Working with victims of crime: A manual applying research to clinical practice (Second Edition)

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3.0 Common Reactions to Crime

It is useful to know the common reactions that victims may experience when trying to cope with the crime. Keep in mind that each victim will have his or her own unique path towards recovery, but being aware of common reactions can help workers better help victims recover. Research indicates that about 25% of victims of violent crime reported extreme levels of distress, including depression, hostility, and anxiety (Norris et al. 1997). Another 22% to 27% reported moderate to severe problems. This means that around 50% of victims of violent crime report moderate to extreme distress. Table 1 shows the reactions that researchers and theoreticians have observed in crime victims. Workers may also recognize these reactions in the victim’s friends and family, since crime affects family and friends, school, work and the broader community (Burlingame and Layne 2001).

Anger

The issue of anger as a reaction is notably more complicated than one might at first assume. Researchers often link anger to property crime and fear to violent crime (Greenberg and Ruback 1992). However, anger is basically a reaction wherein people feel cheated out of something they feel they deserved. In the case of criminal victimization, they have been cheated out of their feelings of safety and fairness and belief in a just world, etc. Thus, anger can be a reasonable reaction to any type of crime. In life, anger can act as a motivator to change. Greenberg and Ruback (1992) point out that many victims create internal fantasies about getting revenge or justice. If these fantasies have positive outcomes (e.g. the perpetrator is caught), they may increase the chance the victim will take action. Thus, so-called righteous anger can help the person move forward, feel energized, to deal with the criminal justice system or get help. On the other hand, researchers have examined post-traumatic stress disorder and anger/revenge/retaliation fantasies in victims of violent crimes (Orth et al. 2008; Orth et al. 2006). They concluded that anger and revenge fantasies may initially make victims feel better, but may cause problems if the person continues to think about the crime and cannot move forward. Under this view, the timing and content of anger management programs may be very important in helping victims become healthy.

• 1. Casarez-Levison (1992)
• 2. Everly et al. (2000)
• 3. Greenberg and Ruback (1992)
• 4. Leahy et al. (2003)
• 5. Mezy (1988)
• 6. Nishith et al. (2002)
• 7. Norris et al. (1997)
  

Updated references:

• 8. Amstadter et al. (2007)
• 9. Boccellari et al. (2007)
• 10. Boeckmann and Turpin-Petrosino (2002)
• 11. Courtois (2004)
• 12. Danieli et al. (2004)
• 13. Daniels et al. (2007)
• 14. DeValve (2005)
• 15. Dunbar (2006)
• 16. Gabriel et al. (2007)
• 17. Garnetts et al. (1990)
• 18. Herek et al. (1997)
• 19. Janoff (2005)
• 20. Lebel and Ronel (2005)
• 21. Manktelow (2007)
• 22. Miller and Heldring (2004)
• 23. Mock (1995)
• 24. Nordanger (2007)
• 25. Orth et al. (2008)
• 26. Pivar and Prigerson (2004)
• 27. Spataro et al. (2004)
• 28. Staub (1996)
• 29. Thielman 2004
• 30. Wertheimer (1990)
• 31. Young et al. (2007)

That said, workers need to be careful of confusing anger with empowerment. If not handled properly, chronic anger can be very harmful to the victim. Workers may want to focus on anger issues if they see the anger as becoming longstanding and interfering with the person’s healing process. Each victim must be treated as an individual. Workers should help the victim learn to manage all emotions in a way that helps in coping with challenges while remaining healthy. This will help the victim move forward and rebuild his or her life. Anger can be a challenging emotion to face, even for the most skilled clinicians. All workers, regardless of training, should reflect on whether they are able to help victims in this area. If not, they need to refer clients to other professionals.

3.1 Severity of Reaction

Severe reactions can be overwhelming to workers. As reactions become less severe, they do not necessarily become easier for victims. This mismatch poses a challenge both to workers and to victims. Research indicates that violence during the crime increases the severity of the response; victims of non-violent crime, however, also fear for their safety, and can have increased psychological symptoms (Green and Pomeroy 2007b; Norris et al. 1997). Crime-related characteristics may also affect the severity of the reaction. (Steel et al. 2004) found that the number of offenders and the duration of childhood sexual abuse were directly related to psychological distress in both male and female victims. Workers need to pay attention to what the victim reports and use that information to help inform assessments of severity.

