Research Paper （topic: campus violence）

Interpersonal Violence and Sexual Assault: Trauma-Informed Communication Approaches in University Counseling Centers. 

A university in the United States Mountain West utilized grant resources to track counseling services for students who were currently experiencing or who had historically experienced relationship violence, sexual assault and/or stalking. This report reflects on the first 2 years of this program, including an overview of prevalence and reporting rates of interpersonal violence from university students. Given the prevalence of recent and historic interpersonal violence among university students, suggestions are offered for bringing a trauma-informed and communication-focused perspective to the solution-focused brief therapy model used in many university counseling centers. A case study outlining these approaches is offered.

Keywords: Campus assault; campus violence; communication; counseling centers; interpersonal violence; relationship violence; sexual assault; short-term therapy

For two academic years, a Department of Justice cooperative agreement provided funding to a public university in the U.S. Mountain West. The funding was specified for mental health treatment of students who had experienced relationship violence, sexual assault and/or stalking. Services were tracked for 2 years to measure the number of students who disclosed domestic/dating violence, sexual assault, and/or stalking. In the first year, the number of students who had experienced interpersonal violence was recorded. In the second year we compiled more detailed descriptive data on demographics and diagnoses of those who reported experiencing interpersonal violence within the past year, and for those who had a lifetime history of family or interpersonal violence. Having provided these specific services within a university counseling center, we were able to report certain trends that occurred in communication between clients and therapists during the course of this project, in the hopes they might apply to other university counseling centers in the United States.

Reflections and suggestions based on our work over the past two academic years come in three parts. First, we present some literature on the prevalence of interpersonal violence on college campuses and within the lifetime experience of college students. We also introduce the use of solution-focused brief therapy as a model for therapeutic settings that require caps on session limits, especially in university counseling center models where treatment duration must conform to academic year standards, among other constraints. Second, we recommend communication techniques from a trauma-informed lens that counseling centers may use to approach relationship violence, sexual assault, and stalking, seen as public health and mental health concerns. These communication behaviors are primarily based in communication accommodation theory (Giles & Powesland, [12]). This theory connects relational benefits (like feelings of affiliation, mutual understanding, and relational satisfaction) to strategic verbal and nonverbal communication shifts that an individual can make to engage in ways that are similar to their conversational partner (Giles, Willemyns, Gallois, & Anderson, [13]). We include reflections regarding client presentation and client communication patterns that recurred within our work over the past 2 years. Finally, we offer a case study with a student who disclosed experiencing interpersonal violence. The case study offers an example of the type of client communication patterns and trauma-informed practitioner work that we believe is vital in working with college student populations.

Interpersonal violence and university students

Many university students experience traumatic incidents, with 12% of university students meeting the criteria for post-traumatic stress disorder (PTSD; Frazier et al., [ 9]). Although the two most commonly reported traumatic events are the unexpected death of a loved one or friend (experienced by 47% of university students) or witnessing a life-threatening event involving someone close (experienced by 30%), it is notable that the next most common traumatic events students report are witnessing family violence (23%) and being on the receiving end of unwanted sexual attention (21%; Frazier et al., [ 9]). Furthermore, 31% of respondents in Frazier and colleagues' ([ 9]) study reported that sexual assault was the "worst event" of their lives and had experienced higher rates of PTSD than those experiencing other forms of trauma.

Studies examining the occurrence of sexual assault on college campuses reveal how considerably underreported this violent crime is. Current rates of sexual assault on campus show that one in five women and one in 16 men are sexually assaulted while in college (Krebs, Warner, Fisher, & Martin, [18]). However, many of these students do not seek formal assistance in coping directly with the mental health impact of sexual assault. This is partially due to the fact that survivors of sexual assault or interpersonal violence are less likely to disclose these events to police or medical staff than they are to a friend or family member (Chen & Ullman, [ 3]; Fisher, Daigle, Cullen, & Turner, [ 8]; Orchowski, Meyer, & Gidycz, [21]; Ullman & Filipas, [24]). Formal reporting or support-seeking from professionals is hindered by a number of factors including complexity of reporting, fears about autonomy and confidentiality, underage alcohol consumption, shared community and living space, and perception of lack of accountability for offenders (Busch-Armendariz, [ 2]). Reportedly, only 33% of women and 25% of men seek out counseling to directly address the mental health impact of sexual assault (Tjaden & Thoennes, [23]).

