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

2. LITERATURE REVIEW (cont'd)

2. LITERATURE REVIEW (cont'd)

2.6 Effect of Pre-Trauma Characteristics on Coping and Recovery

The discussion to this point has noted many individual differences in dealing with victimization. Crime victims can, to differing degrees, engage in specific help seeking, coping or information seeking behaviours. Cognitive changes related to victimization may affect how the person makes these decisions. However, it is also likely that victims under stress will return to well-used coping strategies and cognitive sets. Cognitive sets are defined as well rehearsed thinking and problem-solving patterns. In other words, they are likely to apply pre-trauma strategies to coping with victimization, rather than spontaneously developing new approaches. This natural tendency is addressed by treatments that often incorporate skills training and cognitive therapy to help the victim cope with victimization (Resick et al., 2002). However, this section focuses on those pre-trauma characteristics that may affect how the victim manages their reaction to trauma or criminal victimization. Specifically, this section reviews victim history, personality characteristics and demographic characteristics.

Victim History

As noted above, previous victimization is an important factor in both predicting subsequent victimization and in predicting more severe reaction (Brewin et al., 2000; Byrne et al., 1999; Messman & Long, 1996; Norris et al., 1997; Nishith et al., 2000). Clinically, successful resolution of previous victimization should affect how they cope with any subsequent victimization. Brewin et al. (2000) found that report of a history of childhood abuse increases the victim's risk of developing PTSD. These researchers also noted a lesser link between higher PTSD and general childhood adversity and trauma. Furthermore, those victims who have suffered from high levels of PTSD symptoms resulting from a previous trauma are at increased risk of developing PTSD in subsequent trauma (Brunet, Boyer, Weiss & Marmar, 2001).

As noted above, some researchers indicated that previous victimization, especially childhood sexual abuse, might be linked to subsequent victimization because of cognitive appraisal deficits (Nishith et al., 2000). Messman and Long (1996) indicated that cognitive, personality and behavioural problems that arise out of victimization could interfere with subsequent problem solving. It is important to note, cognitive problem-solving problems would have broad effect. Briefly, if a child (or adult) is victimized, it will affect his or her world-view. This will then become part of the normal cognitive map he or she uses to make decisions, solve problems, cope with disappointment, build relationships and cope with normal daily challenges. Victims would also have a broader cognitive map of what is "normal" behaviour in their world and not know when or how to intervene. The result of this problem in appraising situations is that they may tend to place themselves at higher risk through both conscious and unconscious choices. Subsequent victimization would serve to deepen this learning, reinforcing the maladaptive pattern. Furthermore, the deficits in problem solving may result in their employing maladaptive coping mechanisms, such as avoidance using alcohol and drugs, rather than efforts targeted toward changing the situation. Poor decision-making would also reduce the likelihood that they would recognize when they needed help, or to seek help. This ineffective style may result in a deepening of PTSD symptoms, which would make them more susceptible to PTSD in subsequent victimizations or other trauma. Thus, victims may get caught in a downward spiral even as they focus all their skills and resources on getting better. It is important to emphasize that readers should not view this as victim-blaming but, rather, as an explanation of how people may become trapped in the victim role. However, victim personality can play a major mediating role in how the victim reacts to the crime, manifests symptoms and uses coping skills.

Personality characteristics

Throughout this paper, the interaction between personality characteristics and trauma has been noted when discussing other issues related to victimization. Recall that ruminators tend to seek out social support, and benefit from social support but often report feeling unheard (Nolen-Hoeksema & Davis, 1999). Davis et al. (1998) noted that the fact that some victims are able to identify positive elements of being a survivor is related to the dimension of optimism-pessimism, with optimists being more likely to report positive change. Other researchers have identified self-efficacy as a potential resiliency factor in reaction to trauma (Thompson, Kaslow, Short & Wyckoff, 2002).

