to keep it from affecting her everyday life. The more she tried not to think about it, however, the more times it came to mind. She began to feel stupid and guilty for having gone to a T.A.’s house in the first place, and because she had not been able to anticipate the rape, Jocelyn wondered whether her own behavior had contributed to the rape: Had she dressed in some way or said something that indicated a sexual invitation to him? She was ashamed that she was not strong enough to have prevented the rape or its negative consequences.
Jocelyn had initially believed that only one aspect of her life changed after the rape; she no longer attended discussion sections for her English course. Unfor- tunately, several other problems soon became evident. Her exaggerated startle response became more and more of a problem because her friends were puzzled by her intense reactions to their casual, friendly gestures. Frequent nightmares prevented her from getting any real sleep, and she was having trouble functioning academically. She had no further contact with her T.A. unless she saw him while walking across campus. When that happened, she would duck into a doorway to avoid him. She also began to withdraw from relationships with other people, espe- cially her boyfriend. He responded to this retreat by pressuring her sexually. She no longer had any interest in sex and repeatedly rejected his physical advances. All these problems finally made Jocelyn believe that she was losing control of her feelings, and she decided to seek professional help.
Social History
Jocelyn had grown up in a small midwestern town 100 miles away from the uni- versity. She was the oldest of three children. Both of her parents were successful in their professional occupations, and they were involved in the community and their children’s schools. Jocelyn had attended public schools and was mostly an A student. She was involved in several extracurricular activities.
Jocelyn’s parents were strict about dating and curfews. She had not been inter- ested in attending large parties or drinking when she was in high school. She did have a boyfriend during her junior and senior years. They began dating when they were both 16 years old and became sexually involved a year later. That relationship had ended when they left their hometown to attend different colleges.
Jocelyn recalled that her high school boyfriend had occasionally pressured her into having sex when she thought it was too risky or when she was not interested. She denied having previously been a victim of sexual assault, although one inci- dent that she described did sound abusive to the therapist. When she was about 13 years old, Jocelyn went to a summer music camp to play the trombone, an
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instrument not usually played by a female. One day after rehearsal, the boys in her section ganged up on her, teasing her that “girls can’t play trombones!” One boy began to wrestle with her, and in the melee placed a finger inside her shorts into her vagina. Jocelyn remembered yelling at him. The boy let her go, and then all the boys ran away. Jocelyn had never viewed that event as being assaultive until she thought about it in reference to being raped.
Jocelyn’s adjustment to college had been good; she made several friends, and most of her grades were good. She had never before sought psychological help. Jocelyn felt as if she had the world under control until she was raped by someone she knew.
Conceptualization and Treatment
As Jocelyn began to address her anxiety symptoms, additional problems were caused by other people’s reactions to the account of her rape. These difficulties kept the focus of treatment away from her primary anxiety symptoms. After telling her psychologist that she had been raped, Jocelyn began to tell other people in her life, including her boyfriend and her roommates. Her roommates were understand- ably frightened by what had happened to her, and they tried to divorce themselves from the possibility that it might happen to them. They did this by either accusing her of lying or pointing out differences between them: “I never would have gone to a T.A.’s house.” or, “You’ve slept with more people than me; he must have sensed that.” or, “You didn’t look beat up; you must not have fought back hard enough.” The absence of meaningful support from her friends fueled Jocelyn’s progres- sive withdrawal. Her anxiety symptoms became more pronounced, and she also became depressed.
Her boyfriend’s unfortunate and self-centered reaction to the description of her rape quickly led to the end of their relationship. He sought help to cope with his own feelings about her rape by talking to some mutual friends. Jocelyn had specif- ically asked him not to discuss the attack with other people she knew. Jocelyn’s general feelings of being out of control of her life were exacerbated by her appar- ent inability to contain the spread of gossip about her assault. One specific event, which would have been trivial under ordinary circumstances, led to a series of heated exchanges between Jocelyn and her boyfriend. He approached her from behind and playfully put his arms around her. When she jumped and screamed in fright, he tightened his grip, preventing her escape. After arguing about this incident a number of times, they decided not to see each other anymore.