Although there is no overall pattern based on victim type, all victims of crime experience distress. The general finding that the more violent the crime, the more severe the reaction offers workers insight into what to expect about client reactions. Thus, a victim of a violent crime who reports that he or she feels no distress may need closer monitoring. The report may be valid, but should be examined in relation to coping skills, current behaviour, and life experience. Workers need to work with clients to help them understand distress levels, how the crime has affected their lives, and what they can do to move forward.

Victims are the best source of information about what is happening in their own lives. Recent Canadian data indicates that 21% of crime victims say that their life was not affected much by the crime (AuCoin and Beauchamp 2007). This same survey looked at victims of violent crime and found that approximately 60% of women and 70% of men reported that their daily activities were not disrupted. Workers should be aware that many victims do not report higher levels of distress (remember: be aware of trauma bias; Nelson et al. 2002). Research on female sexual assault victims found that they experience more severe reactions and take longer to heal than non-sexual assault victims (Gilboa-Schechtman and Foa 2001). Both groups had similar levels of post-traumatic stress disorder (PTSD) and anxiety, but the sexual assault group showed higher levels of depression.

Gilboa-Schechtman and Foa (2001) also examined “peak reactions” which may be of interest to workers. Peak reactions refer to the point at which the victim experiences the strongest symptoms. They found that the longer a woman took to have her peak reaction, the more symptoms she experienced. In other words, those who experienced the strongest symptoms shortly after the assault had lower levels of depression and PTSD. Thus, workers should watch a victim’s symptoms closely and pay particular attention to victims who are having intense symptoms long after the crime. These clients may benefit from more intensive treatment from mental health professionals.

What workers need to take away from this research is that the unique experience of some people makes one-to-one attention an extremely important part of treatment. Thus, even in a group setting, workers should work to monitor and check in with all clients, not just those who seem to be experiencing problems during a particular session.

Fortunately, group interventions can be helpful, since all victims will have some reaction to dealing with the crime and its effects. However, workers need to be wary of mixing those with highly severe reactions to those with less severe reactions. Social comparison could negatively affect either group (Greenberg and Ruback 1992). Those with more severe reactions may feel that they should be “stronger,” and those with less severe reactions could fear that they will get worse. It may not be possible to have groups for different levels of severity. Workers need to be aware of this challenge and make sure that victims understand that reaction to victimization is very much an individual path. It is important for group work to emphasize that victims can learn something from each other.

A final point on severity: in a large-scale study, Pimlott-Kubiak and Cortina (2003) examined assault history and gender. In grouping their sample of 16,000 people (8,000 women and 8,000 men), they found that most men and women reported little or no victimization. Of those who reported victimization, two groups were over 90% female: those reporting primarily sexual assault; and those reporting repeated violence that included sexual violence. Both of these groups would likely experience severe reactions. This research probably reinforces workers’ experience of seeing mostly female victims in daily practice. Men were more likely to be in the group who described physical abuse in childhood (67% male) and repeated violence that did not include sexual violence (66% male) (Pimlott-Kubiak and Cortina 2003). Although any good assessment needs to ask about a wide variety of issues, workers working with women need to ask about sexual assault either as a single event, or as part of several violent assaults. When working with men, we need to be more aware of a history of physical abuse in childhood and repeated violence. These results remind us that we need to go beyond the specific crime and ask about trauma history and to use this in our interventions.

Client matching

A major reason for looking at severity of reaction is to develop ideas of how to best help victims rebuild their lives. Some victims may benefit the most from relatively minor interventions, for example, sharing information. Others with more severe reactions might require more intensive support that might be provided in a peer group. Finally, there are those clients experiencing severe reactions that may require a referral to mental health counselling or even hospitalization. It would not make sense to only give information to someone experiencing severe distress, nor would it make sense to require a person coping well to enter therapy. Table 2 describes a model to help workers think about these issues. The key element to understand is that crime victims are a diverse group with diverse needs. This diversity requires workers to adapt to the victim in providing those services that best meet the victim’s needs. It may be helpful for offices to review their programs and materials to see if there are any gaps in services that relate to the various need levels (e.g. clear strategies for low- and high-need clients, but fewer for moderate-need clients).