According to cognitive theory, people guide their choices by their beliefs about their ability to control outcomes. "Perceived self-efficacy refers to beliefs in one's capabilities to organize and execute courses of action required to produce given attainments" (Bandura, 1997, p. 3). Self-efficacy is a merging of self-esteem with a belief that one can influence his or her environment (agency), and encompasses concepts such as learned-helplessness, victim-stance and confidence. Basically, the theory holds that when a person becomes a victim, perceived ability to successfully handle the crisis (self-efficacy) will play a major role in their thoughts, emotions and behaviours. Note that actual power is not important; rather it is the person's internal cognitive perception that influences coping choices. Recall that it is also the belief that others will support one or that the police are investigating a crime that benefits victims, not whether these assumption are correct (Norris et al., 1997). Thus, cognitive elements (i.e., beliefs) play a major role in mediating the effect of victimization and the application of coping responses.

People with high self-efficacy tend to believe they will be able to successfully handle specific crises. That is, over a series of success experiences they have learned certain behaviours that often result in success. A person may have high self-efficacy in one area (e.g., physical skills) but low in another (e.g., arithmetic ability). Self-efficacy becomes important in victims, if the victim feels that they can or cannot successfully cope with the crisis. The role of self-efficacy in victimization may be best explained with an example. A chronically abused victim of domestic violence may choose not to leave an abusive partner because of a belief that they cannot effect change in their life. Adult survivors of child abuse may be more likely to display a learned helplessness style wherein they believe they cannot change their circumstances (low self-efficacy). This possibly results in their not trying to change the outcome of potentially dangerous situations. In contrast, Thompson et al. (2002) noted that high levels of self-efficacy among abused women might enhance their perceived ability to obtain important social and material resources. This would thereby increase the likelihood they would leave an abusive relationship. In a sense, self-efficacy refers to the person's self-perception of being able to generate feasible options. It is interesting to note that many clinical interventions include elements that require the victim to confront and successfully deal with difficult memories and emotions or learn and practice new skills (Nishith et al., 2002; Resick et al., 2002).

Self-efficacy may also explain coping choices. Bandura (1997) indicated that self-efficacy is central to behaviour change and coping because perceptions of efficacy influence the use, intensity, and duration of coping behaviours. Thus, self-efficacy is held as the underlying personality structure that influences coping choices. As stated above, self-efficacy develops out of previous success experiences and is part of the victims learning history. Together learning and self-efficacy will have a major impact on what specific coping skills the victim will feel he or she can employ with success. Thus, if learning has shown that dissociation is the best coping strategy, then it increases the likelihood of it being employed in new situations, especially if other strategies have failed. On the other hand, if the person has had success in receiving support form others, they are more likely to employ that strategy. Again, clinical interventions appear to incorporate these ideas in program development (Nishith et al., 2002; Resick et al., 2002).

It is interesting to note that the more likely the victim was to receive positive support from family and friends, the more likely he or she would be to access professional support (Norris et al., 1997). One possible explanation for this relationship is related to self-efficacy and personality development: attachment style. Briefly, attachment reflects our early experiences and expectations with regard to caretakers and our expectations about whether the caretaker is emotionally available in stressful situations. These early patterns direct how we will deal with stress and interpersonal relationships in our adult life. Thus, a person with high self-efficacy around being able to successfully manoeuvre the complexities of human relationships will tend to excel in social relations. Researchers have examined how attachment style affects coping choices in people dealing with stress and trauma.

Mikulincer et al. (1993) examined these interpersonal working models in Israeli students two weeks after the end of the Gulf War. They found that people with a secure attachment style used relatively more support-seeking strategies in coping with trauma. Thus, it makes sense that they may make use of both natural and professional supports. In infanthood, secure infants do not become overly distressed in the absence of their caretaker, typically showing confidence in the return of the caretaker and thereby more confidence. Basically, they have learned this through repeated exposure that the caretaker will return. Armed with the resulting high self-efficacy in this arena, they are more willing to seek help and more likely to expect that the help will be both available and helpful (Bandura, 1997).

