Rape treatment outcome research: empirical findings and state of the literature

Psychosocial interventions for survivors of rape and sexual assault experienced during adulthood

BACKGROUND

Exposure to rape, sexual assault and sexual abuse has lifelong impacts for mental health and well-being. Prolonged Exposure (PE), Cognitive Processing Therapy (CPT) and Eye Movement Desensitisation and Reprocessing (EMDR) are among the most common interventions offered to survivors to alleviate post-traumatic stress disorder (PTSD) and other psychological impacts. Beyond such trauma-focused cognitive and behavioural approaches, there is a range of low-intensity interventions along with new and emerging non-exposure based approaches (trauma-sensitive yoga, Reconsolidation of Traumatic Memories and Lifespan Integration). This review presents a timely assessment of international evidence on any type of psychosocial intervention offered to individuals who experienced rape, sexual assault or sexual abuse as adults.

OBJECTIVES

To assess the effects of psychosocial interventions on mental health and well-being for survivors of rape, sexual assault or sexual abuse experienced during adulthood.

SEARCH METHODS

In January 2022, we searched CENTRAL, MEDLINE, Embase, 12 other databases and three trials registers. We also checked reference lists of included studies, contacted authors and experts, and ran forward citation searches.

SELECTION CRITERIA

Any study that allocated individuals or clusters of individuals by a random or quasi-random method to a psychosocial intervention that promoted recovery and healing following exposure to rape, sexual assault or sexual abuse in those aged 18 years and above compared with no or minimal intervention, usual care, wait-list, pharmacological only or active comparison(s). We classified psychosocial interventions according to Cochrane Common Mental Disorders Group's psychological therapies list.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 36 studies (1991 to 2021) with 3992 participants randomly assigned to 60 experimental groups (3014; 76%) and 23 inactive comparator conditions (978, 24%). The experimental groups consisted of: 32 Cognitive Behavioural Therapy (CBT); 10 behavioural interventions; three integrative therapies; three humanist; five other psychologically oriented interventions; and seven other psychosocial interventions. Delivery involved 1 to 20 (median 11) sessions of traditional face-to-face (41) or other individual formats (four); groups (nine); or involved computer-only interaction (six). Most studies were conducted in the USA (n = 26); two were from South Africa; two from the Democratic Republic of the Congo; with single studies from Australia, Canada, the Netherlands, Spain, Sweden and the UK. Five studies did not disclose a funding source, and all disclosed sources were public funding. Participants were invited from a range of settings: from the community, through the media, from universities and in places where people might seek help for their mental health (e.g. war veterans), in the aftermath of sexual trauma (sexual assault centres and emergency departments) or for problems that accompany the experience of sexual violence (e.g. sexual health/primary care clinics). Participants randomised were 99% women (3965 participants) with just 27 men. Half were Black, African or African-American (1889 participants); 40% White/Caucasian (1530 participants); and 10% represented a range of other ethnic backgrounds (396 participants). The weighted mean age was 35.9 years (standard deviation (SD) 9.6). Eighty-two per cent had experienced rape or sexual assault in adulthood (3260/3992). Twenty-two studies (61%) required fulfilling a measured PTSD diagnostic threshold for inclusion; however, 94% of participants (2239/2370) were reported as having clinically relevant PTSD symptoms at entry. The comparison of psychosocial interventions with inactive controls detected that there may be a beneficial effect at post-treatment favouring psychosocial interventions in reducing PTSD (standardised mean difference (SMD) -0.83, 95% confidence interval (CI) -1.22 to -0.44; 16 studies, 1130 participants; low-certainty evidence; large effect size based on Cohen's D); and depression (SMD -0.82, 95% CI -1.17 to -0.48; 12 studies, 901 participants; low-certainty evidence; large effect size). Psychosocial interventions, however, may not increase the risk of dropout from treatment compared to controls, with a risk ratio of 0.85 (95% CI 0.51 to 1.44; 5 studies, 242 participants; low-certainty evidence). Seven of the 23 studies (with 801 participants) comparing a psychosocial intervention to an inactive control reported on adverse events, with 21 events indicated. Psychosocial interventions may not increase the risk of adverse events compared to controls, with a risk ratio of 1.92 (95% CI 0.30 to 12.41; 6 studies; 622 participants; very low-certainty evidence). We conducted an assessment of risk of bias using the RoB 2 tool on a total of 49 reported results. A high risk of bias affected 43% of PTSD results; 59% for depression symptoms; 40% for treatment dropout; and one-third for adverse events. The greatest sources of bias were problems with randomisation and missing outcome data. Heterogeneity was also high, ranging from I2 = 30% (adverse events) to I2 = 87% (PTSD).

AUTHORS' CONCLUSIONS

Our review suggests that survivors of rape, sexual violence and sexual abuse during adulthood may experience a large reduction in post-treatment PTSD symptoms and depressive symptoms after experiencing a psychosocial intervention, relative to comparison groups. Psychosocial interventions do not seem to increase dropout from treatment or adverse events/effects compared to controls. However, the number of dropouts and study attrition were generally high, potentially missing harms of exposure to interventions and/or research participation. Also, the differential effects of specific intervention types needs further investigation. We conclude that a range of behavioural and CBT-based interventions may improve the mental health of survivors of rape, sexual assault and sexual abuse in the short term. Therefore, the needs and preferences of individuals must be considered in selecting suitable approaches to therapy and support. The primary outcome in this review focused on the post-treatment period and the question about whether benefits are sustained over time persists. However, attaining such evidence from studies that lack an active comparison may be impractical and even unethical. Thus, we suggest that studies undertake head-to-head comparisons of different intervention types; in particular, of novel, emerging therapies, with one-year plus follow-up periods. Additionally, researchers should focus on the therapeutic benefits and costs for subpopulations such as male survivors and those living with complex PTSD.