The mental health impact of interpersonal violence (both historical and recent) in general is so considerable that in 2002 the World Health Organization labeled intimate partner violence a public health epidemic (Krug, Dahlberg, Mercy, Zwi, & Lozano, [19]). Women on college campuses who experience physical and/or sexual violence are at increased risk for depression; anxiety symptoms are often associated with verbal aggression or physical violence at the hands of a partner or previous partner (Amar & Gennaro, [ 1]; Frazier et al., [ 9]). Mechanic, Weaver, and Resick ([20]) found that psychological abuse and stalking are contributing factors to depression and PTSD, even after controlling for physical violence and sexual assault. A history of interpersonal violence is so prevalent for people seeking physical and mental health services for ostensibly "unrelated" issues that Christopher and Kisler ([ 4]) recommend asking about experiences of interpersonal violence upon female college students' initial presentation of any signs of "mental health distress" (p. 167).

Trauma-Informed communication approaches

There is a great deal of variation in treatment approaches among university counseling centers. While some centers offer long-term, in-depth psychotherapy, the majority of university counseling centers report using a brief therapy model (Gallagher, [10]). A common brief therapy model is de Shazer and Berg's Solution-Focused Brief Therapy (SFBT). This approach directs clinicians to focus on future solutions to problems, rather than delving into problem origins or more in-depth psychosocial history (de Shazer et al., [ 5]). Outcome studies show that those receiving SFBT have significant benefit when compared to those who receive no treatment or other treatment approaches (Gingerich & Eisengrt, [14]). SFBT is adaptable, low-cost, and can foster both emotional and behavioral change (Kim & Franklin, [17]).

Though this brief-therapy model is useful, it may present two challenges in working with college students with trauma. First, focusing primarily on the future may prevent clinicians from recognizing past issues of sexual assault or other relationship violence in the client's history. This may lead to inadvertent triggering or retraumatization (Fallot & Harris, [6]). Second, if current or past sexual assault or other relationship violence is disclosed, the brief therapy model might influence clinicians to shy away from continued treatment after intake or to refer out to community settings those clients who present with these specific concerns. This could stigmatize these student clients, or even lead them to shut down and not utilize the more immediate opportunities for change or healing.

A solution to address these dual challenges is to complement the SFBT approach with the use of a trauma informed care, a multidisciplinary approach that recognizes the potential that any individual receiving care may have experienced a traumatic event in the past. As part of a given interaction, an emphasis on physical, psychological, and emotional safety is paramount and the caregiver begins provisionally with the anticipation that a trauma history may be present regardless of the individual's stated reason for receiving care (Huckshorn & Lebel, [16]). Most university counseling centers offer some level of trauma-specific services in working directly with current or past traumas (some quite extensive, depending upon the session limits or orientation of the center). We recommend that university counseling centers offer trauma-informed services with a particular focus on relationship violence and sexual assault screening and treatment. The first aspect of this focus is attention to our communication with clients.

Communication during screening and first session

We posit that two elements are necessary to trauma-informed work in university counseling centers, especially in regard to relationship violence. The first is the addition of specific questions on the clinic intake form that allow clients to indicate past experiences of relational violence without making these the sole focus of their current visit. Savage, Quiros, Dodd, and Bonavota ([22]) indicate that:

Adding a trauma assessment to the already existing [intake] assessment serves two purposes: it is an aid to inform staff of a client's trauma experiences, and it opens the communication with a client about her trauma experience, signaling that she will be accepted and that her trauma experiences do not have to set her apart. (p. 110)

In our experience a few brief, closed-ended questions regarding relational violence have offered clinicians enough information to move forward in sessions attuned to the impact of current or previous relationship violence without causing visible or verbal discomfort from clients. On the second page of our four-page intake form we ask clients to indicate whether they have experienced several issues with regard to mental health concerns, mental health treatment, and relational violence. These issues are listed in the Appendix.