Secondary victimization

Secondary victimization is related to severity as it can worsen an already difficult situation. Basically this happens when the victim comes into contact with professionals and paraprofessionals and is further traumatized by their response. This can happen through retelling the victim’s story, being treated unfairly or experiencing other behaviours that make him or her feel as though people aren’t listening or don’t believe the story. It is noteworthy that victims who described police as “helpful” felt more connected to others (Norris et al. 1997). However, negative experiences with professionals increased post-traumatic stress symptoms (Campbell et al. 1999) and decreased the likelihood of reporting (Monroe et al. 2005). It is fortunate that those victims who received mental health services after having a negative experience with the system showed decreased distress (Campbell et al. 1999). Some have called for increased training for first-responders (police, emergency room staff) who are likely to encounter victims of crime (Cederborg and Lamb 2008; Hamberger and Phelan 2006).

Table 2: Severity by Service type: A proposed model

Needs Level	Description	Possible service options
Low	They are coping well with few symptoms, easily managed through natural coping skills and social support. They may not have experienced a severe crime and/or may have many ways to cope.	Minimal services: information sharing – provide written material, brochures of available supports, and education about signs of deeper problems. These services would also be useful for those who do not feel they have any problems, but are trying to hide their suffering. These same written materials might be given to people in the victim’s support system.
Moderate	Experiencing some symptoms and need to expand coping skills or need a place to deal with overwhelming emotions. Generally, they cope well but are overwhelmed by being victimized.	Peer-run support groups, paraprofessional and volunteer support. Some professional support may be needed, but only on a short-term basis.
High	Experiencing many symptoms or problems and displaying poor coping behaviours. Overwhelmed by being victimized and with few effective supports. Severe trauma may have occurred. Likely evidence of multiple problems and multiple victimizations.	Need for professional treatment. This may include long-term individual or group therapy or even hospitalization to help the person stabilize.

3.2 Previous Victimization

Researchers have found that some people become victimized again and again throughout their lives (Byrne et al. 1999; Messman and Long 1996; Norris et al. 1997; Nishith et al. 2000; Peleikis et al. 2004). The relationships between trauma incidents are quite complex: new victimization interferes with the person’s ability to cope with past trauma; and previous victimization affects how he or she will cope with the new trauma. In effect, the repeated victimizations interrupt the person’s normal healing process, especially if the revictimization occurs in a relatively short period after initial victimization (Winkel et al. 2003).

Norris et al. (1997) noted that crime victimization challenges peoples’ views of themselves or their worlds. Several studies report that previous victimization is a very strong, and possibly the strongest, predictor of further victimization (Byrne et al. 1999; Messman and Long 1996; Norris et al. 1997; Nishith et al. 2000). Research examining women in violent relationships found that many had been victims of childhood victimization and that the specific type of abuse or neglect increased the chances of different problems in adulthood: sexual abuse increased anxiety, whereas emotional neglect increased dissociation and depression (Lang et al. 2004). Female survivors of childhood sexual abuse are at increased risk of later sexual assault (Peleikis et al. 2004). Furthermore, previous victimization seems to affect the victim’s reaction to new victimization, and reduce their willingness to report the crime to authorities (Buzawa et al. 2007). Researchers have theorized that low self-esteem, learned helplessness, poor relationship skills and choices, difficulty reading risky situations, or poverty may affect the choices made by the revictimized person (Byrne et al. 1999; Messman and Long 1996; Nishith et al. 2000).

Furthermore, those victims who had a very bad reaction to previous trauma are likely to have a bad reaction to new trauma (Brunet et al. 2001). Basically, revictimization gets in the way of the their ability to rebuild themselves and their lives. Workers need to ask about previous traumas (both crime-related and otherwise) and focus on details that might give clues on how best to help victims meet their needs. In addition, following-up with questions about how the victim normally handles stressful situations should also help workers to better predict how their client will react to the current trauma.

