WOLBERT
ANN
9. lanis
IL:
Psychological
Stress.
New
York,
John
Wiley
& Sons.
12.
1958 10.
11.
Weiss Ri, Textbook Baltimore,
Kardiner York,
Payson
A, Spiegel PB
ANN
Gross
of Psychiatry. Edited Williams & Wilkins Hocher,
Coping BY
HE:
H: War
stress by Co.
Stress
reaction,
in Comprehensive
Freedman 1967, pp
AM, Kaplan 1027-1031
and
Neurotic
Illness.
HI.
13.
New
WOLBERT
of the
BURGESS,
Rape
D.N.SC.,
AND
BEHAVIOR
of
people
faced
with
critical
LYNDA
LYTLE
life
situ-
ations is receiving increased attention in the literatune (I). The immediate efforts people use to deal with highly stressful situations are an important assessment point for clinicians who see patients in acute crisis. These coping behaviors may be viewed as problemsolving attempts an individual makes when facing demands that are highly relevant to his/her safety and that tax adaptive resources (2). Before describing the various coping strategies used by rape victims facing attack, it will be useful to review some coping strategies found in other types of crisis or stressful situations.
Presented Association,
at the 128th Anaheim,
Dr. Burgess is Associate Associate Professor of
Mass.
02167.
annual Calif., Professor Sociology.
meeting of the American May 5-9, 1975. of Nursing Boston
LYNDA
Kardiner A: The Traumatic Neuroses of Medicine Monograph Il-Ill. Washington. search Council. 1941 Grinker R, Spiegel I: Men Under Stress. ton, 1945
LYTLE
HOLSTROM
War. Psychosomatic DC. National Philadelphia.
Re-
Blakis-
of the rape
vic-
Victim
The coping behavior ofrape victims can be analyzed in three distinct phases-the threat ofattack, the attack itself and the period immediately thereafter. The authors analyzed the reported coping behavior of 92 women diagnosedas having rape trauma. Most of the women used verbal, physical, or cognitive strategies when threatened, although 34 were physically or psychologically paralyzed. The actual rape prompted coping behaviors in all but I victim. Escaping the situation or the assailant is the primary task immediately after the attack. In counseling the rape victim, it is important to understand her individual style ofcoping, to be supportive ofit, and to suggest alternativesforfuture stressful situations.
THE
AND
14. Burgess AW, Holmstrom LL: Coping behavior tim. AmI Psychiatry 133:413-418. 1976
1941
Behavior
BURGESS
Psychiatric
and Dr. Holmstrom College. Chestnut
is Hill,
HOLMSTROM,
PH.D.
Researchers have focused on different aspects of the coping process. Extrasensory awareness of disaster situations was studied by Stevenson (3) in 19 people who survived the sinking of the Titanic. Glass (4) considered behavior over time in order to be able to view various phases ofbehavior separately. Most ofthe dinical studies have reported on the use of psychological mechanisms as part of the coping process: examples include denial in people with acute myocardial infanction (5), isolation of affect, denial, and regressive behavior in victims ofconcentration camps (6), denial, isolation ofaffect, and motor activity in parents of children with malignant disease (7), and emotional constniction, repression, suppression, denial, and delusion-hallucination formation in severely burned patients (8). Lazarus (9) took a behavioral approach and classified four important coping reaction patterns: I) actions aimed at strengthening the individual’s resources against harm, 2) avoidance, 3) attack. and 4) inaction. There have been several recent studies of victim crisis situations involving major crimes, including forcible rape and situations in which victims have successfully interrupted or prevented attack (10-12). Giacenti and Tjaden (13) reported that out of915 cases in the Denver area, 3 19 victims were able to interrupt the rape by active resistance, fleeing, physically fighting, crying aloud, verbal refusals, and outside intervention. In studying rape prevention, Brodsky (14) has focused primarily on verbal or vocal responses in the interpersonal prerape situation. We saw a variety of ways to look at the coping behavior of rape victims in the literature. We drew on these studies and took a combination of areas to analyze, emphasizing the thoughts. feelings, and actions of rape victims as they related to specific time phases of the attack. Am J Psychiatry
/33:4,
April
/976
413
COPING
BEHAVIOR
TABLE 1 Coping Behavior of 92 Rape Victims
Description
Number
of Behavior
Victims
with
strategies
(N
of Victims
58)* 18 57 21
Cognitive assessment Verbal tactics Physical action Victims
without
strategies
(N
34)
22 12
Physically paralyzed Psychologically paralyzed *
Many
ceed
victims
had
thought he might do harm, wondered why the man had been hanging around all evening, remembered seeing the man before. looked at the car that pulled up, thought it strange the apartment bight did not go on, on heard a noise in the kitchen and went to investigate. Several victims described a subjective awareness alerting them to danger such as being scared when their boyfriend was pushed out of the can or feeling frightened when they realized what was happening.
in Response to Threat of Attack
more
than
one
strategy:
therefore.
the
total
Threat
numbers
cx-
58.
METHOD
We interviewed all persons entering the Boston City Hospital Emergency Department over a one-year penod with the chiefcomplaint ofhaving been raped. Subjects were interviewed at the hospital. usually within hours ofthe attack. The interview included a series of open-ended questions in which victims were asked how they felt and reacted to the circumstances prior to the attack, the attack itself. and the chain ofevents following the attack. Follow-up interviews were possible with 85% ofthe total sample of 146 victims and included further recounting ofthe details ofthe attack. Diagnostic categories were devised from the total sample. and a subsample of92 women aged 17-73 diagnosed as having rape trauma (15) was used in this analysis of coping behavior before. during, and immediately following the attack.
BEFORE
THE
THREATENING
ATTACK:
COPING
BEHAVIOR
IN
A
SITUATION
Most of the victims perceived the rape as a lifethreatening experience. The minority who did not so perceive it still saw the rape as an acutely stressful, frightening. and degrading experience. For almost all victims, this attack was something far out of the ordinary that seriously taxed their adaptive resources. Ear/v
A tt’areness
o./Danger
of Attack
The threat of attack is the point when the person realizes there is definite danger to his or her life-the coping task at this stage is to attempt to avoid or escape the situation. The person is aware something cnitical is going to happen but may not realize that nape is the imminent danger: for example. the person may instead fear robbery or aggravated assault. Coping behavior was analyzed in terms of whether on not victims were able to react to the confrontation with danger. This ability to react often depended on the amount of time between the threat of attack and the attack, the type of attack. and the type of force or violence used. A majority of victims used one or more strategies and a minority ofvictims were unable to use any strategies (see table I). Basic
Strategies
Cognitive assessmnemit. Victims may cope by mentally assessing the situation to determine possible alternatives, e.g. they may think about how they can get away from the assailant’s grasp on escape from a car or room safely. or they may worry that the man will panic and hurt them and plan how to keep calm. Verbal tactics. The majority ofthe coping strategies were verbal: they included talking one’s way out of the situation (‘ ‘I tried to engage them in conversation such as asking where they went to school and why they were doing this’ ‘), stalling for time (‘ I tried to talk to him; tried to get him to come for coffee at a restaurant down the street’ ‘), reasoning with the assailant by trying to change his mind (‘ ‘I’m a married woman”; “I’m a virgin’ ‘), trying to gain sympathy from the assailant (“Look at the trouble you’re causing me”; ‘What will I do?’ ‘) using flattery (‘ ‘You’re an attractive man; surely you don’t have to do this for sex”), bargaining with the assailant (“There’s my TV, take it and go”). feigning illness (‘ ‘I’m sick’ ‘), threatening the assailant (‘ My husband is due home’ ; ‘My kids are in the next room’ ; A policemen lives in this building’ ‘), verbal aggression (‘ ‘Get your hands off me’ : Don’t touch me’ ; What are you doing?”), changing the assailant’s perception of thevictim (“I talked to him like a mother. ‘), joking and sarcasm (a woman awakes to see a man coming in her room saying. ‘I’m escaping from the police’ ; she says, “OK-I’ll let you out the back door”). Physical (U’tiOli Some victims took direct action aimed at preventing the attack by fleeing from the situ.