In contrast, ambivalent people under stressful conditions used more emotion-focused strategies and showed greater emotional distress (anxiety, depression, hostility, and physical symptoms/somatization) and war related intrusive thoughts in response to threat (Mikulincer et al., 1993). In infancy, these people tend to show great distress in the absence of the caretaker and exhibit difficulty being soothed. Avoidant infants also display initial distress at abandonment but eventually become resigned to the absence. They have learned that they cannot control their social world (low social efficacy). Those students classified as having an avoidant attachment style used more distancing strategies such as denying or minimizing their internal distress. These individuals learned that they could not rely on their social environment, but instead focus on their own need to show strength. Thus, Mikulincer et al. (1993) found that avoidant individuals showed greater physical symptoms/somatization and angry outbursts and denied that it had any relationship to trauma. The stress manifested in other ways even though they self-reported no adverse stress reaction. These results indicate that the secure individual is the most likely to seek help, possible because of an increased likelihood of anticipating that such help will result in reduced distress. The other two groups may not have such an expectation.

This research finding differs somewhat from the research on ruminators (Nolen-Hoeksema & Davis, 1999). Recall that ruminators often sought out and benefited from social support, but often found the support was unsatisfying or limited. It is likely that ruminators and those with ambivalent attachments share some common characteristics. One commonality may be the focus on subjective, distress reaction. Thus, an ambivalently attached person and the ruminator may seek out help but focus on their emotional elements of their distress. The support person may make attempts to sooth the victim, but it does not work. This leaves the ruminator or ambivalently attached person feeling unheard and increases his or her distress. In effect, these individuals may be searching for emotional support and finding that others are unable or unwilling to provide the level of support they feel they require. In contrast, when the securely attached person seeks out social support, they may be more effective at identifying support and using it to cope with their trauma, rather than focusing solely on their distress. This linking of the research should be investigated empirically, but it fits the data of the two studies.

Personality variables seem to permeate all aspects of the victimization and recovery process. However, other research findings are worthy of note. Specifically, demographic factors are important to the extent that they help identify certain common elements in victim profiles and reactions. Although generally not open to intervention, they provide useful information to how crime affects people differently. These issues will be briefly reviewed in the following section.

Demographic characteristics

Demographic variables have an uneven relationship with victimization and trauma. Recall that Norris et al. (1997) found that demographic variables did not predict self-reported distress. However, Greenberg and Ruback (1992) found that women were more likely to report fear. Brewin et al. (2000) noted that some studies report that women are more likely to develop PTSD than men, while others do not. They attribute this discrepancy to differences in sampling; in community samples, the gender difference exists, but disappears when dealing with military samples. On a positive note, Leymann and Lindell (1992) found that women reported receiving more positive social support, which we know can be very helpful in alleviating distress.

Age is also examined as related to crime related trauma. Recall that much research has noted the negative effects of childhood sexual abuse (Byrne et al., 1999; Messman & Long, 1996). Studies have also identified a relatively consistent finding that older adults report more crime related fear, regardless of victim status (Weinrath (2000). In a study examining differential effects of sexual assault related trauma, Wilmsen Thornhill and Thornhill (1991) found that women of childbearing age experience a more severe trauma reaction in response to vaginal sexual assault than do women outside childbearing years (either pre-adolescent and post-menopausal). They indicated that all groups report trauma symptoms in response to sexual assault, but that non-child-bearing women show equivalent trauma reactions regardless of the nature of the sexual assault. Women of childbearing age showed increased trauma in cases of vaginal sexual assault and if semen was present. They argued from an evolutionary perspective and noted that the trauma of the sexual assault is compounded by the addition of loosing one's reproductive choice over partner (Wilmsen Thornhill & Thornhill, 1991).

One study around race is particularly relevant to the Canadian context. Weinrath (2000) examined differences regarding fear of crime between Canadian Aboriginals and the general population using census/survey data. His sample sizes were quite impressive, with over 18,000 Aboriginal people surveyed and over 10,000 Canadians. In comparing Aboriginal Canadians to Non-Aboriginal Canadians, he found higher rates of violent victimization among Aboriginal Canadians, but not differences in fear ratings (Weinrath, 2000). He postulated that part of the reason for this discrepancy is that Aboriginal Canadians have particularly stressful lives and that fear of crime does not rate as a high priority. However, in discussing sexual assault, Calhoun and Atkeson (1991) indicate that culture may influence access to personal attitudes, social support, and other characteristics that my delay recovery.