Jocelynfinally approached her English professor and told her that she had been sexually assaulted by the T.A. The professor’s reaction progressed from shock to outrage. She recommended that Jocelyn report the attack to the appropriate campus office. Unfortunately, Jocelyn still refused. She was not ready to report her attacker to the university or to press legal charges, in part because she felt that she could not bear being in the same room with him for any reason. The professor did assign
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Jocelyn to a different T.A. so that she could continue to go to discussions for the class. She also told Jocelyn that she was uncomfortable letting thematter drop. She asked whether Jocelyn would mind if she discussed the situation with the dean and with campus police. Jocelyn agreed reluctantly, only after the professor promised not to use Jocelyn’s name in any of these conversations.
Treatment during this time focused primarily on giving Jocelyn an oppor- tunity to express her considerable anger and frustration about her situation. Jocelyn frequently railed to her therapist against the unfairness of the situation. For example, in order to deal with her fear of walking alone after dark, she was trying to find someone to walk with her. It seemed bitterly ironic, however, that she wanted a friend to protect her from violence from strangers. It was, after all, someone she knew rather well who had raped her.
Jocelyn also felt a great deal of guilt over not having been able to prevent her assault. Perhaps she hadn’t fought hard enough. Maybe she had unknowingly flirted with him. Did he assume that she knew he was inviting her to his house for sex? Was she a fool for not having recognized that implicit invitation? She also felt guilty about the effect of her situation on her boyfriend and roommates. Was she responsible for the fact that she had made them fearful and resentful?
In one session, the therapist pointed out that the intrusive images that Jocelyn now experienced while reading her English textbookmight result from the fact that she had been reading that textbook when her attacker grabbed her from behind. Jocelyn was relieved to hear this explanation, because she had worried that she really was going crazy. This insight did not immediately diminish the frequency of her intrusive images, however, and she remained frustrated and depressed.
By this time, Jocelyn’s nightmares had become increasingly severe. The con- tent of her dreams was more and more obviously rape related. The dream would begin with Jocelyn in a crowded parking lot. Then a shadowy male in dark cloth- ing would approach her, tell her he wanted to rape her, and proceed to attack her. She remembered trying to fight off the attack in her dream, but her limbs felt as if they were in thick glue and her struggles were ineffective. The other people in the parking lot stood watching, clapping and cheering for her assailant. Jocelyn would wake up in the middle of the room, crouched as if awaiting attack. These experiences terrified Jocelyn, and they also frightened her roommates.
The therapist’s treatment strategy moved to a focused, cognitive-behavioral intervention that had two main parts. The first part was to address the cognitive processes that prolong amaladaptive view of traumatic events. Specific procedures included self-monitoring of activities, graded task assignments (such as going out alone), andmodification of maladaptive thoughts regarding the event (such as guilt and self-blame) (Yadin & Foa, 2007). This part of the treatment procedure had actually begun as soon as Jocelyn entered therapy. It was continued in parallel with the second part of the therapy, which is based on prolonged exposure.
In prolonged exposure, the victim reexperiences the original trauma in a safe situation to decrease slowly the emotional intensity associated with the memory of the event. This step is based on the notion that repeated presentation of an
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aversive stimulus will lead to habituation (defined as the process by which a person’s response to the same stimulus lessens with repeated presentations). Jocelyn had, of course, experiencedmany fleeting and terrifying images of the rape during the weeks after it happened. This form of “reliving” the traumatic experi- ence is symptomatic of the disorder. It presumably does not lead to improvement in the person’s condition because the experiences are too intensely frightening and too short-lived to allow negative emotions to be processed completely. In the therapy, Jocelyn was asked to relive the rape scene in her imagination. She described it aloud to the therapist in the present tense. The therapist helped Jocelyn repeat this sequence many times during each session. The sessions were recorded on audiotape, and Jocelyn was required to listen to the tape at least once every day.
As the end of the semester approached, Jocelynwas able to resume her studies. This was an important sign of improvement. Flunking out of school would have been the ultimate proof that the rape had permanently affected her life, and she struggled not to let that happen. She ended the semester by passing three of her four classes, including English. Therapy was terminated somewhat prematurely after 16 sessions (twice weekly for 8 weeks) because the semester was ending, and Jocelyn was going home for the summer. The psychologist could not convince her to continue therapy during the summer, although she still suffered from occasional nightmares and other symptoms. Jocelyn refused to see a therapist in the summer because she would have to tell her parents, and she was not ready to do that.