Exploring the Experiences of Sexual Violence/Abuse Survivors Attending a Recovery Group: A Qualitative Study of Recovery and Evaluation Implications

Sexual violence/abuse (SV/A) is increasingly recognized requiring improved, evidence-based treatments. Delivery of group-based support in survivor services is common but often lacks evaluation. This qualitative study explored how survivors experienced groups and wanted recovery measured. Semistructured interviews with survivors of SV/A from two groups (N = 13, female: 25-64 years: mainly White British, heterosexual) were analyzed using an inductive approach to thematic analysis. Three overarching themes were identified including "anger," recovery "in the company of" others and "different destinations." The work contributes recognition of the need for evaluation with meaning to survivors and the potential for anger to be used in group activism.

Early intervention using written exposure therapy for PTSD and AUD symptoms following sexual assault: Description of design and methodology

The co-occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) is common following sexual assault and associated with more severe symptomology and increased likelihood of sexual revictimization. Integrated interventions aimed at reducing PTSD and AUD symptoms following recent sexual assault are needed and should address barriers to care and early treatment termination. The proposed study will test a novel, brief (5 to 7 sessions) intervention that integrates Written Exposure Therapy for PTSD and Cognitive Behavioral Therapy for AUD, and is initiated within the first six weeks post-assault. In Phase 1, qualitative analysis of content gathered during focus groups with treatment providers will be conducted to inform intervention development. In Phase 2, a proof-of-concept pilot study (n = 10) of the intervention, Substance Use Skills Training and Exposure Post-Sexual Assault (STEPS), will be conducted. In Phase 3, a pilot randomized controlled trial (RCT) among 54 recent sexual assault survivors will be implemented using the updated manualized STEPS intervention to evaluate feasibility and preliminary efficacy in reducing PTSD and AUD symptoms. Ecological momentary assessments will be used to assess daily alcohol use, craving, affect, intrusions and avoidance. The effects of STEPS on commonly associated symptoms (e.g., depression, substance use) will be examined. The proposed study has the potential to make a significant public health impact by advancing knowledge on the link between sexual assault and co-occurring PTSD and AUD and informing early intervention efforts for this high-risk population.

Survivor, family and professional experiences of psychosocial interventions for sexual abuse and violence: a qualitative evidence synthesis

BACKGROUND

It is well-established that experiencing sexual abuse and violence can have a range of detrimental impacts; a wide variety of interventions exist to support survivors in the aftermath. Understanding the experiences and perspectives of survivors receiving such interventions, along with those of their family members, and the professionals who deliver them is important for informing decision making as to what to offer survivors, for developing new interventions, and enhancing their acceptability.

OBJECTIVES

This review sought to: 1. identify, appraise and synthesise qualitative studies exploring the experiences of child and adult survivors of sexual abuse and violence, and their caregivers, regarding psychosocial interventions aimed at supporting survivors and preventing negative health outcomes in terms of benefits, risks/harms and barriers; 2. identify, appraise and synthesise qualitative studies exploring the experiences of professionals who deliver psychosocial interventions for sexual abuse and violence in terms of perceived benefits, risks/harms and barriers for survivors and their families/caregivers; 3. develop a conceptual understanding of how different factors influence uptake, dropout or completion, and outcomes from psychosocial interventions for sexual abuse and violence; 4. develop a conceptual understanding of how features and types of interventions responded to the needs of different user/survivor groups (e.g. age groups; types of abuse exposure; migrant populations) and contexts (healthcare/therapeutic settings; low- and middle-income countries (LMICs)); 5. explore how the findings of this review can enhance our understanding of the findings from the linked and related reviews assessing the effectiveness of interventions aimed at supporting survivors and preventing negative health outcomes.

SEARCH METHODS

In August 2021 we searched MEDLINE, Embase, PsycINFO and nine other databases. We also searched for unpublished reports and qualitative reports of quantitative studies in a linked systematic review, together with reference checking, citation searches and contacting authors and other researchers to identify relevant studies.

SELECTION CRITERIA

We included qualitative and mixed-methods studies (with an identifiable qualitative component) that were linked to a psychosocial intervention aimed at supporting survivors of sexual abuse and violence. Eligible studies focused on at least one of three participant groups: survivors of any age, gender, sexuality, ethnicity or [dis]ability who had received a psychosocial intervention; their carers, family members or partners; and professionals delivering such interventions. We placed no restrictions in respect of settings, locations, intervention delivery formats or durations.

DATA COLLECTION AND ANALYSIS

Six review authors independently assessed the titles, abstracts and full texts identified. We extracted data using a form designed for this synthesis, then used this information and an appraisal of data richness and quality in order to stratify the studies using a maximum variation approach. We assessed the methodological limitations using the Critical Skills Appraisal Programme (CASP) tool. We coded directly onto the sampled papers using NVivo and synthesised data using a thematic synthesis methodology and used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We used a narrative synthesis and matrix model to integrate our qualitative evidence synthesis (QES) findings with those of intervention review findings.

MAIN RESULTS

We identified 97 eligible studies and sampled 37 of them for our analysis. Most sampled studies were from high-income countries, with four from middle-income and two from low-income countries. In 27 sampled studies, the participants were survivors, in three they were intervention facilitators. Two included all three of our stakeholder groups, and five included two of our groups. The studies explored a wide range of psychosocial interventions, with only one type of intervention explored in more than one study. The review indicates that features associated with the context in which interventions were delivered had an impact on how individuals accessed and experienced interventions. This included organisational features, such as staff turnover, that could influence survivors' engagement with interventions; the setting or location in which interventions were delivered; and the characteristics associated with who delivered the interventions. Studies that assess the effectiveness of interventions typically assess their impact on mental health; however, as well as finding benefits to mental health, our QES found that study participants felt interventions also had positive impacts on their physical health, mood, understanding of trauma, interpersonal relationships and enabled them to re-engage with a wide range of areas in their lives. Participants explained that features of interventions and their contexts that best enabled them to benefit from interventions were also often things that could be a barrier to benefiting from interventions. For example, the relationship with the therapist, when open and warm was a benefit, but if such a relationship could not be achieved, it was a barrier. Survivors' levels of readiness and preparedness to both start and end interventions could have positive (if they were ready) or negative (if they were not) impacts. Study participants identified the potential risks and harms associated with completing interventions but felt that it was important to face and process trauma. Some elements of interventions were specific to the intervention type (e.g. faith-based interventions), or related to an experience of an intervention that held particular relevance to subgroups of survivors (e.g. minority groups); these issues could impact how individuals experienced delivering or receiving interventions.