‘
‘
Appraisal ofthe degree ofdanger. threat, or harm is a psychological process that intervenes between a stressful event and coping behavior. This early awareness may be cognitive, perceptual, or affective-often, the victim describes it as a sixth sense’ or a feeling of impending danger. The coping task during this phase is to react quickly to this warning. Only 15 of the 92 women we interviewed spontaneously reported some cognitive or perceptual awareness of the potential danger they faced, and they were not totally clear about the nature of the danger-they just knew that something was wrong. Reports of this vague, obscurely formulated consciousness of danger varied. Victims said they saw a strange man and either ‘ ‘
414
AmmiJ Psychiatry
/33:4,
‘
April
/976
‘
‘
‘
‘
‘ ‘
‘
‘ ‘
‘ ‘
‘
‘
‘
.
‘
ANN
ation or fighting the assailant the broken glass” ; “I tried apartment”).
(‘ ‘I tried to stab him with to push him back out of the
WOLBERT
TABLE 2 Coping Behaviors Description
Lack
AND
of 90 Women
LYNDA
LYTLE
HOLSTROM
During Rape
of Behavior
Number
of Victims
of Strategies
One-third ofthe victims were unable to use any strategy to avoid the attack. The victim might be physically paralyzed and totally overpowered by the assailant. For example, several victims were in their beds sleeping when the assailant gained access to their apartments and attacked them (“It was around 3 a.m. I woke to feel someone jumping on me”). The victim might be walking down the street and suddenly grabbed by one or two assailants. The use of a weapon often paralyzed a person. The following example from a referral case illustrates early awareness of danger and physical paralysis: ‘The door buzzer rang I was expecting friends and opened my door saw three men with a paper in one’s hand I froze paralyzed for a moment something went through my head . shut the door but they pushed it back open . . . with the gun In some cases, the victim was totally stunned on surprised by the change in behavior ofa man whom she knew as a friend, neighbor, or acquaintance. and said He just grabbed me before Iknewit.” Victims may be psychologically paralyzed either through their defensive structure (‘ When I realized what he was going to do I blanked out . tried not to be aware of what was going on’ ‘) or because of their use of alcohol or drugs prior to the attack. Thoughts of death may paralyze a victim (‘ ‘I thought he’d be the last person I’d see alive”). .
‘
.
.
.
.
.
.
.
.
.
.
.
Cognitive strategies Affective response (N =25) Crying Anger Verbal strategies (N =23)
28 17 8
Screaming
14
Talking
9
Physical action Psychological defense Physiological reaction No strategy No data
23 17
10 I 8
.
.
.
.
.
.
said said,
they needed ‘Who you
to use my phone. trying to call, Red
I tried China?’
to joke
and
.
‘ ‘
‘
.
Multiple
BURGESS
.
Strategies
Victims may try a number of strategies: 31 women had multiple strategies, 27 had one, and 34 had none. One woman who was successful in avoiding attack said, “First I tried to calm him down; tried to talk softly to him and said, ‘OK, we be friends. Then I said my brother was due home any time I tried all I knew, verbal and physical . . I screamed and fought The brother did come home and the assailant left without completing the rape. Another victim who tried several strategies was not successful with three men who had forced her into a car as she waited for a bus after her evening classes at a local university. She tried verbal tactics (‘ My husband will be worried and probably call the police if I am not home’ ‘), but the assailants told her that such remarks would “get me dead.” The victim then became silent. She later tried bargaining (“I offered them my money to let me go”) and finally decided to comply (“I decided the only way was to play it their way”). In another case, one can see the coping behaviors of early awareness, an affective reaction of fear, cognitive assessment, and verbal tactics of joking: “I got a warning. saw two men at the end of my hall. got frightened didn’t know how they got there. They ‘
.
.
DURING
THE
ATTACK:
COPING
WITH
THE
RAPE
At the moment of the actual rape attack, it becomes clear to the victim that forced sexual attack is inescapable. The coping task during this phase is to survive the rape despite the many demands forced upon the victim, such as oral, vaginal, and anal penetration. She also may be forced to have conversation with the assailant. Victims coped with the actual rape in a vanety of ways, as table 2 indicates. Cognitive
Strategies
Victims often cope by mentally focusing and directing their attention to some specific thought to keep their minds off the reality of the event and focus on their survival. Remaining calm was a strategy in which the victim specifically controlled herself mentally so as not to provoke additional violence. The victim might talk to herself, as in the following case:
.
.
I kept thinking me, he choked
keep cool. He said he’d kill me. He hit he could kill me. I said to myself, ‘You can handle anything; come on, you can do it. I decided not to fight him . . . he was holding my neck so tight I responded a little to him . . . that blew his mind that I acted as I did. Itwas very quick. thank God. .
.
.
me,
‘
.
.
.
‘
.
.
.
.
.
.
.
Memorizing details was a strategy that paid off later in some cases. One referred victim said, “I focused on their faces and thought to myself, ‘I’ll see you guys in court ifl get out ofthis alive.’ She did. Another victim said, “I played detective tried to observe cvenything. bike the tatoo on his arm, remarks he made, route of travel of the car, license of the car.” Recalling advice people have given on the subject of nape is another strategy victims report: “I remember a conversation I had with my husband. He said if I was attacked not to resist if he wants sex. My husband said “
.
Am J Psychiatry
.
.
133:4,
April
1976
415
COPING
BEHAVIOR
the guy could kill me or the children but sex wouldn’t kill me.” Another victim said, “I remember talking with people about rape and they always said not to resist that a female could be killed, beaten, or mutilated. I didn’t want that to happen.” Memories of previous violent situations provided some victims with alternatives (“I struggled a little then remembered when I was 12 I fought a neighbor boy and got my nose broken”). Praying for help is a tactic to decrease stress and tension (“I wasn’t listening to them but concentrating on praying that my friends who had keys to my apartment would come”). Concentrating on the assailant in terms of who he is and what has led to this attack is also a strategy (“I remember thinking that this person must have a home-must live somewhere why would he do this on Mother’s Day? I thought of the irony of it “) Compliance is a strategy used to “speed it up get it over with.” To many victims, the attack seemed interminable. .
