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

2. LITERATURE REVIEW

2 LITERATURE REVIEW

2.1 Trauma Process

One can examine victimization from several different perspectives including social, legal, economic, political, and others. This particular treatment of victimization will focus on trauma from a psychological perspective. The main reason for this is that it is at this individual level that victimization can have its most profound impact. An individual's reactions to crime affect all that person's life and influences the lives around him or her. Changes that manifest as a result of victimization can upset family, vocational, educational and cultural systems. By reviewing the common cognitive, emotional and behavioural reactions to being victimized one can begin to uncover the dynamics of victimization at the personal level. This focus then has implications for treatment and education initiatives.

This review begins with exploring how people react to the process of victimization, focusing on the cognitive element. I then turn to the issue of cognitive changes - shifts in thinking patterns that researchers have linked to victimization. The next section discusses a related topic, the coping strategies commonly used by victims and issues related to possible problem areas for victims. Finally, the issue of treatment is explored in light of the focus of the paper. First, the paper begins with a review of victimization and its psychological effects.

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 (nausea, stomach problem, muscles tension, etc.). Others have included 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 self-efficacy (i.e., feeling of mastery over one's environment), 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 and the subsequent coping attempts, Casarez-Levison (1992) reviewed and synthesized several different theoretical models that researchers and theoreticians have used to understand how people deal with trauma. Her model follows the person from the precrime state, to the crime and immediate after-effects, early coping/reorganization and, finally, resolution. More specifically, her model includes the following stages:

The above model has some applicability in improving our understanding of the process of victimization. Crime victimization is an invasive process that upsets the normal daily life of the victim, permeating all aspect of his or her life. Furthermore, the model acknowledges that being a victim of crime is an external and unpredictable stressor that is far-reaching. Although the model provides a timeline for victim reactions, one must be cautious in applying these estimates to all victims or to all types of crime. Specific crime characteristics (severity, use of violence, use of a weapon, use of threat), victim characteristics (coping skills, abuse history, personality characteristics) and system characteristics (reaction of officials, help received) can affect the victim's distress level (Gilboa-Schechtman & Foa, 2001; Norris et al., 1997; Ozer, Best, Lipsey & Weiss, 2003). Obviously, this distress also has an impact on subsequent adjustment. The victim's experiences, personality, history and social/economic resources then guide how he or she copes with the crime. Before moving to cognitive changes and coping strategies, we will examine the psychological consequences of victimization, as well as other important issues that may affect the victim's recovery from crime related trauma.

Psychological Consequences

In the previous section, I reviewed a model of how victims might be affected by victimization and possible underlying challenges that face the victim, as well as some commonly associated reactions. Although the symptoms and Casarez-Levison's (1992) model are related to research, as well as theory, it is useful to examine other research that has attempted to understand the crime victim's psychological reality.

In a discussion on the effect of sexual assault, Mezy (1988) delineated several common psychological elements of the rape trauma syndrome, many of which can be generalized to other types of victimization. These included depression, tearfulness, anxiety, flashbacks, guilt, shame, decreased sexual enjoyment, poor concentration, irritability, apathy and phobias. She indicated that these underlying symptoms can manifest in an inability to go out, avoidance of crime-related stimuli, social withdrawal, altered sexual activity, increased dependence on others, alcohol/drug abuse and drastic changes in living circumstances (moving, cutting off the phone, etc.). Obviously some of these symptoms and behaviours are more related to sexual assault or other violent crime, but some may be related to non-violent crime, depending on the strengths and skills of the victim.

In an excellent study of both violent and non-violent crime victims, Norris et al. (1997) examined the psychological consequences of crime via a longitudinal telephone survey study in Kentucky. In their research, they distinguished between activators (the crime), reactions (fear, avoidance), consequences (psychological symptoms: depression, somatization (bodily symptoms), hostility, anxiety and phobic anxiety), and moderators (characteristics that change the relationship between activators and reactions and consequences). The strength of their research is that it is based upon a randomly selected population survey and not a convenient clinical population. The research is also longitudinal, which allows for follow-up to assess symptom change and allows observation with new factors such and life stress and new crimes (Norris et al., 1997). These strengths can give the reader confidence in their results.