AUTHORS' CONCLUSIONS

We had high or moderate confidence in all but one of our review findings. Further research in low- and middle-income settings, with male survivors of sexual abuse and violence and those from minority groups could strengthen the evidence for low and moderate confidence findings. We found that few interventions had published quantitative and qualitative evaluations. Since this QES has highlighted important aspects that could enable interventions to be more suitable for survivors, using a range of methodologies would provide valuable information that could enhance intervention uptake, completion and effectiveness. This study has shown that although survivors often found interventions difficult, they also appreciated that they needed to work through trauma, which they said resulted in a wide range of benefits. Therefore, listening to survivors and providing appropriate interventions, at the right time for them, can make a significant difference to their health and well-being.

Systematic Review: Effectiveness of psychosocial interventions on wellbeing outcomes for adolescent or adult victim/survivors of recent rape or sexual assault

Sexual assault and rape are common forms of sexual violence/abuse. The psychological/health consequences represent significant and ongoing harm. It seems imperative that victim/survivors receive evidence-based support within first response settings. To assess what psychosocial interventions work for victim/survivors of a recent sexual assault. Twenty-seven electronic databases were systematically searched. Narrative data synthesis was used to read across studies. Reporting format follows PRISMA checklist. Ten studies were identifed including range of interventions. The evidence is sparse and scientifically weak, common flaws are reviewed. There is some weak evidence for the impact of video and cognitive behavioural therapy (CBT) based interventions, especially trauma processing. There is a gap in the evidence base on psychosocial interventions for victim/survivors of sexual assault and higher quality research is required.

Refining Sexual Assault Treatment: Recovered Survivors and Expert Therapists Concur on Effective Therapy Components

The goal of the present study was to refine sexual assault therapy through the examination of the level of agreement between survivor and therapist assessments of key recovery-promoting therapeutic interventions. This is the first study to explore the level of agreement between those who partake in the treatment process from either position. Semistructured interviews were conducted in this qualitative study with 10 survivors and 10 experienced therapists. The results document considerable concurrence between them regarding relational and trauma processing treatment components alike. Together, these reports outline key effective interventions, both common and specific in nature, concomitantly supported by both groups.

#MeToo: Disclosure and Response to Sexual Victimization on Twitter

Communication on Twitter surrounding violence against women often occurs through the use of "hashtags" that allow users to engage in shared discourse. The present study examined utilization of the Twitter hashtag #MeToo, which emerged in 2017 as a method for disclosing personal experiences of sexual victimization. Specifically, the present study sought to clarify how Twitter users utilized the #MeToo tag to disclose and respond to sexual violence by conducting a qualitative analysis of a random sample of tweets using #MeToo (N = 1,660). Survivors frequently prioritized the "who," "what," "where," "when," "why," and "how" of personal trauma experiences when disclosing using #MeToo. Twitter users also reflected on the prevalence of violence in society, acted as advocates to highlight the problem of violence against women, called attention to the experiences of other survivors of violence, or utilized the forum in a manner that distracted from survivors' experiences. The present data highlight the utility of Twitter for raising awareness regarding the prevalence of sexual violence, and providing a space where users can share personal trauma, connect to others with similar experiences, and provide support to others.

PTSD: Past, present and future implications for China

There has been a long history since human beings began to realize the existence of post-traumatic symptoms. Posttraumatic stress disorder (PTSD), a diagnostic category adopted in 1980 in the Diagnostic and Statistical Manual of Mental Disorders-Ⅲ, described typical clusters of psychiatric symptoms occurring after traumatic events. Abundant researches have helped deepen the understanding of PTSD in terms of epidemiological features, biological mechanisms, and treatment options. The prevalence of PTSD in general population ranged from 6.4% to 7.8% and was significantly higher among groups who underwent major public traumatic events. There has been a long way in the studies of animal models and genetic characteristics of PTSD. However, the high comorbidity with other stress-related psychiatric disorders and complexity in the pathogenesis of PTSD hindered the effort to find specific biological targets for PTSD. Neuroimage was widely used to elucidate the underlying neurophysiological mechanisms of PTSD. Functional MRI studies have showed that PTSD was linked to medial prefrontal cortex, anterior cingulate cortex and sub-cortical structures like amygdala and hippocampus, and to explore the functional connectivity among these brain areas which might reveal the possible neurobiological mechanism related to PTSD symptoms. For now, cognitive behavior therapy-based psychotherapy, including combination with adjunctive medication, showed evident treatment effects on PTSD. The emergence of more effective PTSD pharmacotherapies awaits novel biomarkers from further fundamental research. Several natural disasters and emergencies have inevitably increased the possibility of suffering from PTSD in the last two decades, making it critical to strengthen PTSD research in China. To boost PTSD study in China, the following suggestions might be helpful: (1) establishing a national psychological trauma recover project, and (2) exploring the mechanisms of PTSD with joint effort and strengthening the indigenized treatment of PTSD.

Sexual Violence, Mental Health, and Prescription Opioid Use and Misuse

INTRODUCTION

Previous research indicates that sexual violence is associated with prescription opioid use and misuse. However, this literature is limited by a lack of sex-specific analyses, an inability to establish temporality between experiences of sexual violence and prescription opioid outcomes, and little understanding of mechanisms underlying these associations.

METHODS

Data from Waves IV (2008) and V (2016-2018) of the National Longitudinal Study of Adolescent to Adult Health (N=10,685) were analyzed in March 2020. The association of sexual violence with past 30-day prescription opioid use and misuse among women and men and mediation by depression and anxiety diagnoses were examined using generalized structural equation modeling. Temporality was established using self-reported age at the first experience of sexual violence and age at first depression and anxiety diagnoses.

RESULTS

Sexual violence was associated with an increased likelihood of prescription opioid use and misuse among women (OR=1.68, 95% CI=1.19, 2.39 for use; OR=1.18, 95% CI=0.95, 1.55 for misuse) and men (OR=2.37, 95% CI=1.37, 4.12 for use; OR=1.71, 95% CI=1.06, 2.75 for misuse). Among women, depression (p=0.0420) and anxiety (p=0.0450) diagnoses mediated the association with prescription opioid use, and anxiety diagnosis (p=0.0210) mediated the association with prescription opioid misuse. Among men, anxiety diagnosis (p=0.038) mediated the association with prescription opioid use, and depression diagnosis (p=0.0390) mediated the association with prescription opioid misuse.