3.3 Diagnoses Commonly Applied to Crime Victims

Workers can benefit from having a basic understanding of diagnostic terms that they may encounter in files or in speaking to mental health professionals. Diagnoses commonly linked to being a crime victim include anxiety and post-traumatic stress disorder (PTSD) and depression (definitions in Figures 2 and 3).^[4] Researchers have noted that these problems can appear in victims of workplace violence (Rogers and Kelloway 2000), stalking (Löbmann et al. 2003; Pimlott-Kubiak and Cortina 2003), sexual assault (Byrne et al. 1999), childhood sexual abuse (Hembree et al. 2004; McDonagh et al. 2005; Merrill, Thomsen, Sinclair, Gold and Milner 2001; Peleikis et al. 2004), childhood physical abuse (Hembree et al. 2004), violent crime (Byrne et al. 1999), gang-related violence (Ovaert, Cashel and Sewell 2003), and family violence (Chemtob and Calson 2004; Hembree et al. 2004; Wolkenstein and Sterman 1998). PTSD is often discussed as related to victimization, especially when violence occurs (Byrne et al. 1999). Several researchers have noted success in reducing PTSD symptoms through treatment. Successful treatments often include opportunities for the victim to share the trauma story while applying new skills to manage feelings and thoughts (Amstadter et al. 2007; Bryant et al. 2003; Hembree and Foa 2003; Nishith et al. 2002).

Furthermore, many crime victims will be dealing with grief, especially those whose loved ones were victim of homicide (Miller 1998). Grief is a normal reaction to loss; however, the normal healthy grieving process can be complicated by many issues, including victimization. Miller (1998) indicates that along with the feelings of sadness, anxiety, and guilt often seen in grief, survivors of homicide victims can also experience fear and an extreme need to keep themselves and other loved ones safe. Within mental health circles, one may speak of grief or complicated grief. Pivar and Prigerson (2004) describe complicated grief as having symptoms that do not decrease in intensity or frequency, are longer in duration (from two to six months) and interfere with the person’s work, school, social or home life (Pivar and Prigerson 2004). In people who have lost a loved one, workers should watch for a) loneliness, b) intruding thoughts about the person, c) yearning for the person, and d) searching for the person. Other symptoms that should tip workers to refer to mental health profes­sionals are:

• purposelessness or feelings of futility about the future;
• feeling numb or detached;
• difficulty acknowledging the death;
• feeling that life is empty or without meaning;
• feeling that part of oneself has died;
• having a shattered world view (loss of sense of security, trust, control);
• assuming symptoms or harmful behaviours of the deceased person; and
• excessive irritability, bitterness, or anger related to the death. (Pivar and Prigerson 2004, 279).

It is important to recognize that you cannot directly compare one loss to another. Workers should also be aware of the cultural norms of the victim to understand the difference between normal and complicated grief (American Psychiatric Association 1994; Nordanger 2007; Pivar and Prigerson 2004). An easy guideline when dealing with this issue is to use the person’s own definition of whether he or she is overwhelmed by grief and needs help. It can also be helpful for workers to consult with experienced colleagues or ask members of the culture about what is normal in their group. You might also rely on these sources to recommend culturally relevant rituals or support people (Nordanger 2007). In these consultation situations, you should always work to protect the confidentiality of your client.

Researchers have found that criminal violence and negative coping predict PTSD, anxiety and depression to varying degrees (Dempsey 2002; Green and Pomeroy 2007b). Daley et al. (2000) found that more chronic stressors, such as the stress experienced by a victim of family violence, are more likely to wear down the victim, whereas an acute stress, such as single-episode assault by a stranger, may deepen feelings of depression. In a study of adolescents who were victims of violence, Kilpatrick et al. (2003) found that almost 75% of adolescents who had PTSD also had either substance abuse problems or depression. Some researchers recommend that treatment efforts in these cases should target the substance use and PTSD at the same time to increase the chances of success (Amstadter et al. 2007). Gilboa-Schechtman and Foa (2001) noted that victims of sexual assault, versus non-sexual assault, were more likely to experience depression. They theorized that anxiety and PTSD are common to all traumas, but that depression is related to certain types of trauma, such as sexual assault (Gilboa-Schechtman and Foa 2001).