In our form, this section is embedded between a demographic section and information regarding the client's family and living situation. This further situates these questions within a series of facts about the client that can help orient clinicians. In this way we can meet one of the challenges of a SFBT approach in a university counseling center (i.e., the focus remains very much on the present situation for the client) while still gathering information to allow for trauma-informed practice.

The second element regarding trauma-informed treatment is to follow-up on these questions after the initial intake without the presumption that affirmative answers to questions involving relationship violence are the main focus of the first session. Savage and colleagues ([22]) advocate asking two brief, but specific follow-up questions regarding traumatic interpersonal violence: how often the traumatic event occurred (once, a few times, or many times), and how old the individual was when the traumatic event(s) occurred. If a client offers verbal or nonverbal information regarding relational violence, the clinician is better able to conceptualize how the trauma history impacts current functioning, even when the trauma is not the primary focus of treatment. However, clients should be offered the option to decline answering these questions, and clinicians should note and respect this choice.

In terms of specific communication that allows clients to follow-up on past trauma experiences after the first session, we advocate affiliation-building practices developed from communication accommodation theory (Giles & Powesland, [12]). This theory has four main aspects as identified by Giles and colleagues ([13]). These include the following: (a) speakers will signal empathy, "positive face" (i.e., indicating likability and perceived competence in the other), and respect through accommodating to the speaking patterns of their partner; (b) that when such accommodations are perceived with positive intent it will enhance the partner's satisfaction, self-esteem, mutual understanding, and felt supportiveness from the speaker; (c) that increasing divergence from the conversational partner signals relational dissatisfaction, disaffection, or disrespect for the conversational partner; and (d) that divergence attributed by the conversational partner to have harmful intent will be evaluated and reacted to negatively.

Thus, in all trauma-related sessions, therapists can strive to accommodate to the client's verbal and nonverbal communication, such as vocal intensity, turns of phrase, posture, gestures, and even rates of silence. This can assist in developing a felt sense of support and trust (Giles, [11]). Though Grinder and Bandler ([15]) term a similar process "mirroring," it is important to note that Giles ([11]) warns against complete matching of the style of another, as it can lead conversational partners to feel patronized or disrespected. Moving toward the phrasing, topics, and nonverbal presentation of a client while not fully matching them will come closer to the "optimal" rate of accommodating (Giles, [11]).

Ferrera ([ 7]) indicates that in psychotherapy contexts accommodation practices can be especially useful in creating opportunities for reciprocal accommodation. By initially matching the pace, tone, phrasing, and so forth of a client the therapist is able to establish rapport and trust. The therapist may then be able to engage in some well-considered divergence from the client's topic or pace. Indeed:

Divergence may be adopted strategically in order to correct a communicative stance in another such as by slowing down in order to recalibrate an overly fast talker who is providing new information at such a fast pace that the hearer cannot absorb it comfortably. (Giles, [11], p. 165)

Using some slight divergence to slow the pace of a session can help build space and relief for a client from the immediate pressure to report difficult topics like the experience of interpersonal violence, especially when it is coupled with continued accommodation on other verbal and nonverbal communication behaviors.

Slight divergence on the part of the therapist may offer the benefit of modeling the possibility of safe, open, nonjudgmental communication. Once rapport has been established in interaction, slight communication divergence is more likely to be perceived with positive or helpful intent (Giles et al., [13]). Thus, the therapist may be able to inspire reciprocal accommodation from the client if they tentatively move to topics or terms that address the impact of interpersonal violence in the first or subsequent sessions. This engages the paradox noted by Ferrara ([ 7]), wherein "in psychotherapy language serves as both the method of diagnosis and the medium of treatment" (p. 187).

Observations from the last 2 years

Over the course of the 2014–2015 year, our counseling center saw 1,051 individuals, 133 (11%) of whom reported a history of unwanted sexual contact, experience of domestic/dating violence, and/or experience of stalking behavior from a partner or previous partner (See Table 1). Forty five of these students experienced these events within the past year. In addition, during the first year of this grant (2013–2014) there were 1,128 total students seen, with 60 individuals (5%) reporting interpersonal violence. Twenty four of those individuals reported a lifetime history of relational violence and 36 experienced victimization within the past year of intake.