A follow-up call to Jocelyn when she returned the following spring, after hav- ing taken a semester off, revealed that Jocelyn had finally told her parents about the rape. They were much more supportive than Jocelyn had anticipated. She had con- tinued treatment with another therapist, and her symptoms had diminished slowly over time. She now had nightmares only on rare occasions, and they were usu- ally triggered by a specific event, such as viewing a sexually violent movie or when someone physically restrained her in a joking manner. Jocelyn decided not to return to therapy at the university’s counseling service, saying that she was tired of being preoccupied by the rape. She believed that it was time for her to concentrate on her studies.
Ten-Year Follow-up
Jocelyn performed well in school and on the job in the years following her rape. She completed college and then earned her master’s degree in library science. She enjoyed her work as a librarian at a small college in her hometown. Her social life recovered more slowly. Jocelyn experienced residual symptoms of posttrau- matic stress disorder (PTSD) intermittently for several years. She no longermet the formal diagnostic criteria for PTSD, however, because her symptoms were not suf- ficiently frequent or severe. In the following material, we describe her experiences during this time.
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Jocelyn still suffered from occasional nightmares if she watched a movie or a TV show with a scene containing sexual violence. Rape scenes did not have to be overtly graphic to cause a nightmare. In fact, scenes in which a rape was alluded to rather than depicted on screen were just as disturbing to Jocelyn. She tried to avoidmovies or TV showswith sexual violence. This decisionmight be interpreted as avoiding stimuli associated with her rape trauma (a symptom of PTSD). Her avoidance was also the product of Jocelyn’s conscious decision not to support the segment of the entertainment industry that profits from depicting such scenes.
Other examples of lingering mild PTSD symptoms included hypervigilance and increased startle response. Jocelyn was hypervigilant in situations that might present a threat to her own safety. For example, when speaking with a male col- league in his office, she was often concerned about the distance to the door and the proximity of assistance if she called for it. Of course, we all protect ourselves by being cautious and alert. But Jocelyn found herself worrying too much about potential threats when none existed. This hypervigilance occasionally intruded on Jocelyn’s professional career. It could make her appear unnecessarily suspi- cious and aloof to her coworkers, especially the men. Jocelyn also continued to be quite jumpy if someone touched her from behind, though the degree of her startle response had diminished greatly since college.
The residual effects of the rape trauma could also be seen in the way that Jocelyn struggled to control her temper, which had become quite volatile. When provoked, the intensity of her subjective response was often out of proportion to the situation. Events that would annoy or irritate most people (such as being treated rudely by a boss) would cause her to become enraged. Because she knew that the intensity of her anger was often inappropriate, she almost always suppressed it. Jocelyn was afraid of what might happen if she acted on her feelings. Suppressing her anger interfered with her ability to have discussions or arguments with other people. If Jocelyn was involved in a discussion, she would often concede a point with which she disagreed to avoid “blowing up.” She became unnecessarily timid about stating her opinions.
Jocelyn’s relationships with men were also affected by the lingering impact of her rape. For a period of time in her early 20s (immediately following the rape), Jocelyn avoided intimate contact with men entirely. She referred to this time as her “celibacy” years. Jocelyn avoided intimacy with men to sort through her own feel- ings about herself, her remaining guilt surrounding her rape, and her feelings about men. Several youngmen found her attractive during this time (perhaps because she was uninterested in them), but she rejected their overtures. Jocelyn’s parents and friends were afraid that surviving the rape had “turned her into a lesbian” because she was not interested in dating men. Perhaps in rebellion against her parents’ con- cerns, Jocelyn joined a women’s poetry cooperative and a women’s music group that included women of all sexual orientations. She found this community to be warm and supportive. She made several close female friends, but she never felt any sexual attraction to them. This was a difficult time in which Jocelyn forged new friendships and also reestablished relationships with her previous social support network whenever possible.
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When Jocelyn eventually began dating again, she seemed to choose relation- ships that allowed her to avoid emotional intimacy. She pursued men who were inappropriate for her (such as someone who lived a thousand miles away, or some- one who was already married). Her affairs were brief and even exciting, but they did not result in significant, long-term relationships. At times, she could not imag- ine having a meaningful emotional relationship with a partner. Establishing clear consent to have intercourse prior to engaging in any type of sexual foreplay was of ultimate importance to her. Therefore, her sexual relationships tended to be “all or nothing”; she either had intercourse with the man she was dating or did not share any physical intimacy at all. Jocelyn realized later that she probably conducted her relationships in this fashion so that decisions of consent were as unambiguous and unemotional as possible.