One question that is often raised when examining PTSD is “Why does one person develop the disorder while others do not?” Research has linked the following to increased chances of developing PTSD or interfering with recovery:

• Crime- or trauma-related factors (e.g. trauma severity related to sexual assault) (Brewin, et al. 2000; Gilboa-Schechtman and Foa 2001; Ozer et al. 2003)
• Perpetrator being known to the victim (Gutner et al. 2006) or a relative (Ullman et al. 2006)^[5]
• Lack of social support (Brewin et al. 2000; Gutner et al. 2006; Ozer et al. 2003) or poor reaction from supports (Mueller et al. 2008)
• Additional life stress (Brewin et al. 2000; Ozer et al. 2003)
• Previous PTSD (Brunet et al. 2001; Ozer et al. 2003)
• Dissociation during or immediately following the crime (Ozer et al. 2003)
• Report of childhood abuse (Brewin et al. 2000; Hembree et al. 2004; Peleikis et al. 2004)

Researchers have noted a lesser link between the following and PTSD:

• Previous trauma (Brewin et al. 2000; Ozer et al. 2003; Scarpa et al. 2006)
• Personal psychiatric history (Brewin et al. 2000; Ozer et al. 2003), depression in particular (Ozer et al. 2003)
• Family psychiatric history (Brewin et al. 2000; Ozer et al. 2003)
• Education (Brewin et al. 2000)
• General childhood adversity (Brewin et al. 2000)
• Gender (Brewin et al. 2000)
• Age at time of trauma (Brewin et al. 2000)
• Race (Brewin et al. 2000)

Fortunately, mental health professionals can help clients with these disorders. Both medical and psychological treatments can be effective. Researchers collaborate with clinicians to develop the best treatment possible. For example, effective PTSD treatment often includes an exposure element wherein the person needs to psychologically face the fear and anxiety by discussing or talking about the crime and crime-related reminders (Bryant et al. 2003; Hembree and Foa 2003; Kamphuis and Emmelkamp 2005; Kubany et al. 2004; McDonagh et al. 2005; Nishith et al. 2002). Workers not trained in these issues need to keep in mind the importance of consultation and making appropriate referrals to mental health professionals. This is especially important because many victims may have a combination of disorders (PTSD, other anxiety disorders, depression, substance abuse, personality disorders, etc.) that may affect how they respond to interventions (Amstadter et al. 2007; Chemtob and Calson 2004; Clarke et al. 2008).

A relatively recent treatment approach for trauma that workers may have heard discussed is called Eye-Movement Desensitization and Reprocessing or EMDR (Shapiro 1995). Although it is beyond the scope of this manual to detail any one treatment, EMDR is gaining in popularity and workers may have some clients undergoing this treatment. Briefly, in EMDR the therapist asks the client to focus on the traumatic event (images, thoughts, etc.), evaluate the negative qualities, and change his or her thinking about the trauma or his reaction during the trauma. While this is happening, the therapist gets the client to visually track a finger rapidly waved back and forth in front of the face (Shapiro 1995). There is much debate in the literature about what makes EMDR work, but outcome studies with victims of crime show reduced PTSD symptoms when compared to wait-list controls and similar results to other PTSD treatments (Hembree and Foa 2003).

Workers will also want to consult with healthcare professionals when working with families or children who were criminally victimized. Children will often have similar reactions to crime victimization as adults (Cohen et al. 2003). However, there can be important developmental issues that experts in child development will be able to assess (Pine et al. 2005). Despite these issues, workers may find that the treatments professionals provide children are similar to those adults receive (Cohen et al. 2003).

3.4 When to Refer to Mental Health Professionals

With respect to seeking help, Norris et al. (1997) found that about 12% of victims sought mental health services. Most of these were victims of violent crime. They found that violence and depression were the biggest predictors of seeking help. It is worth noting that they also found that professional help was only effective if the help was prompt and ongoing (Norris et al. 1997). Most Canadian victim services agencies (81%) indicate that they are able to help victims with mental health difficulties, mostly by partnering with mental health services (Brzozowski 2007).

Mental health workers can provide support for more-challenging clients. Although many victims can benefit from traditional services, some may need the more intensive treatment that professionals trained to deal with mental health issues can provide. These include victims who may have a mental illness, intense stress reactions, complicated grief, complex life histories or other problems. As Lawson (2001) noted, most professionals are trained to understand different types of abuse, can help clients process emotions, can teach skills and help with planning/problem solving. Professionals can also help victims identify and use social support systems, and act as an additional support to the natural supports. Basically, professionals can work with the client to help them cope (Gorman 2001).