CONCLUSIONS

Secondary prevention efforts focused on evidence-based, trauma-informed behavioral health treatment among survivors of sexual violence may prevent prescription opioid use and misuse as strategies for coping with the psychological impact of these traumatic experiences.

Secondary prevention for posttraumatic stress and related symptoms among women whohave experienced a recent sexual assault: A systematic review and meta-analysis

BACKGROUND

Women who have experienced a recent sexual assault (SA) are at high risk for posttraumatic stress disorder (PTSD) and related conditions, with approximately half of women experiencing SA meeting criteria for PTSD. There are no guidelines for the prevention of PTSD and other common mental health disorders after SA. Thus, the purpose of this systematic review and meta-analysis is to synthesize research on secondary preventions for PTSD after SA, determine efficacy whether any intervention seems promising, and ascertain when, how, and to whom interventions should be delivered.

METHODS

After searching electronic databases for secondary preventions for PTSD and related conditions among women who have experienced a recent SA, 17 studies were reviewed, their quality was rated on the clinical trial assessment measure, and 10 studies were meta-analyzed (7 were excluded, as they were not randomized controlled trials or due to the absence of heterogeneity).

RESULTS

Results suggested a small-to-moderate effect of prevention on reducing PTSD and related symptoms. There was no moderating effect of medication versus psychosocial interventions, timing, treatment modality, or targeted versus universal prevention. Half of the studies were of high quality.

CONCLUSION

Cognitive-behavioral secondary preventions for PTSD appear to be safe and effective among women who have experienced a recent SA. Future research should identify best practices and mechanisms of treatment, and once identified, it should move toward implementation science.

The identification and treatment of mental health and substance misuse problems in sexual assault services: A systematic review

BACKGROUND

Specialist sexual assault services, which collect forensic evidence and offer holistic healthcare to people following sexual assault, have been established internationally. In England, these services are called sexual assault referral centres (SARCs). Mental health and substance misuse problems are common among SARC attendees, but little is known about how SARCs should address these needs. This review aims to seek and synthesise evidence regarding approaches to identification and support for mental health and substance misuse problems in SARCs and corresponding services internationally; empirical evidence regarding effective service models; and stakeholders' views and policy recommendations about optimal SARC practice.

METHODS

A systematic review was undertaken. PsycINFO, MEDLINE, IBSS and CINAHL were searched from 1975 to August 2018. A web-based search up to December 2018 was also conducted to identify government and expert guidelines on SARCs. Quality assessment and narrative synthesis were conducted.

RESULTS

We included 107 papers. We found that identification based on clinical judgement, supportive counselling and referral to other services without active follow-up were the most common approaches. Evaluations of interventions for post-rape psychopathology in attendees of sexual assault services provided mixed evidence of moderate quality. Very little evidence was found regarding interventions or support for substance misuse. Stakeholders emphasised the importance of accessibility, flexibility, continuity of care, in-house psychological support, staff trained in mental health as well as specialist support for LGBT groups and people with learning difficulties. Guidelines suggested that SARCs should assess for mental health and substance misuse and provide in-house emotional support, but the extent and nature of support were not clarified. Both stakeholders and guidelines recommended close partnership between sexual assault services and local counselling services.

CONCLUSIONS

This review suggests that there is big variation in the mental health and substance misuse provision both across and within different sexual assault service models. We found no robust evidence about how sexual assault services can achieve good mental health and substance misuse outcomes for service users. Clearer guidance for service planners and commissioners, informed by robust evidence about optimal service organisations and pathways, is required. PROSPERO registration number: CRD42018119706.

The role of age and mode of delivery in the STEPS intervention: a longitudinal pilot-study in treatment of posttraumatic stress symptoms in Danish survivors of sexual assault

Background: The STEPS programme has been succesfully implemented as a group-based treatment of trauma symptoms after rape for adolescents. The STEPS intervention was translated from Dutch to Danish and offered to adults in addition to adolescents as well as an individual intervention in addition to a group-based intervention at a Danish Centre for Rape Victims through 2011 to 2014. The programme was translated from Dutch to Danish and expanded to adults in addition to adolescents as well as to an individual intervention in addition to a group-based intervention at a Danish Centre for Rape Victims through 2011 to 2014. Objective: The present study observes  development in trauma symptoms and ICD-11 diagnostic status during an adapted version of the intervention programme 'STEPS' for survivors of sexual assault. Methods: A prospective uncontrolled study was conducted, monitoring symptoms of posttraumatic stress and other trauma-related symptomatology before treatment, after treatment and at 6 and 12 months' follow up for 103 referrals receiving individual or group-based STEPS. Tentative diagnoses of posttraumatic stress disorder (PTSD) and complex PTSD were assigned to participants according to the ICD-11 to observe the development in diagnostic status across time, and multilevel modelling was used to assess the development of symptom severity and to assess the moderating effect of age-group and mode of delivery. Results: A loglinear function representing large and statistically significant decline in symptomatology over time provided the best fit for all measures of trauma-related symptomatology. The decline was not moderated by age-group or mode of intervention. Dropout rates were independent of mode of intervention and age. Conclusion: The adaption of the STEPS programme to adults and as an individual intervention is feasible and maintains effect sizes comparable to those observed in the original intervention. Further research using randomized controlled trials is needed to ascribe the observed effect to the STEPS programme.

