Victims' Response to Trauma and Implications for Interventions: A Selected Review and Synthesis of the Literature

Foreward

Gaining understanding of the victim's internal psychological world is the task of both researchers and service-deliverers who focus on victimization. Those who work in this area often show an investment in this population that goes beyond standard research study. Furthermore, understanding psychological changes is an integral part of understanding crime victims' internal world. These changes have immediate effect in handling the crime event itself, but also impact on subsequent coping. The author has focused this document on delineating cognitive change in victims. However, the overarching focus is applying how victim characteristics, cognitive changes and coping skill impacts clinical understanding and interventions. This service-focus is reflected in the broad nature of the literature covered and the willingness of the author to move outside the boundaries of cognitive changes and crime victim research when the literature is found lacking. This exploratory approach should provide a useful guide to future policy development, program development, research and clinical investigations.

The interpretations included in this document are solely those of the author and are not necessarily those of Justice Canada or its employees.

Acknowledgements

The author would like to gratefully acknowledge Dr. Lara K. Robinson for her helpful comments on an earlier draft of the document.

Key Findings

The following conclusions are based upon a review of the literature:

Executive Summary

The process of victimization does not end with the crime. Trauma associated with criminal behaviour can affect how victims view themselves, their world and their relationships. Trauma and loss have the potential to threaten one's sense of meaning in life. Furthermore, the psychological effects of trauma can be longstanding and potentially debilitating. This review focuses on cognitive changes that affect the entire person. Problem-solving ability, coping skills, personal, social and work relationships can all become compromised by cognitive changes. The focus of this review and synthesis is to identify cognitive changes that are related to crime victimization and relate this to clinical issues around interventions. A major challenge of the present review is that there is little empirical research in the area of cognitive changes in victimization. Thus, all effort has been made to include related areas to shed light on the very complex psychological world of the victim.

In examining the victim's internal world it is difficult to specify any one psychological profile related to victim reaction. The reality of individual psychology is that each person is different and will react differently to any stressor, including crime. However, one can discuss some likely psychological effects of being a crime victim. Casarez-Levison (1992) indicated victims might experience fear, humiliation, embarrassment, anger, loss, rejection, and physical symptoms. Others include some of the above problems and added depression, anxiety, hostility, avoidance, alienation, reduced self-esteem and increased need for social support in both victims of violent and non-violent crime (Norris, Kaniasty & Thompson, 1997). The psychological trauma associated with victimization may cause disruptions in feelings of control, interpersonal attachment, hypervigilance, sleep disturbance, intrusive memories, and feelings of anxiety, anger, grief, and depression (Everly, Flannery & Mitchell, 2000). At the interpersonal-social level, victimization and trauma can affect a wide variety of systems, including family, marital-peer relationships, the school-work community, or even the broader community (Burlingame & Layne, 2001).

In trying to understand the process of victimization, Casarez-Levison (1992) synthesized several models and delineated four stages in the victimization process: pre-victimization/organization, victimization/disorganization, transition/ protection and reorganization/resolution. This model tracks the victim from a pre-crime state, to coping with the criminal event, to adjusting to the ramifications of the criminal event. Most victims will face feelings of denial and acceptance around their experience. As victims cope with their new role of "survivor" they often question the predictability of their world, belief that the world is a safe place and that the world is fair. This challenges the "just-world" belief that good things happen to good people and bad things happen to bad people (Resick & Schnicke, 1993). Crime severity and pre-victimization characteristics often affect how much the victim faces these challenges. Of note, victims do not return to a pre-victimized state, but are forever changed by victimization. Specific crime characteristics (severity, use of violence, use of a weapon, use of threat), victim characteristics (coping skills, abuse history, personality characteristics, demographics) and system characteristics (reaction of officials, perceived and received support) can affect the victim's distress level (Gilboa-Schechtman& Foa, 2001; Norris et al., 1997; Ozer, Best, Lipsey & Weiss, 2003). This distress has an impact on subsequent adjustment.

In examining psychological consequences of crime, one must recognize that victimization is often an unpredictable event that interferes with the normal routine of the victim. Cognitive and emotional reactions can result in an inability to go out, avoidance of crime-related stimuli, social withdrawal, altered activity, increased dependence on others, alcohol/drug abuse and drastic changes in living circumstances (moving, cutting off the phone, etc.). About half of violent crime victims report moderate to extreme distress, including depression, hostility and anxiety (Norris et al., 1997). Crime severity also affects distress (anger, tension, sadness), safety (fear, avoidance), esteem (low self-worth, inferiority) and trust (cynicism, pessimism). Cognitive outcomes can include memory problems, decision-making deficits, increased susceptibility to social influence, disorientation, concentration problems and so on. Although symptoms may be present during the criminal event, many can continue for some time after the crime, if not properly addressed.