Understanding your limits is an important part of being an effective worker. You need to use consultation from both your supervisors and co-workers to understand your limits. Thus, there are no set rules as to when to refer your client to more professional services. However, there are some issues that should make you think about whether bringing someone else in may be in your client’s best interest. Obviously, the resources and supports available in your area will also affect what other supports you and the victim can access. This does not mean that you cannot support the client but, rather, that you should consider a referral to mental health professionals when you feel you need help. The following list identifies situations that might require a referral:

1. You suspect the person has depression, anxiety, post-traumatic stress disorder, continued dissociation or other mental health problems (especially if substance misuse is also present).
2. There are complicated grief issues that interfere with moving forward.
3. Suicide or self-harm is a concern.
4. Retaliation, or harming others, is a concern (which may require contacting the police or other authorities as well).
5. Intense emotions (anger, sadness, grief) are beyond your skills or resources.
6. The person seems to be unmotivated and stuck.
7. The person does not seem to get as much from group, self-help, or other interventions.
8. The person does not seem to be getting better even though apparently motivated and working hard.
9. The person has a long, complicated history of victimization or abuse.
10. The person has a long history of mental health or substance-abuse problems.

Those working in more isolated areas should contact their local health care professionals for help in solving problems about how to best meet the needs of victims in general. These partnerships can be invaluable in providing new information and professional support. Isolated workers might also use strategies such as telehealth consultation (using phone, e-mail or video-conferencing) to get guidance or receive consultation or supervision. Telehealth systems can also be used to deliver therapy, with the local supports working with the victim and possibly participating in therapy with a professional in another area. Other possibilities include bringing in professionals to conduct workshops, crisis treatment or supervision sessions. It is important for workers to be cautious about digging deeply into complex victims issues without backup. Sometimes this cannot be avoided, since the victim may be ready to deal with these issues. It is important for workers to ensure that they consult with others when outside their areas of expertise. Acting ethically and being respectful of your clients includes being aware of your own limits.

3.5 The Basics

Reactions

• As people deal with having been victimized, workers can identify common reactions. These reactions are normal, but may still mean that the victim requires help to deal with being overwhelmed. Table 1 lists some common reactions discussed in research.
• Anger is a difficult emotion for the victim and also for the supports and workers. Much care is needed to make sure that it is handled properly (Greenberg and Ruback 1992). Workers should understand that anger is a natural reaction to victimization, but that it can also interfere with getting better. Thus, there is no easy answer to how to handle anger; training, judgment and empathy are your best tools for deciding how to help victims showing anger. Supervision/consultation will be key in dealing with your reaction to anger and other emotions.

• 1. Casarez-Levison (1992)
• 2. Everly et al. (2000)
• 3. Greenberg and Ruback (1992)
• 4. Leahy et al. (2003)
• 5. Mezy (1988)
• 6. Nishith et al. (2002)
• 7. Norris et al. (1997)
  

Updated references:

• 8. Amstadter et al. (2007)
• 9. Boccellari et al. (2007)
• 10. Boeckmann and Turpin-Petrosino (2002)
• 11. Courtois (2004)
• 12. Danieli et al. (2004)
• 13. Daniels et al. (2007)
• 14. DeValve (2005)
• 15. Dunbar (2006)
• 16. Gabriel et al. (2007)
• 17. Garnetts et al. (1990)
• 18. Herek et al. (1997)
• 19. Janoff (2005)
• 20. Lebel and Ronel (2005)
• 21. Manktelow (2007)
• 22. Miller and Heldring (2004)
• 23. Mock (1995)
• 24. Nordanger (2007)
• 25. Orth et al. (2008)
• 26. Pivar and Prigerson (2004)
• 27. Spataro et al. (2004)
• 28. Staub (1996)
• 29. Thielman 2004
• 30. Wertheimer (1990)
• 31. Young et al. (2007)

Severity of Reaction

All victims of crime experience some distress (Norris et al. 1997). Research indicates that violence during the crime increases the severity of the reaction and about 50% of victims of violent crime report moderate to severe reactions (Norris et al. 1997).

Victims of sexual assault reported more severe reactions and took longer to heal than victims of non-sexual assault (Gilboa-Schechtman and Foa 2001).

Workers need to be careful of groups that mix victims who have severe reactions with those that have less severe reactions. Social comparison (feeling better off or worse off) with other group members may interfere with treatment if not handled properly (Greenberg and Ruback 1992). Workers should think about how to best match client needs to service level for their clients’ benefit (see Table 2).