.
.
.
.
.
.
.
gled until I realized he was going to rape me. He wanted to nape me more than I could manage to resist”). Some victims quickly discovered that struggling and fighting were just what the assailant wanted (“The more I screamed and fought, the more excited he would get”). Psychological
Defenses
.
.
.
.
.
.
.
.
.
.
.
.
.
Defense mechanisms are another way rape victims cope with the overwhelming fear of attack. Defenses close the cognitive field and thus block out the unbearable feeling. Some women denied the attack (“I never thought it could happen’ ‘), experienced dissociative feelings (“I pinched myself to see if I was real”), suppressed the rape (“I am missing 10 minutes of my life”), or rationalized (“I felt sorry for him if this was the only way he knew how to get sex”). One victim described her reaction as follows: “I did not struggle because of the knife. All those things you read about or plan to do don’t help I felt I was not going to get out alive I was resigned; I felt nothing, empty; felt this can’t happen to me.” .
.
Verbal
Strategies
Victims combined verbal and affective responses by screaming and yelling. This tactic served both to relieve tension involuntarily and to deter the assailant from his full intent. This tactic brought police to the scene in several cases, which sometimes resulted in the assailant being apprehended during the attack. Several victims believed that talking with the assailant during the attack helped them avoid additional violence. The assailant may demand to know how the victim is “enjoying” the rape. One victim handled the situation as follows: “He kept wanting to know if it felt good and I had to say yes to keep him happy He said, ‘I’m on drugs lady and I need money fuck me good or I’ll kill you. He needed to be reassured.” Ifthe attack continues over a period oftime, the victim may try verbal tactics to calm the assailant and thus avoid further demands (“I talked to calm him down I asked questions and he kept talking”). Sancasm may be used as a coping strategy, especially if that is the victim’s usual verbal style. .
.
.
.
.
.
‘
.
.
.
As he was molesting me he asked ifI enjoyed it and I said. “Oh. sure, it is great.” I decided to go along with him. He seemed to need reassurance . . I wasn’t scared then. First thought he’d get his kicks and then it’d be all overI’d be dead. I got faith that he wasn’t going to harm me. .
Some victims tried to gain control in the situation by scaring the assailant(s) (“You’ll be in real trouble if you kill me”; “You’ll be sorry. I’ll get someone to kill you”). This strategy was partially successful in some cases. .
Physical
Action
Victims reported struggling assailants to avoid penetration ened my muscles”). Sometimes a certain point and then stopped 416
.
Am
J Psychiatry
/33:4.
and fighting (“I struggled the victim (“I fought April
1976
with their and tightstruggled to and strug-
.
.
.
.
Physiological
Response
Not all coping behavior is voluntary and conscious. Certainly, some screaming and yelling is involuntary, and victims also reported physiological responses of choking, gagging, nausea, vomiting. pain. urinating, hyperventilating, and losing consciousness. One victim described an epileptic seizure: Only thing I remember is getting the key into the lock to get into the building. Then I got warning signs to my seizure attacks . . getting overheated and the ringing in my ears and that’s all. When I regained consciousness I was in the hall by the door to the basement. I dragged myself out as I heard someone saying. ‘Who left their keys in the door?” .
‘
Another victim described how her involuntary reaction scared the assailant off after he raped her: ‘I felt faint, trembling and cold I went limp. I think he got scared and thought I was out.” ‘
.
AFTER
THE
ASSAI
LANT
ATTACK:
.
.
ESCAPING
FROM
THE
The stressful situation is not oven when the actual rape ends. The victim must alert others to her distress, escape from the assailant, on free herself from where she has been left. The coping task immediately following the rape is to be free or escape from the assailant. Alerting others. Victims are always hopeful that someone will come to their aid, and they may spend time concentrating on how to obtain help. Bargaining for freedom. Often, the victim must negotiate with the assailant through a bargaining process.
The
assailant
sympathy tell, or
and he may
sometimes thus give
get the
apologizes the victim to victim orders
and
tries
to gain
promise not or instructions
to
WOLBERT
ANN
(‘ ‘I’ll
kill you if you tell or go to the police’ : Don’t move from that position for 30 minutes’ ‘). During the bargaining process the victim may cope by remaining silent or agreeing to instructions. Some victims promised not to tell anyone or invented stories to preserve their lives: ‘I told him my girl friend had this happen and when she went to the police they didn’t believe her. I told him I’d never go to the police.” Freeimig omie.se/f. The victim may have to free herself from the situation-if she has been tied and gagged. she has to cope with physically freeing herself. Cognitive assessment of the situation and keeping calm will be most useful strategies to her, as was the situation in the following referral case: ‘I lay still for a moment then realized that the faster I got myself untied, the faster I could get to the police and my friends . . ankle ties . . . getting cramps in my legs . . . so I had to tell myself not to panic and I worked the wrist ties and ankle ties next Mastery. in terms of survival of the attack, may be verbalized by the victim as well as her family and friends when this stage has been managed successfully: ‘The worst is over . . . I got through it . . . I am grateful to survive.” Once free ofthe assailant. the victim must still cope with the stress of the aftermatu of the rape. Victims are often immediately faced with trying to cope with the institutions that are set up to deal with rape (16). ‘
‘ ‘
‘
‘
.
.
.
‘
COUNSEE.ING
IMPLICATIONS
Understanding a person’s coping behavior when faced with a life-threatening situation is an essential step in crisis intervention. Rapoport (17) noted that patterns of coping in crisis situations may be adaptive or maladaptive. Parad and Resnik (18) stated that the purpose of actively focused crisis intervention is to steer the person toward adaptive coping and away from maladaptive behavior. Adams and Lindemann (19) formulated coping principles drawn from a study of catastrophic disabling injuries; they emphasized identifying the acute crisis and the psychological means by which the crisis is to be managed if not mastered. The assessment of coping behavior and strategies provides the clinician with two therapeutic measures. First, such assessment can be used as a supportive measure. By listening to the victim recount the rape. clinicians can identify the coping behavior and acknowledge this information to the victim. This support tells victims that their coping behavior was a positive adaptive mechanism used to survive a life-threatening situation. By verbally conveying this information, the clinician attempts to alleviate some of the guilt suffered by a victim who may think. “I did not do enough-I could have done more.” This therapeutic approach sets in motion a positive sense of self-esteem and worth. As was noted by one victim, who was raped by two assailants at knife point, “At least I
BURGESS
AND
LYNDA
LYTLE
HOLSTROM
wasn’t so whacked out that I couldn’t get a description and license ofthe car.” Reaffirming the strategic use of hen cognitive abilities helped this victim to see herself as a person who was able to do something in a highly stressful situation, even though she was physically immobilized. Such a response by the clinician strengthens the therapeutic alliance in terms of providing positive expectations regarding the victim’s capacity to restore herself to hen precnisis level of functioning. Thus we see that Murphy’s model of resilience (20), wherein a person sees herself as someone who is resilient and expects to recover from the trauma. has significance in counseling nape victims. The second use of assessment of coping behavior is to give the clinician a reference point from which to begin the clinical negotiation for crisis service (21). As the victim states her request and it is negotiated, additional requests may be elicited. For example. one request may be related to primary prevention in terms of what other strategies might be used in such situations. The clinician can explore with the victim the crisis behaviors she used and analyze their effectiveness. New strategies might be suggested as possibilities in future stressful situations. It is important to help expand the person’s problem-solving capabilities (22). We believe our analysis of the coping behavior of rape victims opens up other research areas. There are two questions of major importance: I) what coping strategies seem to result in less psychological trauma after a rape? 2) What additional therapeutic techniques are needed to aid the rape victim?