The activators included both property crime (burglary, larceny, vandalism and any property crime) and violent crimes (sexual assault, robbery, aggravated assault, simple assault and any violent crime). Participants were selected based upon being crime victims at the time of the initial interview. However, the researchers found that those identified as victims at the initial interview were also more likely than non-victims to be re-victimized in the intervening time between the first interview and the subsequent two interviews (at 6 and 12 months). With respect to consequences, the authors found that the no-victimization control was similar to general population norms and that victimization resulted in an increase in psychological symptoms, although not always to extreme levels of distress (Norris et al., 1997).

Regarding the consequences of crime, about 25% of violent crime victims 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 approximately 50% of violent crime victims report moderate to extreme distress. However, there was no specific profile of distress for the victim group. Rather, there was a general elevation on all consequences subscales, with no victimization as lowest profile, property crime victims were higher and violent crime victims were in the highest level. This supports the view that severity plays a major role in subsequent levels of symptomatolgy.

Norris et al. (1997) also noted that crime challenges victims' view of themselves or their worlds. Basically, victimization alters the script they follow in normal daily life. These authors examined distress (anger, tension, sadness), safety (fear, avoidance), esteem (low self-worth, inferiority) and trust (cynicism, pessimism). Their results indicated that severity of violent victimization affects distress both directly and indirectly, through safety, esteem and trust. In severity of non-violent crime, victimization has no direct relationship to distress but is mediated by safety, esteem and trust. Thus, in non-violent crime the actual victimization is only important in that affects the victim's internal processes (especially safety), whereas, in violent crime, it affects these internal processes and has its own direct affect (Norris et al., 1997). This reinforces the traumatic nature of violent crime over non-violent crime and that any victimization has a negative effect.

Reactions to criminal victimization showed a similar profile, with violent crime victims showing the greatest amount of avoidance and fear (Norris et al., 1997). With respect to recovery, both victim groups showed a reduction in symptoms as time passed. The violent crime victim group showed the greatest reduction, however, the relative ranking of each group stayed the same. That is, neither victim group achieved the levels of the no-crime group and the violent crime group still showed more distress than the violent crime group. However, Norris et al. (1997) pointed out that the victim groups differed on several variables from the no-crime group (demographics, previous symptoms, occurrence of subsequent crimes). Thus, they analyzed the data controlling for the effects of these possible confounds. They found that demographic variables and previous symptoms did not seem to have an effect but that further victimization prolonged self-reported distress symptoms. From a clinical perspective, this result is unsurprising as it is reasonable to assume that the either chronic victimization or repeat victimization would cause a deepening of distress and associated psychological symptoms.

With respect to moderators, Norris et al. (1997) noted the importance of accessing natural (family, friends, etc.) and professional (police, lawyer, clergy, medical, mental health) sources of support. They indicated that about 12.5% of victims seek mental health services, with the victims of violent crime accessing services more often. In contrast, victims of property-crime and no victimization accessed services at comparable rates. Of note, depression and use of violence during the crime predicted who accessed mental health services. Also, the more likely a victim was to use natural supports the more likely they were to access professional supports (Norris et al., 1997). Furthermore, receiving support also buffered fear reaction. Later sections will discuss the role of support in cognitive reaction and coping, but it is clear that support is a major element to moderating the negative effects of victimization. Before moving to these sections, the longitudinal nature of Norris et al. (1997) research allows one to examine important issues such as: time to heal, secondary victimization by the system and interference by subsequent victimization.

Time to Heal

Criminal victimization seems to have long-lasting effects. Norris et al. (1997) found that both violent and non-violent crime victims show a reduction in symptoms over the first few months post-crime, but then the reduction levelled off. At the end of their longitudinal study (15 months) the relative ranking of distress maintained, with violent crime victims the most distressed, non-violent crime victims second and no-crime participants reporting the lowest levels of distress. On the other hand, with a much smaller sample, Hagemann (1992) reported that most victims in his research were functioning quite well one year after the crime (fewer symptoms, crime no longer a central part of their life, etc.). However, he indicated that they did not necessarily return to a pre-victimization identity. A possible explanation for this discrepancy is that victims of sexual assault may put their symptoms on hold (Resick et al. 2002). Thus, although the passage of time may give the person the opportunity to return to a "functional" life, victimization appears to have long-lasting effects (Gilboa-Schechtman & Foa, 2001; Norris et al., 1997).