Recognition of these ongoing difficulties led Jocelyn to decide to go back into therapy with a local psychologist. She had just met a new boyfriend and seemed to sense something special about this relationship from the beginning. Jocelyn wanted to work on issues involving intimacy, trust, and sexuality, in the hope that progress in these areas would help her to forge a better relationship with her new boyfriend (who did eventually become her husband).
During this therapy, Jocelyn acknowledged that she felt very close to her boyfriend, but she had a great deal of difficulty learning to trust him. She found it hard to believe him when he said that he loved her. They were also having some trouble in their sexual relationship. Many forms of touching, if the touch was not gentle enough, were upsetting to Jocelyn. If her partner accidentally did anything that caused her discomfort during physical intimacy, Jocelyn would think to her- self: “This is it. He’s been good until now, but now he’s going to hurt me.” Because of these irrational thoughts, Jocelyn frequently interrupted sexual contact with her boyfriend abruptly. He found these reactions confusing, and their relationship was becoming strained.
Jocelyn’s therapist used cognitive therapy to address these problems. Her goal was to eliminate the systematic biases in thinking that were responsible for Jocelyn’s maladaptive feelings and behavior. She treated Jocelyn’s distorted pat- terns of thinking and her biased conclusions as being “testable hypotheses.” She used their therapy sessions as an opportunity to identify, test, and challenge these hypotheses. Several strategies were employed. Her distorted thoughts were either “decatastrophized” (developing “what-if” strategies to deal with feared conse- quences), “reattributed” (considering alternative causes of events), or “redefined” (changing the perspective of the problem so that the person feels some control over it). For example, Jocelyn’s reactions to painful stimuli during physical inti- macy with her boyfriend were “reattributed” (Could your discomfort be the result of something other than his desire to hurt you?). Her fears during normal verbal arguments with men were “decatastrophized” (What is the worst thing that could really happen?).
Therapy also included some elements of anger management training (Novaco & Taylor, 2006). In the initial phase of this process, Jocelyn learned to monitor her own anger and the situations that triggered it. Applied relaxation was employed to
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help her learn to regulate arousal in situations that were potentially provocative. The same cognitive restructuring procedures that had been used to address her anxiety and fear were now used to help her modify distorted thoughts andmisinter- pretations of events that sometimes led to inappropriate anger. Finally, the therapist helped her to rehearse assertive communication skills that would allow Jocelyn to express herself clearly in situations that had previously led to withdrawal or the suppression of her true feelings.
Cognitive therapy and anger-management training helped Jocelyn improve her communication skills with others, including her boyfriend, as well as people at work. Her mood was more stable, and she felt better about herself. She also developed a deeper, more meaningful relationship with her boyfriend. They were married soon after the therapy was completed.
The fact that Jocelyn’s PTSD symptoms persisted for several years after the rape may seem discouraging. Nevertheless, beyond her subtle relationship prob- lems, the long-term impact of the rape was not devastating. Jocelyn was able to complete school, have a successful career, regain closeness with family and friends, and (with a little additional help in therapy) form an intimate and lasting relationship with a loving partner. She occasionally mourns the loss of her 20s because her relationships were so chaotic, but she also has many important plans and hopes for the future.
Discussion
Rape is an alarmingly frequent problem on college campuses and in other areas of our society (Elliott, Mok, & Briere, 2004). Consider, for example, the results of the National Health and Social Life Survey, the first large-scale examination of sexual behavior in the United States since the Kinsey reports (Laumann, Gagnon, Michael, & Michaels, 1994). In this national probability sample of women between the ages of 18 and 59, 22 percent reported that they had been forced by a man to do something sexually that they did not want to do. Only 4 percent of these coercive sexual acts were committed by a stranger.
Unfortunately, most rapes are never reported. On college campuses, less than 5 percent of rapes are reported to police (Cole, 2006). Victims like Jocelyn, whose immediate reactions to the rape included intense fear, helplessness, avoidance, and emotional detachment, may be particularly unlikely to contact legal authorities.