REFERENCES
I . Coelho G. Hamburg D. Adams I (eds): Coping and Adaptation. New York. Basic Books, 1974 2. Lazarus RS, Averill JR. Opton E Ir: The psychology of coping: issues of research and assessment, in Coping and Adaptation. Edited by Coelho G. Hamburg D. Adams I. New York, Basic
Books. 3.
1974.
Stevenson
pp 249-315
I:
Precognitions
pects ofStress. Edited Thomas, 1970. pp 3-28 4.
of
Glass Al: The psychological Ibid. pp 62- 69
5. Hackett
TP. Cassem
6.
ening illness. Chodoff P: vival. Ibid.
7.
Chodoff
disasters.
by Abram
aspects
NH:
Ibid. pp Psychological pp 44-61
P. Friedman
in
Psychological
HS. Springfield. of emergency
Psychological
As-
Ill. Charles
C
situations.
reactions
to life-threat-
29-43 response
SB,
to concentration
Hamburg
DA:
Stress.
camp
defenses
sur-
and
coping behavior: observations in parents of children with malignant disease. Am J Psychiatry 120: 743-749. 1964 8. Hamburg DA. Hamburg B. deGoza 5: Adaptive problems and
mechanisms
in severely
burned
patients.
Psychiatry
16:1-20.
1953
9. Lazarus RS: Psychological Stress and the Coping Process. New York. McGraw Hill Book Co. 1966. pp 258-318 10. Burgess AW, Holmstrom LL: Rape:’Victims of Crisis. Bowie, Md. Robert I Brady Co. 1974 II. Schultz LG (ed): Rape Victimology. Springfield. Ill, Charles C Thomas. 1975 12. Queens Bench Foundation: Rape Victimization Study. San Francisco, Calif. Queens Bench Foundation. 1975
Am J Psychiatry
/33:4,
April
/976
417
RAPE
13.
14.
15. 16. 17.
CRISIS
INTERVENTION
Giacenti TA. Tjaden C: The crime of rape in Denver. Denver, Cob. Denver High Impact Anticrime Council. 1973 (unpublished report) Brodsky SL: Prevention of rape: deterrence by the potential victim. in Sexual Assault: The Victim and the Rapist. Edited by Walker Mi. Brodsky SL. Lexington. Mass. DC Heath and Co. 1976 Burgess AW, Holmstrom LL: Rape trauma syndrome. Am I Psychiatry 131: 981-986. 1974 Holmstrom LL. Burgess AW: Rape: The Victim Goes on Trial. New York. Wiley-lnterscience (in press) Rapoport L: The state of crisis: some theoretical considerations. Social Service Review 36:211-217. 1962
Development Program
of a Medical
BY SHARON AND SUSAN
L. NIW)MBIE, PELL. R.N.
M.S.W..
Center
ELLEN
BASSUK,
,
.
the
is the
United
rape
States: 31,000
(from
Revised
version
the American 1975. authors
ton,
Mass.
tervention chiatry. Bassuk
the to
of a paper Psychiatric
FBI 51,000
psychological rising violent
reported
cases)
a 68% between
presented
at the 128th
Association,
Anaheim,
attack crime in
increase in 1968 and
annual Calif..
meeting May
of 5-9.
Israel Hospital. 330 Brookline Ave., BosMs. McCombie is Director, Rape Crisis InProgram, Drs. Bassuk and Savitz are Assistants in Psyand Ms. Pell is Head Nurse, Inpatient Psychiatric Unit. Drs. and Savitz are also Instructors in Psychiatry. Harvard Medi-
The
cal School, 418
a physical, social, and person. It is the fastest
are with Beth
02215,
Boston,
where
Mass.
Am J Pschiat
/33:4,
April
1976
Parad
HI.
emergency nik HLP. 19.
Resnik care, Ruben
HLP:
JE. Lindemann and Adaptation.
Adams
I. New
York.
20.
Murphy LB: Coping. Ibid. pp 69-100
21.
Burgess ulations.
22.
Hamburg Arch Gen
M.D.,
AW. Lazare Englewood DA. Adams Psychiatry
Crisis
ROBERTA
The
practice
in Emergency HL. Bowie.
Adams Coping
Rape
The Rape Crisis Intervention Program at Beth Israel Hospital utilizes volunteer mnultidisciplina’ counseling teams dra wn from psychiatry social work, psychology, and nursing staffs. The premise of the program is that ear/v crisis intervention can prevent later development ofpsvchological disturbances in victims Counselors accompany victims throughout emergency room procedures:frllow-up begins 48 hours after the initial contact and continues at regular intervalsfor at least a ‘ear. The authors discuss the problems ofimplementation, which include staff resistance,funding questions. and varying levels of counseling sophistication, and describe how these difficulties have been handledin theirprogram. They note that this program is becoming a resource center for the community.
RAPE upon
18.
E: Basic
of
Psychiatric
Md. Charles Coping Edited
with
by
Books,
crisis
intervention
Care. Press,
Edited by Res1975. pp 23-34
long-term
Coelho 1974.
vulnerability
and
A: Community Cliffs. NI.
Mental Prentice-Hall,
IE: A perspective 17:277-284. 1967
G,
pp
resilience
disability,
in
Hamburg
D.
127-138 in childhood.
Health: Target 1976 on
in
coping
Pop-
behavior.
Intervention
SAVITZ.
M.1).,
1973. and police figures in Boston show a 43.5% increase between 1972 and 1973 (1). Rape has been viewed primarily as a sexual rather than a violent assault. The traditional assumption is that the woman in some way invited the attack. This attitude obscures recognition of the trauma experienced by the victims and interferes with the devebopment of adequate community and institutional resources to treat them. This is reflected in the absence or fragmentation of medical and psychological care for nape victims. In response to this problem, a comprehensive support system for the rape victim has been developed at the Beth Israel Hospital. a metropolitan teaching facility oriented toward community medicine. Particularly in urban areas,, hospital emergency rooms are the typicab health care facility utilized by victims at the time of the rape. Prior to the development of our project, emergency room records showed that an average of one victim a week received medical care during 19721973. The psychiatric service was consulted only if the victim presented a management problem for the emergency room staff. Follow-up was generally inconsistent. Clinicians were impressed, however, by the number of women who appeared at the Psychiatry Clinic months or years later for whom the rape was a major component in the presenting symptomatology. At the time of the assault, these women had not sought psychiatric assistance. Indeed, many had never told anyone about the rape. The Rape Crisis Intervention Program is based on the premise that early intervention can prevent the development of psychological and psychosomatic distur-
ANN
9. lanis
IL:
Psychological
Stress.