Secondary Victimization by the System

Much is made of the secondary victimization associated with contact with the justice system. Norris et al. (1997) examined those individuals who contacted the authorities in response to their victimization. They focused on severity of the crime, was the perpetrator known to the victim, did the police look for evidence, did police promise to investigate, was there an arrest, did the victim describe the police as helpful, and victim alienation (pessimism, cynicism and hopelessness). They found that crime severity and knowing the perpetrator increased alienation, whereas viewing the police as helpful reduced alienation (Norris et al., 1997). Thus, appropriate reaction of criminal justice personnel can have a positive effect on the victim. Victims view both investigation and arrest as positive and it increased the perception that police were helpful, thereby reducing alienation.

It is interesting to note that actual arrests were less important than the promise that an investigation would occur. Victim beliefs seem to be a major moderating factor, rather than tangible results (Norris et al., 1997). Victims appear to require that something be done rather than an overall "thirst for justice". One hypothesis is that victims are less concerned with abstract concepts of justice but, rather, need assurances that people in their immediate world are acting to help and protect them. Another hypothesis is that victims' benefit by being attended to, and having their experience of victimization validated and taken seriously. These hypotheses require empirical validation but make logical sense, especially when one considers how victims react in the immediate aftermath of victimization.

Campbell, Sefl, Barnes, Ahrens, Wasco and Zaragoza-Diesfeld (1999) examined secondary victimization at the system level among sexual assault survivors. In their sample, 66% of survivors were assaulted by someone they knew, 94% were sexually assaulted by a single assailant, 38% were not physically injured in the attack, 30% of the sexual assaults included the use of a weapon and 70% of victims had no alcohol prior to the sexual assault. They found that although individual characteristics and crime-related characteristic did not predict post-traumatic stress, negative experiences with the criminal justice /medical systems did increase post-traumatic stress symptoms.

Similarly, Warshaw (1993) examined the emergency room charts of 52 women who had clear sign of abuse. She found that medical staff performed the required elements of their job such as reporting possible abuse or prescribing pain medication. However, very few asked any questions regarding future risk or abuse. In fact, in 78% of cases of possible abuse, the doctor did not report the relationship between the victim and assailant (Warshaw, 1993). As one synthesizes these findings one is struck by the effect professional supports can have on victims. In a process-oriented study, Hagemann (1992) reported that lack of concern and treating the victims as a statistic resulted in negative views on the part of the victim. Thus, personnel in the criminal justice and medical systems should be aware of the potential impact of their actions and take measure to minimize secondary victimization.

Although the relationship between professional reaction and distress is concerning, it is also important to examine moderators. Non-stranger sexual assault victims who experienced a high degree of secondary victimization and received minimal help from the criminal justice or medical system experienced higher distress scores (Campbell et al., 1999). However, if the survivor received mental health services after difficult contact with the medical system, there was a reduction in the reported negative effects. These results suggest that medical and criminal justice procedures can have a negative impact on the victim, but that these effects can be ameliorated by referral to other supports. However, as Moriarty and Earle (1999) indicated, after being examined and questioned by police and medical personnel, the survivor may be understandably reluctant to recount their story to yet another stranger. Thus, not only should medical/criminal justice personnel be aware of these issues, they should work to minimize the effects and respectfully support victims in accessing other services.

Interference by subsequent victimization

Several studies report that previous victimization is a very strong, if not the strongest, predictor of subsequent victimization (Byrne et al., 1999; Messman & Long, 1996; Norris et al., 1997; Nishith et al., 2000). Furthermore, previous victimization seems to affect the victim's reaction to new victimization. In their review of revictimization in survivors of childhood sexual abuse (CSA), Messman and Long (1996) indicated that CSA survivors are at increased risk for victimization in later years. They further indicated that researchers identified several factors that may mediate this link, including, self-esteem, learned helplessness, relationship choices, learned behaviour patterns/expectations and differences in causal attributions. These elements point to long-lasting cognitive changes that affect thinking and behavioural patterns that may place the person at increased risk for further victimization. However, Messman and Long (1996) pointed out that these links remain theoretical, as there is minimal empirical validation. They also emphasize that these links should not be seen as victim-blaming, but rather as potential leads to effective program development for victims.