Table 1. Survivors of Sexual Assault, Domestic/Dating Violence, and Stalking Seen at the University Counseling Center from July 1, 2014 Through June 30, 2015.

Type of Relational Violence	Experienced Within the Past Year	Lifetime Experience (Not Including the Past Year)
Unwanted sexual contact/sexual assault	20	73
Domestic/dating violence	21	37
Stalking	1	0

3 Note. Though 133 clients were seen within the year some individuals fell in more than one category, as they had experienced more than one form of relational violence or they had experienced such violence both within the last year and also in their past.

Reports of interpersonal violence were not the presenting concern that drew individuals to counseling in the majority of these cases, whether the violence was current or historical. These adverse experiences often appeared as an important factor in students' current level of functioning without being their primary concern in the session. Clients who had experienced relational violence predominantly presented with anxiety, depression, a relational problem, or a phase of life problem (see Table 2), and generally depression, anhedonia, decreased ability to concentrate, anxiety, relationship problems and/or changes in sleep or appetite patterns occur much more frequently than an explicit presentation of interpersonal violence

Table 2. Diagnoses for Clients Who Had Experienced Sexual Assault, Domestic/Dating Violence, and Stalking Seen at The University Counseling Center from July 1, 2014 through June 30, 2015.

Presenting Concern	Number of Students Presenting with Concern
Anxiety	30
Depression	22
Relational Problem	15
Phase of Life Problem	15
Adjustment Disorder	11
Post-traumatic Stress Disorder	9
Bipolar Disorder (I or II)	7
Alcohol Dependence/Abuse	5
Cannabis Dependence/Abuse	4
Eating Disorder	3
Panic Disorder	3
ADD/ADHD	3
Obsessive-Compulsive Disorder	2
Bereavement	2
Social Phobia	1
Dysthymia	1
Nicotine Dependence/Abuse	1
Cocaine Dependence/Abuse	1
Identity problem	1
Trichotillomania	1

4 Note. Though 133 clients were seen within the year not all students were diagnosed with a disorder/v-code and some had more than one diagnosis of concern. ADD/ADHD = attention deficit disorder/attention deficit hyperactivity disorder.

Case study

Eric first arrived at our counseling center as a 20-year-old visual arts student. Eric identified as Caucasian, gay, and from a middle-upper class rural home with an intact parental relationship. Eric began therapy at his own initiative, reporting that many of his family members regularly sought counseling throughout their lives to manage depression, bipolar disorder, and panic disorder. Eric's presenting concern in our first session was anxiety and family conflict, and he stated that his goal would be to explore the family patterns and dynamics that characterized his childhood and that he believed were still shaping him strongly and adversely. Eric reported that in his family of origin his mother's chronic illness and distress trumped any adverse experiences that other family members might have, and that the prevailing family norm had been to present positively as a family (both within the family and in their external presentation). Eric reported having difficulty expressing his own needs and desires in his family, and experienced anxiety regarding his attempts to differentiate in a healthy way from his family of origin.

As part of his intake paperwork, Eric had completed the clinic form (see Appendix) designed to record past mental health issues and trauma. Eric answered affirmatively to the questions asking if he had experienced unwanted sexual contact/experiences, harassing/controlling/abusive behaviors, and a situation that made him feel fear/helplessness/horror. Eric indicated that these three experiences had all occurred more than a year ago. Eric did not bring up these experiences at the start of the first session, remaining focused on family conflict. The therapist listened to the stories of family conflict and reflected the emotional content of these conflicts evident in Eric's descriptions. Approximately 30 minutes into the 50-minute session the therapist checked with Eric to see if it was acceptable to ask a few questions regarding his intake form, with the goal of developing a fuller picture of how Eric arrived in the session that day with his presenting goals. Eric was reminded that he did not need to address any topics on the sheet that he was not comfortable addressing in that session.