New
York,
John
Wiley
& Sons.
12.
1958 10.
11.
Weiss Ri, Textbook Baltimore,
Kardiner York,
Payson
A, Spiegel PB
ANN
Gross
of Psychiatry. Edited Williams & Wilkins Hocher,
Coping BY
HE:
H: War
stress by Co.
Stress
reaction,
in Comprehensive
Freedman 1967, pp
AM, Kaplan 1027-1031
and
Neurotic
Illness.
HI.
13.
New
WOLBERT
of the
BURGESS,
Rape
D.N.SC.,
AND
BEHAVIOR
of
people
faced
with
critical
LYNDA
LYTLE
life
situ-
ations is receiving increased attention in the literatune (I). The immediate efforts people use to deal with highly stressful situations are an important assessment point for clinicians who see patients in acute crisis. These coping behaviors may be viewed as problemsolving attempts an individual makes when facing demands that are highly relevant to his/her safety and that tax adaptive resources (2). Before describing the various coping strategies used by rape victims facing attack, it will be useful to review some coping strategies found in other types of crisis or stressful situations.
Presented Association,
at the 128th Anaheim,
Dr. Burgess is Associate Associate Professor of
Mass.
02167.
annual Calif., Professor Sociology.
meeting of the American May 5-9, 1975. of Nursing Boston
LYNDA
Kardiner A: The Traumatic Neuroses of Medicine Monograph Il-Ill. Washington. search Council. 1941 Grinker R, Spiegel I: Men Under Stress. ton, 1945
LYTLE
HOLSTROM
War. Psychosomatic DC. National Philadelphia.
Re-
Blakis-
of the rape
vic-
Victim
The coping behavior ofrape victims can be analyzed in three distinct phases-the threat ofattack, the attack itself and the period immediately thereafter. The authors analyzed the reported coping behavior of 92 women diagnosedas having rape trauma. Most of the women used verbal, physical, or cognitive strategies when threatened, although 34 were physically or psychologically paralyzed. The actual rape prompted coping behaviors in all but I victim. Escaping the situation or the assailant is the primary task immediately after the attack. In counseling the rape victim, it is important to understand her individual style ofcoping, to be supportive ofit, and to suggest alternativesforfuture stressful situations.
THE
AND
14. Burgess AW, Holmstrom LL: Coping behavior tim. AmI Psychiatry 133:413-418. 1976
1941
Behavior
BURGESS
Psychiatric
and Dr. Holmstrom College. Chestnut
is Hill,
HOLMSTROM,
PH.D.
Researchers have focused on different aspects of the coping process. Extrasensory awareness of disaster situations was studied by Stevenson (3) in 19 people who survived the sinking of the Titanic. Glass (4) considered behavior over time in order to be able to view various phases ofbehavior separately. Most ofthe dinical studies have reported on the use of psychological mechanisms as part of the coping process: examples include denial in people with acute myocardial infanction (5), isolation of affect, denial, and regressive behavior in victims ofconcentration camps (6), denial, isolation ofaffect, and motor activity in parents of children with malignant disease (7), and emotional constniction, repression, suppression, denial, and delusion-hallucination formation in severely burned patients (8). Lazarus (9) took a behavioral approach and classified four important coping reaction patterns: I) actions aimed at strengthening the individual’s resources against harm, 2) avoidance, 3) attack. and 4) inaction. There have been several recent studies of victim crisis situations involving major crimes, including forcible rape and situations in which victims have successfully interrupted or prevented attack (10-12). Giacenti and Tjaden (13) reported that out of915 cases in the Denver area, 3 19 victims were able to interrupt the rape by active resistance, fleeing, physically fighting, crying aloud, verbal refusals, and outside intervention. In studying rape prevention, Brodsky (14) has focused primarily on verbal or vocal responses in the interpersonal prerape situation. We saw a variety of ways to look at the coping behavior of rape victims in the literature. We drew on these studies and took a combination of areas to analyze, emphasizing the thoughts. feelings, and actions of rape victims as they related to specific time phases of the attack. Am J Psychiatry
/33:4,
April
/976
413
COPING
BEHAVIOR
TABLE 1 Coping Behavior of 92 Rape Victims
Description
Number
of Behavior
Victims
with
strategies
(N
of Victims
58)* 18 57 21
Cognitive assessment Verbal tactics Physical action Victims
without
strategies
(N
34)
22 12
Physically paralyzed Psychologically paralyzed *
Many
ceed
victims
had
thought he might do harm, wondered why the man had been hanging around all evening, remembered seeing the man before. looked at the car that pulled up, thought it strange the apartment bight did not go on, on heard a noise in the kitchen and went to investigate. Several victims described a subjective awareness alerting them to danger such as being scared when their boyfriend was pushed out of the can or feeling frightened when they realized what was happening.
in Response to Threat of Attack
more
than
one
strategy:
therefore.
the
total
Threat
numbers
cx-
58.
METHOD
We interviewed all persons entering the Boston City Hospital Emergency Department over a one-year penod with the chiefcomplaint ofhaving been raped. Subjects were interviewed at the hospital. usually within hours ofthe attack. The interview included a series of open-ended questions in which victims were asked how they felt and reacted to the circumstances prior to the attack, the attack itself. and the chain ofevents following the attack. Follow-up interviews were possible with 85% ofthe total sample of 146 victims and included further recounting ofthe details ofthe attack. Diagnostic categories were devised from the total sample. and a subsample of92 women aged 17-73 diagnosed as having rape trauma (15) was used in this analysis of coping behavior before. during, and immediately following the attack.
BEFORE
THE
THREATENING
ATTACK:
COPING
BEHAVIOR
IN
A
SITUATION
Most of the victims perceived the rape as a lifethreatening experience. The minority who did not so perceive it still saw the rape as an acutely stressful, frightening. and degrading experience. For almost all victims, this attack was something far out of the ordinary that seriously taxed their adaptive resources. Ear/v
A tt’areness
o./Danger
of Attack
The threat of attack is the point when the person realizes there is definite danger to his or her life-the coping task at this stage is to attempt to avoid or escape the situation. The person is aware something cnitical is going to happen but may not realize that nape is the imminent danger: for example. the person may instead fear robbery or aggravated assault. Coping behavior was analyzed in terms of whether on not victims were able to react to the confrontation with danger. This ability to react often depended on the amount of time between the threat of attack and the attack, the type of attack. and the type of force or violence used. A majority of victims used one or more strategies and a minority ofvictims were unable to use any strategies (see table I). Basic
Strategies
Cognitive assessmnemit. Victims may cope by mentally assessing the situation to determine possible alternatives, e.g. they may think about how they can get away from the assailant’s grasp on escape from a car or room safely. or they may worry that the man will panic and hurt them and plan how to keep calm. Verbal tactics. The majority ofthe coping strategies were verbal: they included talking one’s way out of the situation (‘ ‘I tried to engage them in conversation such as asking where they went to school and why they were doing this’ ‘), stalling for time (‘ I tried to talk to him; tried to get him to come for coffee at a restaurant down the street’ ‘), reasoning with the assailant by trying to change his mind (‘ ‘I’m a married woman”; “I’m a virgin’ ‘), trying to gain sympathy from the assailant (“Look at the trouble you’re causing me”; ‘What will I do?’ ‘) using flattery (‘ ‘You’re an attractive man; surely you don’t have to do this for sex”), bargaining with the assailant (“There’s my TV, take it and go”). feigning illness (‘ ‘I’m sick’ ‘), threatening the assailant (‘ My husband is due home’ ; ‘My kids are in the next room’ ; A policemen lives in this building’ ‘), verbal aggression (‘ ‘Get your hands off me’ : Don’t touch me’ ; What are you doing?”), changing the assailant’s perception of thevictim (“I talked to him like a mother. ‘), joking and sarcasm (a woman awakes to see a man coming in her room saying. ‘I’m escaping from the police’ ; she says, “OK-I’ll let you out the back door”). Physical (U’tiOli Some victims took direct action aimed at preventing the attack by fleeing from the situ.