• Women may be at risk for more severe reactions since they are more likely than men to experience sexual assault or repeated victimizations (including sexual assault) (Pimlott-Kubiak and Cortina 2003).
• Professionals need to be careful of causing the victim even more distress (secondary victimization) by not being sensitive to the victim’s state of mind (Campbell et al. 1999).

Table 2: Severity by Service type: A proposed model

Needs Level	Description	Possible service options
Low	They are coping well with few symptoms, easily managed through natural coping skills and social support. They may not have experienced a severe crime and/or may have many ways to cope.	Minimal services: information sharing – provide written material, brochures of available supports, and education about signs of deeper problems. These services would also be useful for those who do not feel they have any problems, but are trying to hide their suffering. These same written materials might be given to people in the victim’s support system.
Moderate	Experiencing some symptoms and need to expand coping skills or need a place to deal with overwhelming emotions. Generally, they cope well but are overwhelmed by being victimized.	Peer-run support groups, paraprofessional and volunteer support. Some professional support may be needed, but only on a short-term basis.
High	Experiencing many symptoms or problems and displaying poor coping behaviours. Overwhelmed by being victimized and with few effective supports. Severe trauma may have occurred. Likely evidence of multiple problems and multiple victimizations.	Need for professional treatment. This may include long-term individual or group therapy or even hospitalization to help the person stabilize.

Previous Victimization

Researchers have found that previous victimization is a very strong predictor of further victimization (Byrne et al. 1999; Messman and Long 1996; Norris et al. 1997; Nishith et al. 2000). Victims who have had a bad reaction to previous trauma are likely to have a bad reaction to new trauma (Brunet et al. 2001).

Previous victimization tends to affect the victim’s reaction to new victimization, perhaps through low self-esteem, habits of learned helplessness, poor relationship skills or choices, difficulty in reading risky situations, or poverty (Byrne et al. 1999; Messman and Long 1996; Nishith et al. 2000). These results remind us that we need to go beyond the specific crime and ask about trauma history and to use this information in our interventions.

Common Diagnoses of Victims of Crime

Diagnoses commonly linked to being a crime victim include depression, anxiety, and post-traumatic stress disorder (PTSD).

Depression symptoms can include low mood, low appetite or weight loss, sleep problems, energy changes, self-blame or feelings of guilt, feelings of worthlessness or hopelessness, difficulty concentrating, and thoughts of death (American Psychiatric Association 1994).

Anxiety symptoms can include fear, distress, and worry or physical symptoms (e.g. sweating, shaking, difficulty breathing, nausea, chest pain, dizziness), behaviour change (e.g. avoidance, rituals) and behaviours that try to reduce distress (American Psychiatric Association 1994).

PTSD is a form of anxiety disorder that is linked to a specific incident, such as a crime, natural disaster, or accident (American Psychiatric Association 1994). PTSD may include such symptoms as fear, helplessness, intrusive and recurrent memories, nightmares, reliving the event, intense distress, being jumpy, avoidance or suppression of thoughts or feelings, and specific symptoms such as sleep problems, irritability, angry outbursts, poor concentration, hypervigilance and exaggerated startle response (American Psychiatric Association 1994).

Complicated grief, or intense grief that goes on for a long time, can be a problem for some victims and their survivors.

Risk factors for developing PTSD include crime- or trauma-related factors (Brewin et al. 2000; Gilboa-Schechtman and Foa 2001; Ozer et al. 2003); a lack of social support (Brewin et al. 2000; Ozer et al. 2003); additional life stress (Brewin et al. 2000; Ozer et al. 2003); previous PTSD (Brunet et al. 2001; Ozer et al. 2003); and dissociation during or immediately after the crime (Ozer et al. 2003).

When to Refer to Mental Health Professionals

Workers should carefully consider when to refer clients to mental health professionals.

If they are not trained in mental health issues, workers should consult and make appropriate referrals to professionals. Partnerships with healthcare and telehealth, consultation, and visiting professionals are possible solutions for workers in isolated areas.

• ^[4] Workers may also encounter the term acute stress disorder,which has similar symptoms as PTSD but lasts less than a month (Brewin et al. 2003).

• ^[5] Ullman et al. (2006) also found that victims of perpetrators who were strangers showed increased PTSD symptoms.

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