Thus, demographic variables do offer some interesting avenues; however, it does seem to be specific personality, support and crime characteristics that have the major influence on trauma reaction. These internal attitudes and beliefs, in combination with signs of distress, will likely mediate how a victim copes with their trauma and whether they seek help. It is to help-seeking that the discussion turns, focusing on how people can differ on their willingness to participate in active interventions, such as treatment. Treatment readiness and matching clients to specific intervention techniques may be a productive avenue of service delivery.

2.7 Matching Clients to Interventions: Treatment Readiness

One possible model that could be applied to understanding how victims might greet interventions is the Transtheoretical Model of Change (TMC) (Prochaska, DiClemente & Norcross, 1992). The TMC is so called because these researchers wanted to examine how people change their behaviour independent of any particular theoretical model. Thus, they examined self-changers and those in more formal interventions to identify common strategies and approaches and developed the TMC. Simply put, the TMC holds that people cycle through different psychological and behavioural processes when faced with change. The model and associated research may have implications for victims and their supports in helping to target specific thinking and behavioural actions that increase the likelihood of successfully coping. The TMC postulates five stages of readiness with respect to change: precontemplation, contemplation, preparation, action and maintenance.

In the precontemplation stage the person has no intention to change behaviour or address problems. Generally, this research has focused on those who do not see making any change in the foreseeable future (Prochaska et al., 1992). Individuals primarily in the precontemplation stage are often unaware of the problem or deny the extent or severity of the problem. Often, these people come to therapy because others have pressured them to seek help. As Prochaska et al. (1992) indicated, these individuals might want to change but do not truly intend to make a serious effort in the near future. In crime victims, this pattern could be hypothesized in the victim who denies problems or trauma associated symptoms but loved-ones have noticed marked changes in temperament, behaviour or overall health. The avoidant people described above would tend to fall into this group (Mikulincer et al., 1993).

People in the contemplation stage are aware of their problem and are seriously considering making a change. However, they have not made a commitment to take action. Often these people spend much time examining the pros and cons of the problem and the solution to the problem. They often seem to struggle with their positive evaluations of the status quo and the amount of effort, energy, and loss it will cost to overcome the problem. In victims, this might manifest in their acknowledging the problem and their need for help, but also focus on issues of shame, fear of telling someone, fear of reactions, fear that talking about it might make things worse. This ambivalence can freeze them into inaction, despite recognition of the negative effects of not doing anything.

Prochaska et al. (1992) also described a typically short stage named the preparation stage. People in this stage recognize the problem and intend to do something in a very brief time. In examining habit change, these individuals have often tried to make changes in the past year, but have failed to make lasting changes (Prochaska et al., 1992). In victims seeking treatment, this might be the person who has made some changes on his or her own and is awaiting an appointment or has tried therapy in the past but stopped before resolving all his or her issues.

In the action stage, people are actively trying to make changes to their behaviour, thoughts/feelings, or environment in order to address their problems. This stage requires greater commitment from the person and is the focus of change activities. Often this is what most others (family, spouse, therapist) recognize as "change". Prochaska et al. (1992) indicated that this false linking between action and the change process ignores the work required to get to this point. Further, they point out that this emphasis on action also ignores the work needed to maintain changes. Another element to the action stage is reaching a specific goal. For example, a victim experiencing PTSD may choose a reduction in specific symptoms, but successful treatment rises to success with the extinguishing of negative symptoms to the pre-trauma levels.

Finally, people in the maintenance stage work to prevent relapse and reinforce the gains made during the action stage (Prochaska et al., 1992). Maintenance is not a static stage, but the continuation of the change process. Thus, people may need to maintain themselves for a short time or maintain certain actions or habits throughout their lifetime. Clinically, for victims who typically repressed negative symptoms, this might mean talking to natural supports about daily stressors rather than letting things build to pathological levels. Further, given that past victimization places the person at risk for future victimization, maintenance may need to incorporate positive behaviours that break this cycle.