‘
‘
Appraisal ofthe degree ofdanger. threat, or harm is a psychological process that intervenes between a stressful event and coping behavior. This early awareness may be cognitive, perceptual, or affective-often, the victim describes it as a sixth sense’ or a feeling of impending danger. The coping task during this phase is to react quickly to this warning. Only 15 of the 92 women we interviewed spontaneously reported some cognitive or perceptual awareness of the potential danger they faced, and they were not totally clear about the nature of the danger-they just knew that something was wrong. Reports of this vague, obscurely formulated consciousness of danger varied. Victims said they saw a strange man and either ‘ ‘
414
AmmiJ Psychiatry
/33:4,
‘
April
/976
‘
‘
‘
‘
‘ ‘
‘
‘ ‘
‘ ‘
‘
‘
‘
.
‘
ANN
ation or fighting the assailant the broken glass” ; “I tried apartment”).
(‘ ‘I tried to stab him with to push him back out of the
WOLBERT
TABLE 2 Coping Behaviors Description
Lack
AND
of 90 Women
LYNDA
LYTLE
HOLSTROM
During Rape
of Behavior
Number
of Victims
of Strategies
One-third ofthe victims were unable to use any strategy to avoid the attack. The victim might be physically paralyzed and totally overpowered by the assailant. For example, several victims were in their beds sleeping when the assailant gained access to their apartments and attacked them (“It was around 3 a.m. I woke to feel someone jumping on me”). The victim might be walking down the street and suddenly grabbed by one or two assailants. The use of a weapon often paralyzed a person. The following example from a referral case illustrates early awareness of danger and physical paralysis: ‘The door buzzer rang I was expecting friends and opened my door saw three men with a paper in one’s hand I froze paralyzed for a moment something went through my head . shut the door but they pushed it back open . . . with the gun In some cases, the victim was totally stunned on surprised by the change in behavior ofa man whom she knew as a friend, neighbor, or acquaintance. and said He just grabbed me before Iknewit.” Victims may be psychologically paralyzed either through their defensive structure (‘ When I realized what he was going to do I blanked out . tried not to be aware of what was going on’ ‘) or because of their use of alcohol or drugs prior to the attack. Thoughts of death may paralyze a victim (‘ ‘I thought he’d be the last person I’d see alive”). .
‘
.
.
.
.
.
.
.
.
.
.
.
Cognitive strategies Affective response (N =25) Crying Anger Verbal strategies (N =23)
28 17 8
Screaming
14
Talking
9
Physical action Psychological defense Physiological reaction No strategy No data
23 17
10 I 8
.
.
.
.
.
.
said said,
they needed ‘Who you
to use my phone. trying to call, Red
I tried China?’
to joke
and
.
‘ ‘
‘
.
Multiple
BURGESS
.
Strategies
Victims may try a number of strategies: 31 women had multiple strategies, 27 had one, and 34 had none. One woman who was successful in avoiding attack said, “First I tried to calm him down; tried to talk softly to him and said, ‘OK, we be friends. Then I said my brother was due home any time I tried all I knew, verbal and physical . . I screamed and fought The brother did come home and the assailant left without completing the rape. Another victim who tried several strategies was not successful with three men who had forced her into a car as she waited for a bus after her evening classes at a local university. She tried verbal tactics (‘ My husband will be worried and probably call the police if I am not home’ ‘), but the assailants told her that such remarks would “get me dead.” The victim then became silent. She later tried bargaining (“I offered them my money to let me go”) and finally decided to comply (“I decided the only way was to play it their way”). In another case, one can see the coping behaviors of early awareness, an affective reaction of fear, cognitive assessment, and verbal tactics of joking: “I got a warning. saw two men at the end of my hall. got frightened didn’t know how they got there. They ‘
.
.
DURING
THE
ATTACK:
COPING
WITH
THE
RAPE
At the moment of the actual rape attack, it becomes clear to the victim that forced sexual attack is inescapable. The coping task during this phase is to survive the rape despite the many demands forced upon the victim, such as oral, vaginal, and anal penetration. She also may be forced to have conversation with the assailant. Victims coped with the actual rape in a vanety of ways, as table 2 indicates. Cognitive
Strategies
Victims often cope by mentally focusing and directing their attention to some specific thought to keep their minds off the reality of the event and focus on their survival. Remaining calm was a strategy in which the victim specifically controlled herself mentally so as not to provoke additional violence. The victim might talk to herself, as in the following case:
.
.
I kept thinking me, he choked
keep cool. He said he’d kill me. He hit he could kill me. I said to myself, ‘You can handle anything; come on, you can do it. I decided not to fight him . . . he was holding my neck so tight I responded a little to him . . . that blew his mind that I acted as I did. Itwas very quick. thank God. .
.
.
me,
‘
.
.
.
‘
.
.
.
.
.
.
.
Memorizing details was a strategy that paid off later in some cases. One referred victim said, “I focused on their faces and thought to myself, ‘I’ll see you guys in court ifl get out ofthis alive.’ She did. Another victim said, “I played detective tried to observe cvenything. bike the tatoo on his arm, remarks he made, route of travel of the car, license of the car.” Recalling advice people have given on the subject of nape is another strategy victims report: “I remember a conversation I had with my husband. He said if I was attacked not to resist if he wants sex. My husband said “
.
Am J Psychiatry
.
.
133:4,
April
1976
415
COPING
BEHAVIOR
the guy could kill me or the children but sex wouldn’t kill me.” Another victim said, “I remember talking with people about rape and they always said not to resist that a female could be killed, beaten, or mutilated. I didn’t want that to happen.” Memories of previous violent situations provided some victims with alternatives (“I struggled a little then remembered when I was 12 I fought a neighbor boy and got my nose broken”). Praying for help is a tactic to decrease stress and tension (“I wasn’t listening to them but concentrating on praying that my friends who had keys to my apartment would come”). Concentrating on the assailant in terms of who he is and what has led to this attack is also a strategy (“I remember thinking that this person must have a home-must live somewhere why would he do this on Mother’s Day? I thought of the irony of it “) Compliance is a strategy used to “speed it up get it over with.” To many victims, the attack seemed interminable. .