Impact of setting insecurity on Cognitive Processing Therapy implementation and outcomes in eastern Democratic Republic of the Congo

Background: While evidence is growing for the efficacy of trauma-focused mental health interventions in low- and middle-income countries, concerns have been raised about whether these types of interventions can be effectively delivered in contexts with ongoing conflict and violence. Cognitive Processing Therapy (CPT) has been shown to be effective in reducing sexual violence survivors' psychological symptoms in eastern Democratic Republic of the Congo (DRC), a region with a history of chronic conflict. Objective: The purpose of the present study is to assess the degree to which exposure to different levels of ongoing insecurity impacts effectiveness of an evidence-based trauma-focused psychotherapy for sexual violence survivors. Method: Participants were 158 female sexual violence survivors receiving CPT in seven communities in South Kivu. Participants completed weekly assessments of their symptoms of PTSD and depression as part of CPT. Degree of site insecurity was categorized as high or low levels of ongoing insecurity based on information collected from supervisors and clinicians. Hierarchical linear modelling was used to examine change over time moderated by level of insecurity at the site. Results: Overall, women reported a significant reduction in psychological symptoms over time (b = -2.04, p <.001). Residing in a site of greater insecurity was associated with higher initial symptoms (b = 5.91, p <.01), but similar improvement over time (b = -0.30, p =.10) compared to women living in relatively more secure sites. High rates of attendance and treatment completion were observed. Conclusions: These results support the effectiveness of trauma-focused therapies when provided in a well-structured and well-supervised program even in contexts of ongoing conflict and violence.

Campus Sexual Assault: Future Directions for Research

Campus sexual assault (CSA) has received unprecedented attention over recent years, resulting in an abundance of federal guidance and mandates. In response, efforts to address and prevent CSA at Institutions of Higher Education (IHE) across the country have grown quickly, including the development and implementation of programs and policies. Because the changes on campuses have occurred at such a rapid pace, a number of gaps exist within the field of CSA research. To ensure that changes on IHE are evidence-based, there is a need to review the existing research available and the inquiry still needed, based on key areas outlined in federal guidance, the expressed needs of campus community members, survivors, and students who commit sexual offenses on college campuses. The purpose of this review is to summarize the empirical research related to CSA gained from the past two decades and identify areas in which further work is needed, specifically related to key areas identified in recent guidance provided to IHE. This article concludes with guidance for research moving forward to help strengthen response and prevention efforts.

Do early interventions prevent PTSD? A systematic review and meta-analysis of the safety and efficacy of early interventions after sexual assault

Objective: To review the safety and efficacy of early interventions after sexual assault in reducing or preventing posttraumatic stress disorder (PTSD). Method: Systematic searches were performed on studies (1980-2018) that examined the efficacy of interventions for PTSD within 3 months after sexual assault. Results: The review identified 7 studies (n = 350) with high risk of bias that investigated 5 interventions. Only two studies reported on safety. Contact with the authors of six studies provided no indications for the occurrence of adverse events. Two studies reported the efficacy using PTSD diagnosis as dependent variable but found no difference between groups. All studies reported on efficacy using PTSD severity as dependent variable. For the meta-analysis, 4 studies (n = 293) were included yielding significantly greater reductions of PTSD severity than standard care at 2 to 12 months follow-up (g = -0.23, 95% CI [-0.46, 0.00]), but not at 1 to 6 weeks post-intervention (g = -0.28, 95% CI [-0.57, 0.02]). The heterogeneity of the interventions precluded further analyses. Discussion: Findings suggest that early interventions can lead to durable effects on PTSD severity after sexual assault. However, due to limited availability of data, it is impossible to draw definite conclusions about safety and efficacy of early interventions, and their potential to prevent PTSD.

Metacognitive therapy vs. eye movement desensitization and reprocessing for posttraumatic stress disorder: study protocol for a randomized superiority trial

BACKGROUND

The psychological treatment of choice for patients with severe posttraumatic stress disorder (PTSD) is cognitive behavioural exposure therapy or Eye Movement Desensitisation Reprocessing (EMDR). Whilst these are the most effective treatments, approximately 30-45% of the patients show no significant improvements and follow-up data are sparse. Furthermore, a proportion of patients with severe trauma does not benefit or avoid exposure therapy due to the potential to overwhelm them. Therefore, it is necessary to search for effective methods that do not require exposure. Metacognitive therapy (MCT), a recent treatment approach to PTSD that does not require exposure, has potential strong treatment effects but so far a comparison with EMDR has not been made.

METHODS/DESIGN

This study is a two-arm, parallel, randomized, superiority trial comparing the effectiveness of MCT with EMDR. One hundred patients with a primary diagnosis of chronic PTSD will be included and will receive 12 sessions of one of the treatments. The primary outcome is severity of PTSD symptoms assessed with the Posttraumatic Diagnostic Scale (PDS) measured post-treatment (3 months). Secondary outcomes include symptom severity (PDS) and measures of anxiety, depression, metacognitive beliefs at 3-month and 12-month follow up.

DISCUSSION

This randomized study is the first to compare MCT with EMDR with 12-month follow-up. The study will indicate the comparative effectiveness of MCT against EMDR and the stability of effects when delivered in an outpatient clinical setting.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01955590 . Registered on 24 September 2013.

An Overview of Sexual Trauma in the U.S. Military

This article discusses the scope and impact of military sexual trauma (MST) in the U.S. Armed Forces. The authors explore aspects of the military setting that may make recovery from this form of sexual violence particularly difficult. Risk factors for MST as well as associated mental, physical, sexual, and relational health consequences are reviewed. The authors also introduce clinical issues unique to male and lesbian, gay, bisexual, and transgender (LGBT) survivors. Finally, first-line psychotherapies and pharmacotherapies for subsequent mental health difficulties are reviewed, as are strategies for reducing barriers to health care for this population.

The contribution of gender-based violence and network trauma to gender differences in Post-Traumatic Stress Disorder

Background

Posttraumatic stress disorder (PTSD) occurs twice as commonly amongst women as men. Two common domains of trauma, network trauma and gender based violence (GBV), may contribute to this gender difference in PTSD rates. We examined data from a nationally representative sample of the Australian population to clarify the characteristics of these two trauma domains in their contributions to PTSD rates in men and women.

Methods

We drew on data from the 2007 Australian National Survey of Mental Health and Well-being to assess gender differences across a comprehensive range of trauma domains, including (1) prevalence of lifetime exposure; (2) identification of an index trauma or DSM-IV Criterion A event; and (3) the likelihood of developing full DSM-IV PTSD symptoms once an index trauma was identified.