Should other people have reported Jocelyn’s rape when they heard about it? Her therapist was clearly prevented from filing a complaint by the ethical prin- ciple of confidentiality. If her therapist had reported the rape against Jocelyn’s objections, the therapist would have violated her trust and seriously damaged their therapeutic relationship. Her English professor, on the other hand, was not strictly bound by this professional obligation. Policies guiding the behavior of faculty members in this circumstance vary from one university to the next and are the topic of important debate. Some would argue that Jocelyn’s professor should have reported the rapist to police or campus administrators, even if it meant acting
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against Jocelyn’s own wishes. One justification would be to protect other students. Other people might believe that Jocelyn’s decision not to report the rape should be respected so that shewould not feel evenmore helpless or out of control.Would she be exposed to further danger if charges were filed without her knowledge? What would happen if the rapist tried to retaliate, and Jocelyn did not know that he had been confronted by authorities? What action could be taken against him without Jocelyn’s direct testimony, and how would his right to due process be protected? These are all difficult questions. We encourage people to seek advice on these mat- ters from local police officials and from sexual assault resource agencies. Just as many state laws now require therapists to break confidentiality to warn potential victims of violence, new regulations may be passed to deal with the plight of rape victims and the need to report this heinous crime.
One frequent outcome of rape is PTSD. PTSD is included in DSM-5 (APA, 2013) under the general heading of Trauma- and Stressor-Related Disorders. The diagnostic criteria for PTSD require that the person must have been exposed to a traumatic event that included exposure to actual or threatened death, serious injury, or sexual violation. Following exposure to this event, a diagnosis of PTSD also requires that the person exhibit symptoms in each of four clusters: reexperiencing, avoidance, negative cognitions and mood, and arousal. We will review features within each of these clusters in the following paragraphs.
One of the key elements of PTSD is the recurrence or reexperiencing of stim- uli associated with the event that triggered the onset of symptoms. Jocelyn initially experienced this aspect of the disorder in the form of intrusive, violent images that came to mind whenever she opened her English textbook. Her recurrent night- mares were another symptom linked to reexperiencing the event. Whenever one of these images or dreams occurred, Jocelyn would become extremely fearful and distract herself (escape) as quickly as possible. This type of reexperiencing of the trauma should be distinguished from the procedures used in cognitive-behavioral treatment. The latter is designed to ensure prolonged exposure in the context of a safe and supportive environment, which allows the person’s intense emotional response to diminish gradually.
Avoidance of trauma-related stimuli includes another cluster of PTSD symp- toms. Jocelyn’s avoidance was manifested by withdrawal from her friends, her decision against reporting the rape, and perhaps her reluctance to return to therapy for several years. Patients suffering from PTSD typically avoid distressing memo- ries, thoughts, or feelings that might be associated with the traumatic event. They also avoid people, places, and things that might remind them of the event.
The third cluster of symptoms that define PTSD includes alteration in cog- nition and negative mood that begin or get worse following the traumatic event. These symptoms can include the inability to remember some important aspects of the event as well as feelings of detachment or estrangement from others. Joce- lyn’s problems with her boyfriend and her other friends are relevant in this regard. Her feelings of dissociation, such as asking, “Is that me?” when looking into the
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mirror, were consistent with this aspect of PTSD. Negative mood states, such as guilt, anger, and shame, and the inability to experience happiness and loving feel- ings also fall into this symptom domain.
Jocelyn’s increased arousal was consistent with the fourth domain of symp- toms associated with a diagnosis of PTSD. Her exaggerated startle response, irri- tability in interpersonal relationships, difficulty studying, and sleep disturbance are all signs of the heightened arousal that is associated with this disorder. The length of time that had elapsed since the initial appearance of her symptoms and the obvi- ous impact that these symptoms had on her adjustment also indicate that Jocelyn met the formal diagnostic criteria for PTSD (which require that the symptoms last for at least 1 month).
The core symptoms of PTSD are, in some ways, quite similar to those of anxiety disorders. These include recurrent, intrusive images, avoidance, hyper- vigilance, and startle responses. In these elements, PTSD resembles obsessive compulsive disorder, phobic disorder, and generalized anxiety disorder. But PTSD also shares many symptoms with dissociative disorders such as amnesia, fugue, andmultiple personality. These include flashbacks, memory impairment, and body dissociation (Friedman, 2009; Zohar, Juven-Wetzler, Myers, & Fostick, 2008). This is why PTSD is no longer classified with the anxiety disorders and is, instead, listed under a separate heading in DSM-5.