.
.
.
.
.
.
.
gled until I realized he was going to rape me. He wanted to nape me more than I could manage to resist”). Some victims quickly discovered that struggling and fighting were just what the assailant wanted (“The more I screamed and fought, the more excited he would get”). Psychological
Defenses
.
.
.
.
.
.
.
.
.
.
.
.
.
Defense mechanisms are another way rape victims cope with the overwhelming fear of attack. Defenses close the cognitive field and thus block out the unbearable feeling. Some women denied the attack (“I never thought it could happen’ ‘), experienced dissociative feelings (“I pinched myself to see if I was real”), suppressed the rape (“I am missing 10 minutes of my life”), or rationalized (“I felt sorry for him if this was the only way he knew how to get sex”). One victim described her reaction as follows: “I did not struggle because of the knife. All those things you read about or plan to do don’t help I felt I was not going to get out alive I was resigned; I felt nothing, empty; felt this can’t happen to me.” .
.
Verbal
Strategies
Victims combined verbal and affective responses by screaming and yelling. This tactic served both to relieve tension involuntarily and to deter the assailant from his full intent. This tactic brought police to the scene in several cases, which sometimes resulted in the assailant being apprehended during the attack. Several victims believed that talking with the assailant during the attack helped them avoid additional violence. The assailant may demand to know how the victim is “enjoying” the rape. One victim handled the situation as follows: “He kept wanting to know if it felt good and I had to say yes to keep him happy He said, ‘I’m on drugs lady and I need money fuck me good or I’ll kill you. He needed to be reassured.” Ifthe attack continues over a period oftime, the victim may try verbal tactics to calm the assailant and thus avoid further demands (“I talked to calm him down I asked questions and he kept talking”). Sancasm may be used as a coping strategy, especially if that is the victim’s usual verbal style. .
.
.
.
.
.
‘
.
.
.
As he was molesting me he asked ifI enjoyed it and I said. “Oh. sure, it is great.” I decided to go along with him. He seemed to need reassurance . . I wasn’t scared then. First thought he’d get his kicks and then it’d be all overI’d be dead. I got faith that he wasn’t going to harm me. .
Some victims tried to gain control in the situation by scaring the assailant(s) (“You’ll be in real trouble if you kill me”; “You’ll be sorry. I’ll get someone to kill you”). This strategy was partially successful in some cases. .
Physical
Action
Victims reported struggling assailants to avoid penetration ened my muscles”). Sometimes a certain point and then stopped 416
.
Am
J Psychiatry
/33:4.
and fighting (“I struggled the victim (“I fought April
1976
with their and tightstruggled to and strug-
.
.
.
.
Physiological
Response
Not all coping behavior is voluntary and conscious. Certainly, some screaming and yelling is involuntary, and victims also reported physiological responses of choking, gagging, nausea, vomiting. pain. urinating, hyperventilating, and losing consciousness. One victim described an epileptic seizure: Only thing I remember is getting the key into the lock to get into the building. Then I got warning signs to my seizure attacks . . getting overheated and the ringing in my ears and that’s all. When I regained consciousness I was in the hall by the door to the basement. I dragged myself out as I heard someone saying. ‘Who left their keys in the door?” .
‘
Another victim described how her involuntary reaction scared the assailant off after he raped her: ‘I felt faint, trembling and cold I went limp. I think he got scared and thought I was out.” ‘
.
AFTER
THE
ASSAI
LANT
ATTACK:
.
.
ESCAPING
FROM
THE
The stressful situation is not oven when the actual rape ends. The victim must alert others to her distress, escape from the assailant, on free herself from where she has been left. The coping task immediately following the rape is to be free or escape from the assailant. Alerting others. Victims are always hopeful that someone will come to their aid, and they may spend time concentrating on how to obtain help. Bargaining for freedom. Often, the victim must negotiate with the assailant through a bargaining process.
The
assailant
sympathy tell, or
and he may
sometimes thus give
get the
apologizes the victim to victim orders
and
tries
to gain
promise not or instructions
to
WOLBERT
ANN
(‘ ‘I’ll
kill you if you tell or go to the police’ : Don’t move from that position for 30 minutes’ ‘). During the bargaining process the victim may cope by remaining silent or agreeing to instructions. Some victims promised not to tell anyone or invented stories to preserve their lives: ‘I told him my girl friend had this happen and when she went to the police they didn’t believe her. I told him I’d never go to the police.” Freeimig omie.se/f. The victim may have to free herself from the situation-if she has been tied and gagged. she has to cope with physically freeing herself. Cognitive assessment of the situation and keeping calm will be most useful strategies to her, as was the situation in the following referral case: ‘I lay still for a moment then realized that the faster I got myself untied, the faster I could get to the police and my friends . . ankle ties . . . getting cramps in my legs . . . so I had to tell myself not to panic and I worked the wrist ties and ankle ties next Mastery. in terms of survival of the attack, may be verbalized by the victim as well as her family and friends when this stage has been managed successfully: ‘The worst is over . . . I got through it . . . I am grateful to survive.” Once free ofthe assailant. the victim must still cope with the stress of the aftermatu of the rape. Victims are often immediately faced with trying to cope with the institutions that are set up to deal with rape (16). ‘
‘ ‘
‘
‘
.
.
.
‘
COUNSEE.ING
IMPLICATIONS
Understanding a person’s coping behavior when faced with a life-threatening situation is an essential step in crisis intervention. Rapoport (17) noted that patterns of coping in crisis situations may be adaptive or maladaptive. Parad and Resnik (18) stated that the purpose of actively focused crisis intervention is to steer the person toward adaptive coping and away from maladaptive behavior. Adams and Lindemann (19) formulated coping principles drawn from a study of catastrophic disabling injuries; they emphasized identifying the acute crisis and the psychological means by which the crisis is to be managed if not mastered. The assessment of coping behavior and strategies provides the clinician with two therapeutic measures. First, such assessment can be used as a supportive measure. By listening to the victim recount the rape. clinicians can identify the coping behavior and acknowledge this information to the victim. This support tells victims that their coping behavior was a positive adaptive mechanism used to survive a life-threatening situation. By verbally conveying this information, the clinician attempts to alleviate some of the guilt suffered by a victim who may think. “I did not do enough-I could have done more.” This therapeutic approach sets in motion a positive sense of self-esteem and worth. As was noted by one victim, who was raped by two assailants at knife point, “At least I
BURGESS
AND
LYNDA
LYTLE
HOLSTROM
wasn’t so whacked out that I couldn’t get a description and license ofthe car.” Reaffirming the strategic use of hen cognitive abilities helped this victim to see herself as a person who was able to do something in a highly stressful situation, even though she was physically immobilized. Such a response by the clinician strengthens the therapeutic alliance in terms of providing positive expectations regarding the victim’s capacity to restore herself to hen precnisis level of functioning. Thus we see that Murphy’s model of resilience (20), wherein a person sees herself as someone who is resilient and expects to recover from the trauma. has significance in counseling nape victims. The second use of assessment of coping behavior is to give the clinician a reference point from which to begin the clinical negotiation for crisis service (21). As the victim states her request and it is negotiated, additional requests may be elicited. For example. one request may be related to primary prevention in terms of what other strategies might be used in such situations. The clinician can explore with the victim the crisis behaviors she used and analyze their effectiveness. New strategies might be suggested as possibilities in future stressful situations. It is important to help expand the person’s problem-solving capabilities (22). We believe our analysis of the coping behavior of rape victims opens up other research areas. There are two questions of major importance: I) what coping strategies seem to result in less psychological trauma after a rape? 2) What additional therapeutic techniques are needed to aid the rape victim?