Similarly, Byrne et al. (1999) reported that assault survivors might be caught in a downward cycle with respect to poverty and victimization. Re-victimization doubled the likelihood that women with an assault history would move below the poverty level over time. Further, poverty is a risk factor for subsequent victimization. Similarly, those women who experienced a new assault were more than twice as likely to be unemployed at follow-up than women who did not experience a new assault. These results indicate that re-victimization interferes with the victim's reintegration process or, under Casarez-Levison's (1992) model, re-organize.

It also does not seem to matter the length of time between victimizations, Nishith et al. (2000) also noted the link between CSA and becoming a victim of sexual and physical assault as an adult. They offered several explanations for this increased risk. They pointed out that CSA survivors might apply ineffective or dysfunctional skills in developing and maintaining relationships. These deficits interfere with correctly appraising risk and making sound judgements. CSA survivors also may experience symptoms of unresolved traumatic stressors (e.g., depression, dissociation, anxiety, post-traumatic stress symptoms and substance abuse) that interfere with judgement, problem solving or ability to defend oneself (Nishith et al., 2000). The authors added that common problems associated with CSA (emotional lability, inappropriate self-soothing behaviour, poor interpersonal boundaries) might increase the likelihood of putting oneself into risky situations. Finally, they also indicated that environmental stressors related to poverty (e.g., poor neighbourhood) might increase risk of further victimization (Nishith et al., 2000).

The preceding section reviewed the psychological processes associated with victimization. It is easy to understand how an individual, when faced with the stress of a random negative event, can have trouble coping. Further, severity, individual differences and social support appear to moderate the depth of the effects of victimization. In the subsequent sections, the paper focuses on some of these issues surrounding these areas.

2.2 Trauma Sub-Groups: The Role of Severity

Although much of the current document will examine victims of crime as a whole, there is some evidence that shows differences in reaction to victimization. As noted above, there are differences between victims of property and person crimes (Norris et al., 1997). Victims of non-violent crime do experience fear for their safety and may also experience increased psychological symptoms, however victims of violent crime show more pronounced fears and symptoms. Recall that Norris et al.'s (1997) results indicated that violence severity affects distress. They found no specific profile of distress for any of the victim groups. This is an important finding as it indicates that specific crime victim sub-groups (e.g., domestic violence, sexual assault, violent assault, property crimes, corporate crime) may be less important than the severity of the crime. It is through severity that the victim is traumatized and experiences distress. Recall that Norris et al. (1997) found that victims of violent crime show the most severe reaction, with over 50% experiencing moderate to severe distress. These results indicate that the link between victimization and reaction may be important only as it relates to crime severity. In other words, the more severe the crime, the more severe the reaction.

This hypothesis is supported by research by Gilboa-Schechtman and Foa (2001) who examined victims of violent crime. In examining victims of assault, these authors distinguished between victims of physical assault and victims of sexual assault. They found that sexual assault victims had more severe reactions than non sexual assault victims. They found that sexual assault victims had a stronger reaction and took significantly longer for trauma symptoms to reduce. They also found a similar reaction between to two groups with respect to post-traumatic stress disorder (PTSD) and anxiety. However, only sexual assault produced depression (Gilboa-Schechtman & Foa, 2001).

These same researchers also examined a phenomenon called "peak reaction" (Gilboa-Schechtman & Foa, 2001). Peak reactions refer to the point in which the victim experiences the strongest symptoms. They found that delayed peak reaction was related to increased symptoms. Victims whose peak reaction occurred shortly after the assault had lower levels of depression and PTSD than individuals whose peak reaction occurred later. They theorize that delayed peak reaction may be related to a delay in engagement, which has implications for treatment. The finding that long-term PTSD was related to the timing of peak avoidance (similar to lack of emotional engagement) further supports this hypothesis (Gilboa-Schechtman & Foa, 2001). Thus, severity may be the important issue in looking at crime victim's reactions, not the specifics of the crime. From a psychological perspective this interpretations is attractive as it points to commonality in the underlying cognitive and adaptive (coping) processes.