With respect to coping, Norris et al. (1997) noted the importance of accessing natural (family, friends, etc.) and professional (police, lawyer, clergy, medical, mental health) sources of support. Although victims tend to prefer natural supports (Leymann & Lindell, 1992), about 12% of victims seek mental health services, with the victims of violent crime accessing services more often (Norris et al., 1997). Other common coping strategies include: information seeking, emphasizing survival, self-comparison, social comparison, activities in service of regaining control, activism, avoidance, denial and self-deception, dissociation and cognitively narrowing the focus. Victims have many possible coping strategies at their disposal and their choice of strategy is likely a combination of cognitive skills, history and individual personality variables. The above list is not exhaustive as each person will have their own unique set of thoughts and feelings and these will work in synergy to create coping strategies and behaviours.

In examining trauma and crime victimization, much of the clinical research has focused on post-traumatic stress disorder (PTSD), anxiety and depression (Byrne et al., 1999; Dempsey, 2002). Researchers have found that violence and negative coping explained 30% of the variance in PTSD, 11% of the variance in anxiety and 20% of the variance in depression (Dempsey, 2002). These disorders have been linked to workplace violence (Rogers & Kelloway, 2000), sexual assault (Byrne et al., 1999), childhood sexual abuse, (Merrill, Thomsen, Sinclair, Gold & Milner, 2001), critical incidents (Everly et al., 2000), violent crime (Byrne et al., 1999) and family violence (Wolkenstein & Sterman, 1998). PTSD specifically, has been identified as a relatively common result of victimization (Byrne et al., 1999).

One possible strategy to address trauma in victims is Critical Incident Stress Management (CISM). CISM is a merging of crisis intervention models and group psychological debriefing techniques (Everly et al., 2000). Through application of pre-crisis preparation, large-scale procedures, individual acute crisis counselling, defusings, debriefings, family crisis interventions and follow-up procedures one hopes to avoid the worst effects of trauma. Although there is debate regarding the effectiveness of CISM, this approach does recognize the need for immediate victim services (Everly et al., 2000). Crime victims may benefit from early crisis intervention from the perspective of helping them overcome initial challenges, rather than focusing on reducing outcomes such as post-traumatic stress, anxiety and depression that may be better left for therapy (Calhoun & Atkeson, 1991).

Another model that could be applied to understanding how victims might cope with interventions is the Transtheoretical Model of Change (TMC) (Prochaska, DiClemente & Norcross, 1992). The TMC holds that people cycle through different psychological and behavioural processes when faced with change. The five stages are: pre-contemplation (no intention to change), contemplation (awareness of their problem and are seriously considering change), preparation (intend to do something soon), action (actively trying to make change) and maintenance (maintaining change and preventing relapse). The TMC shows good generalizability to different problem areas and change processes. The model also gives recommendations to help people move quickly through the change process. This could be particularly relevant in helping match victims to appropriate services and improve outcomes. There is little research on applying the TMC to victim interventions, but there is indication that it could be useful.

Finally, there are several improvements needed to develop a solid literature base on cognitive changes in crime victimization. The primary need is to expand this literature substantially as there has been little work in this area. In such an expansion, researchers should focus on longitudinal research which will allow examination of pre-crime status and change, use of common methods and measures, use of match comparison/control groups, using other-report and self-report on outcome measures, and comparing normal coping to coping with victimization. The literature could also benefit from an examination of vicarious traumatization on natural supports and research on the utility of CISM and TMC to crime victims. Finally, all this research should include use of real world victims that does not exclude more difficult cases.

In conclusion, it is apparent that victims undergo cognitive and emotional changes through the process of victimization. Victims requiring services need to quickly access appropriate interventions. Matching clients to services could use severity as a guide. Unfortunately, much of this is conjecture as there is little research in the area. Victims can be helped if we improve research, match clients to treatments, provide a continuum of services, support practical treatments, work to prevent future victimization, and support service-deliverers. Education, crisis intervention, support, group interventions and intensive individual therapy are all a part of this service continuum.