REFERENCES
I . Coelho G. Hamburg D. Adams I (eds): Coping and Adaptation. New York. Basic Books, 1974 2. Lazarus RS, Averill JR. Opton E Ir: The psychology of coping: issues of research and assessment, in Coping and Adaptation. Edited by Coelho G. Hamburg D. Adams I. New York, Basic
Books. 3.
1974.
Stevenson
pp 249-315
I:
Precognitions
pects ofStress. Edited Thomas, 1970. pp 3-28 4.
of
Glass Al: The psychological Ibid. pp 62- 69
5. Hackett
TP. Cassem
6.
ening illness. Chodoff P: vival. Ibid.
7.
Chodoff
disasters.
by Abram
aspects
NH:
Ibid. pp Psychological pp 44-61
P. Friedman
in
Psychological
HS. Springfield. of emergency
Psychological
As-
Ill. Charles
C
situations.
reactions
to life-threat-
29-43 response
SB,
to concentration
Hamburg
DA:
Stress.
camp
defenses
sur-
and
coping behavior: observations in parents of children with malignant disease. Am J Psychiatry 120: 743-749. 1964 8. Hamburg DA. Hamburg B. deGoza 5: Adaptive problems and
mechanisms
in severely
burned
patients.
Psychiatry
16:1-20.
1953
9. Lazarus RS: Psychological Stress and the Coping Process. New York. McGraw Hill Book Co. 1966. pp 258-318 10. Burgess AW, Holmstrom LL: Rape:’Victims of Crisis. Bowie, Md. Robert I Brady Co. 1974 II. Schultz LG (ed): Rape Victimology. Springfield. Ill, Charles C Thomas. 1975 12. Queens Bench Foundation: Rape Victimization Study. San Francisco, Calif. Queens Bench Foundation. 1975
Am J Psychiatry
/33:4,
April
/976
417
RAPE
13.
14.
15. 16. 17.
CRISIS
INTERVENTION
Giacenti TA. Tjaden C: The crime of rape in Denver. Denver, Cob. Denver High Impact Anticrime Council. 1973 (unpublished report) Brodsky SL: Prevention of rape: deterrence by the potential victim. in Sexual Assault: The Victim and the Rapist. Edited by Walker Mi. Brodsky SL. Lexington. Mass. DC Heath and Co. 1976 Burgess AW, Holmstrom LL: Rape trauma syndrome. Am I Psychiatry 131: 981-986. 1974 Holmstrom LL. Burgess AW: Rape: The Victim Goes on Trial. New York. Wiley-lnterscience (in press) Rapoport L: The state of crisis: some theoretical considerations. Social Service Review 36:211-217. 1962
Development Program
of a Medical
BY SHARON AND SUSAN
L. NIW)MBIE, PELL. R.N.
M.S.W..
Center
ELLEN
BASSUK,
,
.
the
is the
United
rape
States: 31,000
(from
Revised
version
the American 1975. authors
ton,
Mass.
tervention chiatry. Bassuk
the to
of a paper Psychiatric
FBI 51,000
psychological rising violent
reported
cases)
a 68% between
presented
at the 128th
Association,
Anaheim,
attack crime in
increase in 1968 and
annual Calif..
meeting May
of 5-9.
Israel Hospital. 330 Brookline Ave., BosMs. McCombie is Director, Rape Crisis InProgram, Drs. Bassuk and Savitz are Assistants in Psyand Ms. Pell is Head Nurse, Inpatient Psychiatric Unit. Drs. and Savitz are also Instructors in Psychiatry. Harvard Medi-
The
cal School, 418
a physical, social, and person. It is the fastest
are with Beth
02215,
Boston,
where
Mass.
Am J Pschiat
/33:4,
April
1976
Parad
HI.
emergency nik HLP. 19.
Resnik care, Ruben
HLP:
JE. Lindemann and Adaptation.
Adams
I. New
York.
20.
Murphy LB: Coping. Ibid. pp 69-100
21.
Burgess ulations.
22.
Hamburg Arch Gen
M.D.,
AW. Lazare Englewood DA. Adams Psychiatry
Crisis
ROBERTA
The
practice
in Emergency HL. Bowie.
Adams Coping
Rape
The Rape Crisis Intervention Program at Beth Israel Hospital utilizes volunteer mnultidisciplina’ counseling teams dra wn from psychiatry social work, psychology, and nursing staffs. The premise of the program is that ear/v crisis intervention can prevent later development ofpsvchological disturbances in victims Counselors accompany victims throughout emergency room procedures:frllow-up begins 48 hours after the initial contact and continues at regular intervalsfor at least a ‘ear. The authors discuss the problems ofimplementation, which include staff resistance,funding questions. and varying levels of counseling sophistication, and describe how these difficulties have been handledin theirprogram. They note that this program is becoming a resource center for the community.
RAPE upon
18.
E: Basic
of
Psychiatric
Md. Charles Coping Edited
with
by
Books,
crisis
intervention
Care. Press,
Edited by Res1975. pp 23-34
long-term
Coelho 1974.
vulnerability
and
A: Community Cliffs. NI.
Mental Prentice-Hall,
IE: A perspective 17:277-284. 1967
G,
pp
resilience
disability,
in
Hamburg
D.
127-138 in childhood.
Health: Target 1976 on
in
coping
Pop-
behavior.
Intervention
SAVITZ.
M.1).,
1973. and police figures in Boston show a 43.5% increase between 1972 and 1973 (1). Rape has been viewed primarily as a sexual rather than a violent assault. The traditional assumption is that the woman in some way invited the attack. This attitude obscures recognition of the trauma experienced by the victims and interferes with the devebopment of adequate community and institutional resources to treat them. This is reflected in the absence or fragmentation of medical and psychological care for nape victims. In response to this problem, a comprehensive support system for the rape victim has been developed at the Beth Israel Hospital. a metropolitan teaching facility oriented toward community medicine. Particularly in urban areas,, hospital emergency rooms are the typicab health care facility utilized by victims at the time of the rape. Prior to the development of our project, emergency room records showed that an average of one victim a week received medical care during 19721973. The psychiatric service was consulted only if the victim presented a management problem for the emergency room staff. Follow-up was generally inconsistent. Clinicians were impressed, however, by the number of women who appeared at the Psychiatry Clinic months or years later for whom the rape was a major component in the presenting symptomatology. At the time of the assault, these women had not sought psychiatric assistance. Indeed, many had never told anyone about the rape. The Rape Crisis Intervention Program is based on the premise that early intervention can prevent the development of psychological and psychosomatic distur-