The therapist began with a few open-ended questions regarding Eric's reports of moderate alcohol use and past mental health treatment. Eric exhibited comfort responding to these questions through his nonverbal reactions (relaxing into the chair, speaking at moderate volume and pace, and appropriate eye contact throughout questions and responses). With this response noted, the therapist moved incrementally toward questions regarding the historical experience of trauma/unwanted sexual contact by gesturing to this section on the form and stating "You've offered me some information here about your past experiences. I'm wondering if you feel comfortable letting me know more about your history with the unwanted or difficult experiences you've noted here." Eric responded with some shift in nonverbal behaviors (downcast eyes, increased pauses) and much shorter sentences than his previous replies. Eric's change in both his verbal and nonverbal behaviors were noted, and were read by the therapist as indicative of shame, fear, or other form of distress related to this trauma history. Eric stated that his "no" had not always been respected during sexual intimacy in the past. He then shifted to talking about how he had preserved his virginity through early dating experiences in high school, and that he continues today to be reserved in expressing himself sexually in relationships. In this way Eric transitioned the conversation to a point of positive face or competence, likely in an effort to avoid the distress he associated with the trauma.

Eric further moved the topic back to his goal to focus on himself and to liberate himself from troubling family dynamics by linking his reserved nature back to his family of origin. During this interaction the therapist continued exhibiting an open posture oriented toward the client (choosing to diverge somewhat to model openness rather than mirroring the client's nonverbal withdrawal), though eye contact was not possible with the client looking away. The therapist followed the client's speaking pace and topic shift, offering a focus on Eric's positive face along with empathy for Eric's previous trauma. This was done with a brief summary statement paraphrasing Eric's mixed experiences with sometimes being able to keep boundaries that he wanted and sometimes not being heard when he set a boundary. Then, the therapist emphasized that if Eric wanted to continue at the clinic, the therapist could work with him on examining these concerns in the relationships he chose to focus on, with family appearing as the main concern of the moment.

Eric responded to these communicative moves by the therapist with returned eye contact, and the verbal statement that he'd like to focus on family. Eric's verbal and nonverbal communication were read by the therapist as cues regarding his readiness to address one level of distress (family dynamics) and unwillingness/inability in that moment to access all levels (i.e., previous trauma). The hour was wrapped up with an overall session recap, ending with the standard reminder offered in this clinic that clients are usually seen for brief rather than ongoing therapy, and that Eric was welcome to continue refining or shifting what he wanted to work on during that time as other needs became salient. During this ending to the session Eric returned to a more relaxed posture and continued his eye contact and verbal responsivity to the therapist, indicating that some level of comfort and affiliation had been established within the session.

Over the course of the next several sessions, Eric showed rapport and openness with the therapist through a mix of affiliative nonverbal signals and disclosive verbal statements relating to his family. Topics covered included Eric's body image and gender identity as shaped through interactions with his mother, Eric's newly developed resistance to her expectations of him, and Eric's conceptualization of his psychological estrangement from his father. Consistent with a SFBT approach, the focus broadly remained on "exception" questions, such as when Eric was able to resist his mother's views, was able to connect with his father, and was able to set boundaries with which he felt comfortable. The therapist continued to follow Eric's pace and topic choices, helping him to elicit a preferred future and considering behavioral shifts that would help move him in that direction. In the seventh session, Eric returned to the feeling of not being heard by others, though this was still in relation to his family. The therapist reflected: "There have been a few times in your life that you haven't felt heard or that your boundary hasn't been respected. What are you thinking about in relation to this today?" Eric responded with a metaphor of burners on a stove, stating that with recent changes in claiming autonomy from his parents he had "turned down" the burner representing distress in that relationship. This had resulted in the "turning up" of a burner focused on his dating relationships and what he desired to change there.

At this time Eric disclosed that 3 years ago he was sexually assaulted by a male friend. He stated that he hadn't realized how much that "episode" still affected him, and how hurt and powerless he felt in that interaction. Eric spoke in detail about the assault, recounting both physical and psychological wounds. Contrary to the first session, where the assault was only alluded to, this session was marked with direct verbal communication about the assault as well as steady eye contact and body orientation toward the therapist.