It is important to note that Prochaska et al. (1992) did not see this as a developmental model that, once finished, never needs to be revisited. In fact, a person initiating change may exist at all stages simultaneously, depending on the particular symptom or issue. Thus, a victim may recognize they have a problem resulting from victimization and may seek out medication to help deal with depression or anxiety. This behaviour is consistent with action. However, this same person may refuse to enter any type of psychotherapy or group work and indicate that they do not need to talk about their problem. This would be more indicative of the precontemplative stage or, perhaps, contemplative. Further, this same person may take the medications briefly and then discontinue because of side effects. This would move them back into contemplative or preparation stage depending on what they choose to do next. It is the dynamic nature of the TMC that makes it particularly attractive to clinicians.

Under the TMC, classical resistance to therapy is cast in a different light as a mismatch between stage and intervention. Clinicians, paraprofessionals and others typically create programs focused solely on the motivated and "ready" client. Self-help programs and books also target this group. This "action" bias results in many people failing at making successful changes. Unfortunately, these failure experiences become internalized, potentially decreasing the likelihood of future change attempts. In describing smoking cessation, Prochaska et al. (1992) noted that about 50%-60% of smokers are in the precontemplation stage, 30%-40% are thinking about quitting (contemplation stage) and only 10%-15% are ready to quit (preparation/action).

Clinically, these stages have implications for therapy. One activity for moving people out of contemplation into the next stages is to employ a formal or informal decisional balance exercise (Prochaska et al., 1994). Through the use of a grid system, the person is able to concretely examine anticipated gains (benefits) and the anticipated losses (costs). In examining twelve different samples of people trying to change various behaviours, Prochaska et al. (1994) found that for all samples, Precontemplators emphasized the cons of changing the problem behaviours. They also found that in eleven samples those in the action stage emphasized the pros of changing (the one exception were those with cocaine addiction). In seven of the samples the crossover between the pros and cons of the problem behaviour occurred during the contemplation stage (exercise acquisition changes in the preparation stage; delinquent behaviours, sunscreen use, high-fat diets, and mammography screening changed in the action stage and may have occurred during the preparation stage).

Of note, Rosen (2000) reported that 70% of the between stage variance in cognitive-affective processes occurred in the contrast between precontemplation and all other stages. These cognitive-affective processes of change include: gathering information (consciousness-raising), reconsidering consequences on oneself (self-reevaluation), experiencing and expressing emotions (dramatic relief), considering consequences on others (environmental reevaluation), and attending to changing social norms (social liberation). These results have profound implications for crime victims and help-seeking behaviour, as it may be those who feel they have no problems related to the crime that need to be identified and screened. That is, the biggest change step is deciding they need help.

With respect to behavioural processes, Rosen reported that 50% of the between-stage variance for behavioural processes was between precontemplation and all other stages. Behavioural processes include: substituting new behaviours (counter-conditioning), controlling environmental cues (stimulus control), being rewarded by self or others (reinforcement management), using social support (helping relationships), and committing to change (self-liberation). In reviewing these actions, one can understand how the TMC came out of a clinical literature focused on changing health behaviours and substance use disorders. Rosen (2000) reported that clients in psychotherapy, as opposed to therapy focused on specific behaviours, were more likely to show between stage variation in use of consciousness-raising, self-reevaluation, and use of a helping relationship. Generally, use of behavioural processes within psychotherapy tended to be weaker, however, none of the psychotherapies examined involved behaviourally oriented treatments. Rosen (2000) warned against seeing the TMC as a panacea to understanding change in treatment, specifically noting that it does not easily fit into the psychotherapy model.

The importance of this concept may be illustrated through an example. Recall the research examining attachment style (Mikulincer et al., 1993); in this case the avoidant victim would be seen as being precontemplative. He or she does not admit to trauma related symptoms; he or she shows higher levels of physical symptoms/somatization and anger. It is likely that loved-ones witnessing these reactions would notice the distress and pressure the victim to seek help. However, if met with the typical action-oriented interventions, the victims would shutdown, get very little from treatment and likely drop out. However, based upon the TMC research, the victims may be better met with interventions focused on education regarding different reaction to crime (consciousness-raising) or looking at how he/she has changed since the crime (self-reevaluation) and how that has affected family and friends (environmental reevaluation). Rather than the direct challenge of his/her stance that the crime did not bother him/her, he/she is given an opportunity to learn how it could have affected them. This eases them into examining their reaction, and allows him/her to better decide what he/she needs to do to improve functioning. This remains theoretical and I will now discuss the research applying the TMC to victims.