Results

Men reported more traumatic events (TEs) overall but women reported twice the prevalence of lifetime PTSD (women, 13.4%; men, 6.3%). Women reported a threefold higher level of exposure to GBV and were seven times more likely to nominate GBV as the index trauma as compared to men. Women were twice more likely than men to identify a network trauma as the index trauma and more likely to meet full PTSD symptoms in relation to that event (women, 20.6%; men, 14.6%).

Conclusion

Women are more likely to identify GBV and network trauma as an index trauma. Women’s far greater exposure to GBV contributes to their higher prevalence of PTSD. Women are markedly more likely to develop PTSD when network trauma is identified as the index trauma. Preventing exposure to GBV and providing timely interventions for acute psychological reactions following network trauma may assist in reducing PTSD rates amongst women.

Trauma cognitions are related to symptoms up to 10 years after cognitive behavioral treatment for posttraumatic stress disorder

OBJECTIVES

This study examined (a) relationships between trauma-related cognitions and posttraumatic stress disorder (PTSD) symptoms from pretreatment through a long-term period after cognitive-behavioral therapy (CBT) for PTSD and (b) whether these relationships were impacted by treatment type.

METHOD

Participants were 171 women randomized into treatment for PTSD after rape. Measures of self-reported trauma-related cognitions and interviewer-assessed PTSD symptoms (i.e., Posttraumatic Maladaptive Beliefs Scale, Trauma-Related Guilt Inventory, and Clinician-Administered PTSD Scale) were obtained at pretreatment, posttreatment, and 3-month, 9-month, and 5-10 year follow-ups. Multilevel regression analyses were used to examine relationships between trauma-related cognitions and PTSD symptoms throughout the study period and whether these relationships differed as a function of treatment type (i.e., Cognitive Processing Therapy or Prolonged Exposure).

RESULTS

Initial multilevel regression analyses that examined mean within-participant associations suggested that beliefs regarding Reliability and Trustworthiness of Others, Self-Worth and Judgment, Threat of Harm, and Guilt were related to PTSD symptoms throughout follow-up. Growth curve modeling suggested that patterns of belief change throughout follow-up were similar to those previously observed in PTSD symptoms over the same time period. Finally, multilevel mediation analyses that incorporated time further suggested that change in beliefs was related to change in symptoms throughout follow-up. With 1 minor exception, relationships between beliefs and symptoms were not moderated by treatment type.

CONCLUSIONS

These data suggest that trauma-related cognitions are a potential mechanism for long-term maintenance of treatment gains after CBT for PTSD. Moreover, these cognitions may be a common, rather than specific, treatment maintenance mechanism. (PsycINFO Database Record

Violence against women and mental health

Violence against women is widely recognised as a violation of human rights and a public health problem. In this Series paper, we argue that violence against women is also a prominent public mental health problem, and that mental health professionals should be identifying, preventing, and responding to violence against women more effectively. The most common forms of violence against women are domestic abuse and sexual violence, and victimisation is associated with an increased risk of mental disorder. Despite clinical guidance on the role of mental health professionals in identifying violence against women and responding appropriately, poor identification persists and can lead to non-engagement with services and poor response to treatment. We highlight that little research has been done on how to improve identification and treatment of victims and perpetrators in contact with mental health services, but that mental health services could play a major role in primary and secondary prevention of violence against women.

Experiences of women who reported sexual assault at a provincial hospital, South Africa

BACKGROUND

Sexual assault poses a serious health problem to both the survivor and the health system. Experiencing sexual assault requires women to seek medical and psychological assistance as part of their journey towards recovery. This study examined the experiences of women who received post-sexual assault services from a specialised care centre within a provincial hospital.

METHODS

A qualitative, exploratory and contextual design was used to explore and describe experiences of women. Data were obtained through individual in-depth interviews from a total of 18 women aged between 18 and 55 years. Interviews were supplemented by the researcher's field notes and audiotape recordings.

RESULTS

Findings yielded two main themes: Women expressed their lived experiences of sexual assault characterised by different forms of trauma. The second theme was an expression of a need for safety and support.

CONCLUSION

Women who experience sexual assault are left with devastating effects such as physical and psychological harm and social victimisation. There is also a need for safety and support towards the recovery of these women. This study recommends that professional practitioners involved in the management of sexual assault be sensitised regarding the ordeal experienced by women and stop perceiving survivors as crime scene 'clients' from whom only medico-legal evidence has to be collected. Professional practitioners and family members must be supportive, non-judgemental and considerate of the dignity of survivors. The establishment of sexual assault response teams (SART) is also recommended. There should also be inter-professional education for better coordination of services rendered to sexually assaulted women.

Sexual Orientation, Race, and Trauma as Predictors of Sexual Assault Recovery

Sexual minorities and racial minorities experience greater negative impact following sexual assault. We examined recovery from sexual assault among women who identified as heterosexual and bisexual across racial groups. A community sample of women (N = 905) completed three yearly surveys about sexual victimization, recovery outcomes, race group, and sexual minority status. Bisexual women and Black women reported greater recovery problems. However, Black women improved more quickly on depression symptoms than non-Black women. Finally, repeated adult victimization uniquely undermined survivors' recovery, even when controlling for child sexual abuse. Sexual minority and race status variables and their intersections with revictimization play roles in recovery and should be considered in treatment protocols for sexual assault survivors.

Associations between Forced Sexual Initiation, HIV Status, Sexual Risk Behavior, Life Stressors, and Coping Strategies among Adolescents in Nigeria

Objectives

Some individuals experience their first sexual intercourse through physically forced sex, which affects the way they experience and cope with stress. We examined differences in sexual risk behavior, experience of stressors, and use of stress-coping strategies among adolescents in Nigeria based on their history of forced sexual initiation and HIV status.

Methods

We analyzed data from 436 sexually active 10–19-year-old adolescents recruited through a population-based survey from 12 Nigerian states. Using Lazarus and Folkman’s conceptual framework of stress and coping, we assessed if adolescents who reported forced sexual initiation were more likely to report HIV sexual risk practices, to report as stressors events related to social expectations, medical care and body images, and loss and grief, and to use more avoidance than adaptive coping strategies to manage stress. We also assessed if HIV status affected experience of stressors and use of coping strategies.