It is difficult to estimate the true prevalence of PTSD from epidemiolog- ical studies because the disorder is precipitated by traumatic events (Keane, Marshall, & Taff, 2006). These events may be personal, affecting one person at a time, as in the case of rape, but they may also be events that affect a large number of people simultaneously, as in the case of a hurricane. How many people in the general population are exposed to traumatic events that might trigger PTSD? The National Comorbidity Study (NCS) found that 60 percent of men and 51 percent of women reported at least one such traumatic event at some time during their lives (Kessler et al., 1999). Many of these people had been exposed to more than one traumatic event. The most frequently reported traumatic events were witnessing someone being badly injured or killed, being involved in a natural disaster, being involved in a life-threatening accident, and being the victim of an assault or robbery. These alarming numbers indicate that traumatic events are unfortunately a relatively common experience in our society.
The overall rate of PTSD in the general population is higher for women (10 percent) than for men (5 percent) (Kilpatrick & Acierno, 2003). This pattern may be surprising in light of the fact that men are somewhat more likely to be exposed to traumatic events. How can it be explained? The NCS investigators suggest that, in comparison to men, women may be more likely to be exposed to traumatic events that are psychologically catastrophic. Rape is one example. Women are much more likely to be raped than men, and the rate of PTSD (for both male and female victims) is much higher following rape than following any other type of traumatic event. What are the distinguishing features of rape that account for its devastating impact? In comparison to many other traumatic events,
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rape involves directed, focused, intentional harm that is associated with the most intimate interpersonal act (Calhoun & Wilson, 2000).
Etiological Considerations
Not all victims of trauma develop PTSD.What determines whether or not a victim will develop PTSD following a traumatic event? There do not appear to be sys- tematic differences between crime victims who develop PTSD and those who do not in terms of demographic characteristics such as race, employment, education, and income. Some evidence suggests a relationship between depression prior to the crime, the level of stress associated with the crime (e.g., an attack with life threat, actual injury, or completed rape), and the probability of developing PTSD. If the victim is depressed before the assault, and if the victim is assaulted in a particularly severe manner, then she is more likely to suffer from PTSD follow- ing the crime in comparison to victims of lower stress crimes (Bonanno, Galea, Bucciarelli, & Vlahov, 2007; Ozer & Weiss, 2004).
Cognitive factorsmay also influencewhether a rape victimwill developPTSD. A perceived life threat may be present even in situations that are not overtly violent. In fact, the severity of perceived life threat, rather than actual life threat, may be the best predictor of whether a person will develop PTSD (Başoğlu & Paker, 1995). The person’s beliefs about whether she or he can control future events are also important. Victims who perceive (perhaps with justification) that future negative events are uncontrollable are much more likely to have severe PTSD symptoms than those victims who perceive some future control (Başoğlu & Mineka, 1992). This indication is particularly important when viewed in light of the fact that many women who have been raped report that they expect to be raped again.
Risk for persistent problems following a traumatic event is also increased by avoidance of emotional feelings and rumination about the traumatic event. Victims who suppress their feelings of anger may have an increased risk of developing PTSD after a rape (Foa & Riggs, 1995). Intense anger may interfere with the modification of the traumatic memory (to make it more congruent with previ- ous feelings of safety). Anger also inhibits fear, so the victim cannot habituate to the fear response. Jocelyn’s ongoing problems with the experience of anger may have helped to prolong her other symptoms of PTSD, such as nightmares and hyperarousal.
Protective factors such as the person’s level of social support may help to prevent or limit the development of PTSD and other psychological consequences of rape (Andrews, Brewin, & Rose, 2003; Keane, Fisher, Krinsley, & Niles, 1994). Unfortunately, simply having a social support network may not be enough. The tendency of the victim to withdraw and avoid situations is an inherent part of the disorder. This avoidance may mean that victims do not take advantage of social support, even if it is available to them. In Jocelyn’s case, the reactions of her friends often led to further problems and made her feel less in control and more alienated
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from other people. This kind of problem may help to explain why some studies do not find that social support serves as a protective factor.