Unfortunately, there is little research on the application of the TMC to victims of crime. One study applied the TMC to therapy with adult survivors of childhood sexual abuse (Koraleski & Larson, 1997). Out of 83 survivors in therapy for sexual abuse they identified 38 (45.8%) as being in the contemplation stage, 7 (8.4%) as in the preparation stage, and 26 (31.3%) as in the action stage. Consistent with the model, they found that clients in the action-stage used behavioural processes of change more than those in the contemplation stage. They indicate that survivors use cognitive-affective processes earlier in therapy and then move to greater use of behavioural processes, pointing out that this parallels the sequence of issues discussed in clinical descriptions of sexual abuse therapy (Koraleski & Larson, 1997).

However, Koraleski and Larson (1997) did not find that victims in the contemplative stage were more likely to use cognitive-affective methods. The TMC posits that these processes are more frequently used in the early stages and are used less frequently as the person moves to action. Contrary to this, psychotherapy clients tend to use these strategies throughout the stages and may be necessary in traditional psychotherapy (Koraleski & Larson, 1997). From a clinical perspective this makes sense. When focusing on one habit or problem area, the person is able to target change activities, however, as problems become more multi-faceted and complex, the person may need to revisit many areas of beliefs and emotions in order to address the problem. Thus, general psychotherapy, with its more global focus, may result in a person being in action stage on some issues, in precontemplation on others and so on with each stage. In fact, it could be argued that therapy is a process of initially helping the clients address self-identified problems and then addressing other problem areas as they come to light through the therapeutic process.

Along the line of applicability of the TMC model to victims of crime, one other area needs to be reviewed. Traditionally, the goal of therapy, as held by the TMC, is the extinguishing of the problem behaviour (e.g., smoking cessation, eating poorly, etc.). However, in dealing with the psychological after-effects of crime, this may be an unrealistic goal. In other words, the goal may not be extinguishing behaviour, but rather reducing the distress caused from the crime. It may be more important to look at the TMC model to define new outcome data (Morera, Johnson, Parsons, Warnecke, Freels, Crittenden & Flay, 1998).

Based on the research above, moving from precontemplation to contemplation is a major step. Smith, Subich and Kalodner (1995) found that those clients who prematurely terminate therapy are more likely to be in the precontemplation stage. These clients tend to report less therapeutic progress, experience more psychological distress and rarely reach their goals. At a logistical level, they tend to miss appointments, sit on waiting lists and take up clinician time. Under the TMC, this behaviour is understandable in that the mismatch between action-stage oriented interventions with people who do not recognize they have a problem. Helping precontemplators move out of this holding pattern may both improve their lives and improve the efficacy of interventions by increasing motivation and decreasing so-called resistance. Thus, interventions that focus on helping victims decide they have a problem may be very useful in service-delivery. Researchers have found that TMC measures have excellent stability and high levels of reliability (Madera et al., 1998). They note that TMC measures appears to have applicability as an outcome measure to examine whether change efforts are helpful in moving a person through the stages more effectively.

2.8 Conclusion of the Literature Review

In conclusion, it is apparent that victims do experience cognitive, emotional and behaviour changes as a function of being victimized. Previctimization characteristics, crime-specific characteristics, reaction of supports, coping strategies, differences in personality variables and use of interventions all intertwine. The preceding review attempted to fill the wide gaps in the literature on cognitive changes in crime victims by amalgamating very disparate research areas. Thus, much of what has been discussed needs to be seen as a starting point in this area.

Given the preceding discussion, one can make some general conclusions by linking this research with clinical understanding. The next three sections focus on further integrating the literature review by focusing on the implications of this literature. The primary focus of this integration will be to identify salient clinical issues. However, the third section focuses on general recommendations regarding how to improve the literature to further support victim initiatives and clinical practice.