Results

Eighty-one adolescents (18.6%) reported a history of forced sexual initiation; these participants were significantly more likely to report anal sex practices (OR: 5.04; 95% CI: 2.14–11.87), and transactional sex (OR: 2.80; 95% CI: 1.56–4.95). Adolescents with no history of forced sexual initiation were more likely to identify as stressors, life events related to social expectations (OR: 1.03; 95% CI: 0.96–1.11) and loss and grief (OR: 1.34; 95% CI: 0.73–2.65), but not those related to medical care and body images (OR: 0.63; 95% CI: 0.34–1.18). They were also more likely to use adaptive responses (OR: 1.48; 95% CI: 0.62–3.50) than avoidance responses (OR: 0.90; 95% CI: 0.49–1.64) to cope with stress, though these differences were not significant. More adolescents with a history of forced sexual initiation who were HIV positive identified as stressors, life events related to medical care and body images (p = 0.03) and loss and grief (p = 0.009). Adolescents reporting forced sexual initiation and HIV-negative status were significantly less likely to use religion as a coping strategy (OR: 0.28; 95% CI: 0.09–0.83).

Conclusion

History of forced sexual initiation and HIV status affected perception of events as stressors and use of specific coping strategies. Our study findings could inform best practice interventions and policies to prevent and address forced sexual initiation among adolescents in Nigeria and other countries.

Rape against Brazilian Women: Characteristics of Victims and Sex Offenders

BACKGROUND

Violence against women is a serious social problem and affects mainly young women. This study aimed to evaluate sexual violence against women in Campina Grande, Brazil.

METHODS

A retrospective study with analysis of 886 forensic medical reports of sexual violence from the Institute of Legal Medicine of Campina Grande, Brazil, was conducted between January 2005 and December 2009. Sociodemographic variables related to victims, offenders and aggressions were analyzed. Significance level of 5% was adopted.

RESULTS

Two hundred and ninety-one cases of rape (32.8%) were confirmed, the majority of victims aged between 0 and 19 years (89.9%), were single (98.8%) and had low educational level (86.9%), with association with marital status (P = 0.02). The sex offender was known to the victim in 84.2% of cases and in 93.8% of cases, he acted alone. There was an association between rape and the relationship with the offenders (P = 0.01) and the age of the offenders (P = 0.03). The rape occurred in most cases at the home of victims (49.3%), with the use of violence in 72.3% of cases, but only 5.7% of the victims exhibited physical injuries. There was an association between rape and variables date of occurrence (P = 0.001), previous virginity (P = 0.001) and violence during practice (P = 0.001).

CONCLUSION

Over one third of women were victims of rape, predominantly adolescents, unmarried and with low educational level. The offenders were known to the victims, and acted alone in most situations, making use of physical violence.

Prolonged Exposure for Treating PTSD Among Female Methadone Patients Who Were Survivors of Sexual Abuse in Israel

The aims of this pilot study were: (a) to test the feasibility of prolonged exposure (PE) therapy conducted by a social worker staff on female patients in methadone program clinics who were survivors of child sexual abuse or rape and (b) to examine preliminary outcomes of PE on posttraumatic stress disorder (PTSD), depression, and illicit drug use at pre- and posttreatment, and up to 12-month follow-ups. Twelve female methadone patients who were survivors of child sexual abuse or rape diagnosed with PTSD were enrolled in 13-19 weekly individual PE sessions. Assessments were conducted at pre-, mid-, and posttreatment, as well as at 3, 6, and 12-month follow-ups. The treatment outcomes measures included PTSD symptoms, depressive symptoms, and illicit drug use. Ten of the 12 study patients completed treatment. PTSD and depressive symptoms showed significant reduction. No relapse to illicit drug use was detected. These preliminary results suggest that PE may be delivered by methadone social workers with successful outcomes. Further research should test the efficacy of PE among methadone patients in a randomized control trial with standard care as the control condition.

Rape-related symptoms in adolescents: short- and long-term outcome after cognitive behavior group therapy

BACKGROUND

Efficacy studies on treatment in adolescent victims of single rape are lacking, even though sexual victimization is most likely to occur during adolescence and despite the fact that adolescents are at risk to develop subsequent posttraumatic stress disorder.

AIM

The aim of this prospective observational study was to evaluate the short- and long-term outcomes of a nine-session cognitive behavior group therapy (STEPS), including a parallel six-session parents' group on rape-related symptomatology in female adolescents (13-18 years). STEPS includes psychoeducation, exposure in sensu as well as in vivo, cognitive restructuring, and relapse prevention.

METHODS

Fifty-five female adolescents with mental health problems due to single rape, but without prior sexual trauma, received STEPS while their parents participated in a support group. Subjects were assessed on posttraumatic stress (PTS) and comorbid symptoms using self-report questionnaires prior to and directly after treatment, and at 6 and 12 months follow-up.

RESULTS

Repeated measures analysis showed a significant and large decrease in symptoms of PTS, anxiety, depression, anger, dissociation, sexual concerns, and behavior problems directly after treatment, which maintained at 12 months follow-up. Time since trauma did not influence the results. Dropout during STEPS was 1.8%.

CONCLUSIONS

The results potentially suggest that the positive treatment outcomes at short- and long-term may be caused by STEPS. The encouraging findings need confirmation in future controlled studies on the effectiveness of STEPS because it may be possible that the treatment works especially well for more chronic symptoms, while the less chronic part of the sample showed considerable improvement on its own.

Controlled trial of psychotherapy for Congolese survivors of sexual violence

BACKGROUND

Survivors of sexual violence have high rates of depression, anxiety, and post-traumatic stress disorder (PTSD). Although treatment for symptoms related to sexual violence has been shown to be effective in high-income countries, evidence is lacking in low-income, conflict-affected countries.