In accommodating to the client's communication pace, to the terminology used to describe the "episode" and his "no" not being heard, and to the overall content of his disclosures during their early sessions, the therapist built affiliation and trust that may have helped Eric feel comfortable addressing his previous trauma in counseling. Strategic divergence from Eric's communication also played a role here. Continued open nonverbal behaviors when Eric withdrew (mainly through eye contact and body posture) may have modeled openness that Eric was able to enact in later sessions when he came back to the topic of sexual assault. Gentle and brief validation of Eric's experience as important (through verbal comments and questions that gently redirected Eric toward the appropriateness of discussing his own experience in session rather than solely his mother's illness) were ways that the therapist accommodated Eric but also diverged from past relational patterns that ignored his needs and experiences.

Once Eric introduced his history of interpersonal violence in session, the focus of therapy shifted to processing and framing Eric's sense of self in relation to this assault (and, over time, whether he wanted to label it as an "assault" instead of an "episode") along with a continued emphasis of moving toward his desired sense of self as someone who sets boundaries that are respected. The therapist met with the client four more times to consider this trajectory, as well as Eric's ambivalence regarding his ability to make healthy choices in future sexual/dating interactions. By the end of this time Eric reported feeling more comfortable with his past, as well as feeling increased confidence in his future choices. In the notes from the last session the therapist wrote:

Eric continues to feel pride in and gratitude toward himself for how far he has come in reorienting his view of himself and relationships. Eric reports feeling more empowered to live in possibility and make choices about which doors in life he opens and which he closes.

Though necessarily brief in nature, this case study exemplifies a common presentation of students in this counseling center over the past 2 years. Notably, the presenting concerns were anxiety and relational concerns rather than a focus on the experience of interpersonal violence. Through trauma-related questions embedded within the intake form and some open-ended inquiries from the therapist, a history of interpersonal violence was established and recognized. Through communication from the therapist that largely converged with the client's own verbal and nonverbal communication, accompanied with slight divergence as rapport was established, the client was offered a context to address his experience of interpersonal violence as it felt salient and safe to do so. The client reported satisfaction in meeting his therapeutic goals and in processing previous trauma within a brief therapy setting. The client was provided with referrals to community resources at the mutually agreed upon termination of counseling, though he reported that he did not feel a need to use them and would instead keep them in case he needed them in the future. In cases with clients who are experiencing more pronounced trauma, identification of the trauma and careful choice of language and tone on the part of the therapist could be utilized in a similar way to this case, but community and clinical resources might be utilized more immediately

Conclusions

Interpersonal violence is a major public health, mental health, and safety concern on college campuses of all sizes and makeup in the United States. Without taking a multipronged and aggressive approach to alleviating this complex problem, students' felt sense of safety may be compromised, and the effects of interpersonal violence may plague young adults seeking to attain an education, better themselves, and develop careers. University counseling centers are one piece of the puzzle to providing safe spaces for students to address any issues of concern when it comes to experiences of interpersonal violence, whether past or present.

Brief therapy models, utilizing trauma-informed and communication accommodation practices, may be used in university counseling settings as valuable tools to assess current levels of functioning in all areas of a student's life. We encourage use of such approaches and the reporting of outcomes so that the most effective treatment approaches can be supported, which in turn can lead to the overall betterment of students.

Acknowledgments

Special thanks to Brigit R. Johnson, MA and Mary Giuliani, MA for assistance with literature review research.

Funding

The authors acknowledge and thank the University of Montana Curry Health Center and the U.S. Department of Justice for their support of this research.

Appendix: Counseling center intake form

Questions	Never	Within the Past Year	More Than a Year Ago
Attended counseling for mental health concerns?
Taken a prescribed medication for mental health concerns?
Been hospitalized for mental health concerns?
Had unwanted sexual contact(s) or experience(s)?
Experienced harassing, controlling, and/or abusive behavior from another person (e.g., friend, family member, partner, or authority figure)?
Experienced a traumatic event that caused you to feel intense fear, helplessness, or horror?
Seriously considered injuring another person?
Intentionally caused injury to another person?
Purposely injured yourself without suicidal intent (e.g., cutting, hitting, burning, hair pulling, etc.)?
Seriously considered attempting suicide?
Made a suicide attempt?

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By Christina Granato Yoshimura and Kimberly Brown Campbell

Reported by Author; Author