Attitudes that society holds toward victims of sexual assault are also important in relation to social support (Ullman & Filipas, 2001). Some people apparently believe that certain women somehow deserved to be raped. These women undoubt- edly receive less social support than other victims. People may also be more sup- portive after hearing the details of an assault that was clearly nonconsensual—one in which the victim violently fought back when attacked by a stranger—than when the circumstances surrounding the assault were more ambiguous (the woman’s protests were verbal and not physical).Myths about rape, especially about acquain- tance rape, may decrease the amount of social support received by victims of these crimes.
Jocelyn’s case also highlights another frequent consequence of rape trauma. Many victims develop sexual dysfunctions. These problems include decreased motivation for sexual activity, arousal difficulties, and inhibited orgasm (Gillock, Zayfert, Hegel, & Ferguon, 2005). Their onset is undoubtedly mediated by a com- plex interaction of emotional responses to the rape, including anxiety, depression, and guilt. They can be exacerbated by interpersonal difficulties with, and lack of support from, sexual partners, as illustrated by Jocelyn’s boyfriend at the time of her rape. Sexual difficulties may be an important consideration in planning treat- ment for some victims of sexual trauma.
Treatment
The most effective forms of treatment for PTSD involve the use of either cognitive-behavior therapy or antidepressant medication, alone or in combination (Foa, Keane, Friedman, & Cohen, 2009; Forbes et al., 2010). The psychological intervention that has been used and tested most extensively is prolonged exposure. This procedure starts with initial sessions of information gathering. These are followed by several sessions devoted to reliving the rape scene in the client’s imagination. Clients are instructed to relive the assault by imagining it and describing it to the therapist, as many times as possible, during the 60-minute ses- sions. Sessions are tape-recorded, and patients are instructed to listen to the tape at least once a day. Patients are also required to participate in situations outside the therapy sessions that are deemed to be safe but also elicit fear or avoidance responses. An adapted form of this treatment was used in Jocelyn’s therapy.
Cognitive therapy is another effective psychological approach to the treatment of PTSD. It can be used on its own or in combinationwith prolonged exposure. Per- ceived threat, more than actual threat, is a better predictor ofmany of the symptoms of PTSD. Cognitive therapy can address maladaptive ways of perceiving events in the person’s environment. It can also be used to change unrealistic assumptions and beliefs that lead to negative emotions such as guilt. For example, in Jocelyn’s case, her therapist might have used cognitive-therapy procedures to reduce her feelings of guilt about the assault and its consequences (that is, blaming herself
Chapter 10 Posttraumatic Stress Disorder: Rape Trauma 131
for the rape). Cognitive therapy and prolonged exposure are both effective and approximately equal in their effects on reducing symptoms of PTSD (Bradley, Greene, Russ, Dutra, & Westen, 2005).
Various types of antidepressant medication are also effective forms of treat- ment for PTSD (Osterman, Erdos, Oldham,& Ivkovic, 2011). Carefully controlled outcome studies indicate that selective serotonin reuptake inhibitors, such as ser- traline (Zoloft) and paroxetine (Paxil), lead to a reduction in PTSD symptoms for many patients within a period of 6 weeks. In actual practice, cognitive-behavior therapy is often combined with the use of medication.
Final Comments
We have used the term victim rather than survivor to describe a person who expe- rienced a traumatic event. This choice was made primarily because victim is the term used in the scientific literature on PTSD. We also want to point out, how- ever, that many rape victims prefer to think of themselves as survivors to enhance their sense of control over events in their environments. Further information and resources are also available in Robin Warshaw’s book I Never Called It Rape (1994). Her descriptions are less technical than this case, and they may provide additional sources of support.
Discussion Questions
1. Discuss the issues surrounding Jocelyn’s reluctance to report her rape. Should her therapist have reported it to the police without her patient’s consent? Was there a better way for the English professor to handle the situation?
2. How did Jocelyn’s friends respond to her problems? Did they help the situa- tion or make it worse? Is there anything that they could have done that would have been more beneficial to her?
3. Do you think that a person can develop PTSD after witnessing an assault, a bad accident, or some other kind of traumatic event (that happened to some- one else)? Or does PTSD only occur in people who are directly the victims of trauma? What kind of evidence would be needed to answer this question empirically?
4. Do you think that PTSD is best classified in a separate heading of “Trauma- and Stressor-Related Disorders?” Or should it be classified more broadly as a form of anxiety disorder (along with phobias and panic disorder)? Does it belong under the heading of dissociative disorders?