METHODS

In this trial in the Democratic Republic of Congo, we randomly assigned 16 villages to provide cognitive processing therapy (1 individual session and 11 group sessions) or individual support to female sexual-violence survivors with high levels of PTSD symptoms and combined depression and anxiety symptoms. One village was excluded owing to concern about the competency of the psychosocial assistant, resulting in 7 villages that provided therapy (157 women) and 8 villages that provided individual support (248 women). Assessments of combined depression and anxiety symptoms (average score on the Hopkins Symptom Checklist [range, 0 to 3, with higher scores indicating worse symptoms]), PTSD symptoms (average score on the PTSD Checklist [range, 0 to 3, with higher scores indicating worse symptoms]), and functional impairment (average score across 20 tasks [range, 0 to 4, with higher scores indicating greater impairment]) were performed at baseline, at the end of treatment, and 6 months after treatment ended.

RESULTS

A total of 65% of participants in the therapy group and 52% of participants in the individual-support group completed all three assessments. Mean scores for combined depression and anxiety improved in the individual-support group (2.2 at baseline, 1.7 at the end of treatment, and 1.5 at 6 months after treatment), but improvements were significantly greater in the therapy group (2.0 at baseline, 0.8 at the end of treatment, and 0.7 at 6 months after treatment) (P<0.001 for all comparisons). Similar patterns were observed for PTSD and functional impairment. At 6 months after treatment, 9% of participants in the therapy group and 42% of participants in the individual-support group met criteria for probable depression or anxiety (P<0.001), with similar results for PTSD.

CONCLUSIONS

In this study of sexual-violence survivors in a low-income, conflict-affected country, group psychotherapy reduced PTSD symptoms and combined depression and anxiety symptoms and improved functioning. (Funded by the U.S. Agency for International Development Victims of Torture Fund and the World Bank; ClinicalTrials.gov number, NCT01385163.).

Supportive and Insight-Oriented Psychodynamic Psychotherapy for Posttraumatic Stress Disorder in an Adult Male Survivor of Sexual Assault

This is a single case study of a middle-aged man with posttraumatic stress disorder (PTSD) and Dissociative Disorder Not Otherwise Specified following sexual assault as an adult. Treatment consisted of supportive psychodynamic psychotherapy, focusing on reintegrating the patient into his community, followed by insight-oriented psychodynamic psychotherapy with an emphasis on processing trauma and decreasing PTSD and dissociative symptoms. Daily subjective, self-report measures were used to track his symptoms over a 29-month period. Simulation Modeling Analysis for time-series was utilized to assess the phase change from pretreatment baseline phase to total treatment phase and also between supportive psychotherapy phase and insight-oriented psychotherapy phase. Symptoms tracked included overall distress, preoccupation with the trauma, and dissociation. All symptoms significantly improved from the pretreatment baseline phase to the total treatment phase. Overall distress and preoccupation with the trauma significantly improved from the supportive to the insight-oriented psychotherapy phase.

Randomized trial comparison of emotion regulation and relational psychotherapies for PTSD with girls involved in delinquency

Posttraumatic stress disorder (PTSD) is prevalent in youth involved in delinquency, but it is often not effectively treated. A randomized clinical trial was conducted comparing the outcomes of an emotion regulation therapy (Trauma Affect Regulation: Guide for Education and Therapy, or TARGET) with a relational supportive therapy (Enhanced Treatment as Usual, or ETAU) with 59 delinquent girls (age 13-17 years) who met criteria for full or partial PTSD. Mixed model regression analyses demonstrated generally large effects for pre-post change in PTSD symptoms for both therapies but not in emotion regulation. Both therapies had small to medium effect size changes in anxiety, anger, depression, and posttraumatic cognitions. Treatment × Time interactions showed small to medium effects favoring TARGET for change in PTSD (intrusive reexperiencing and avoidance) and anxiety symptoms, posttraumatic cognitions, and emotion regulation, and favoring ETAU for change in hope and anger. Results provide preliminary support for TARGET as a potentially efficacious therapy for PTSD with delinquent girls. Relational therapies such as ETAU also may be beneficial for delinquent girls with PTSD, particularly to enhance optimism and self-efficacy and reduce anger.

The mental health focus in rape crisis services: tensions and recommendations

In the evolution of rape crisis services, tensions persist between rape crisis service programs and mental health professionals. Changes within these programs and professions have brought the embedded concerns to the surface, but they remain unexamined and unresolved. Recent research on rape trauma and survivors' mental health needs has added to tensions by calling for description and evaluation of rape crisis services and timely psychological treatment for survivors. This article offers a new perspective by discussing the tensions in an open but balanced way so as to promote discussion and solutions. Recommendations and action steps are offered for promoting constructive dialogue and change to improve direct services for survivors.

Prolonged exposure for the treatment of Spanish-speaking Puerto Ricans with posttraumatic stress disorder: a feasibility study

BACKGROUND

Most of the empirical studies that support the efficacy of prolonged exposure (PE) for treating posttraumatic stress disorder (PTSD) have been conducted on white mainstream English-speaking populations. Although high PTSD rates have been reported for Puerto Ricans, the appropriateness of PE for this population remains unclear. The purpose of this study was to examine the feasibility of providing PE to Spanish speaking Puerto Ricans with PTSD. Particular attention was also focused on identifying challenges faced by clinicians with limited experience in PE. This information is relevant to help inform practice implications for training Spanish-speaking clinicians in PE.

RESULTS

Fourteen patients with PTSD were randomly assigned to receive PE (n = 7) or usual care (UC) (n = 7). PE therapy consisted of 15 weekly sessions focused on gradually confronting and emotionally processing distressing trauma-related memories and reminders. Five patients completed PE treatment; all patients attended the 15 sessions available to them. In UC, patients received mental health services available within the health care setting where they were recruited. They also had the option of self-referring to a mental health provider outside the study setting. The Clinician-Administered PTSD Scale (CAPS) was administered at baseline, mid-treatment, and post-treatment to assess PTSD symptom severity. Treatment completers in the PE group demonstrated significantly greater reductions in PTSD symptoms than the UC group. Forty percent of the PE patients showed clinically meaningful reductions in PTSD symptoms from pre- to post-treatment.

CONCLUSIONS

PE appears to be viable for treating Puerto Rican Spanish-speaking patients with PTSD. This therapy had good patient acceptability and led to improvements in PTSD symptoms. Attention to the clinicians' training process contributed strongly to helping them overcome the challenges posed by the intervention and increased their acceptance of PE.