Chapter 8

The Mental Health Community

Victims of crime often suffer a broad range of psychological and social
injuries that persist long after their physical wounds have healed. Intense
feelings of anger, fear, isolation, low self-esteem, helplessness, and
depression are common reactions.1 Victimization can shatter the most basic
assumptions that allow people to function normally in their daily livesthat
they are safe from harm, that the world is meaningful and just, and that
they are good, decent people. This happens not only to victims of violent
assaults but also to victims of crimes such as burglary and fraud.2
Survivors of prolonged, repeated trauma, such as battered women and abused
children, often suffer severe mental health problems.

The emotional damage and social isolation caused by victimization can be
compounded by a lack of support and even stigmatization by friends, family,
and social institutions, producing a second wound for victims. Those
closest to the victim may be traumatized by the crime. They may be so
overwhelmed by their own anger, fear, and guilt that they are unable to
provide much care and understanding. Some friends and family members,
particularly of victims of sexual assault, distance themselves from the
victim and blame them for what happened.3 To protect their own belief in a
just world where people get what they deserve, and to establish distance
from the possibility of random or uncontrollable injury, many people prefer
to see victims as responsible for their fate.

When victims seek help, they are sometimes met with similar insensitivity.
They often feel revictimized by the criminal or juvenile justice process,
which traditionally has been more concerned with the rights of the accused
than with those of the victim. Justice may become a central issue for
victims as they seek to reconstruct their lives and begin to heal.4
Participation in the justice process is therapeutic when it helps victims
to better understand what happened, allows them an opportunity to tell
their story, and validates their loss and sense of being wronged. When
victims are ignored, their feelings of trauma may be intensified and
prolonged.

Progress Since the President's Task Force

on Victims of Crime

The Presidents Task Force on Victims of Crime observed in 1982 that violent
crime produces psychological as well as physical injuries.5 In issuing its
recommendations, the Task Force challenged the mental health community to:

 Provide immediate and long-term psychological treatment programs for
victims of crime and their families.

 Establish training programs that will enable practitioners to treat crime
victims and their families.

 Study the immediate and long-term psychological effects of criminal
victimization.

 Work with public agencies, victim compensation boards, and private
insurers to make psychological treatment readily available to crime victims
and their families.

 Maintain direct liaison with other victim service agencies.

In addition, the Task Force suggested that legislation be enacted to ensure
that designated victim counseling is legally privileged and not subject to
defense discovery or subpoena.

While the physical and financial injuries of criminal victimization were
emphasized in the victims movement, for many years crimes psychological
toll was not fully recognized. In the early 1980s, landmark documents
called attention to the fact that victims of violent crime often experience
crime-related mental health problems. In 1980, the third edition of the
American Psychiatric Associations Diagnostic and Statistical Manual
included post-traumatic stress disorder as a new diagnostic category and
noted that it could be caused by violent crimes such as rape and assault.6
Four years later, the American Psychological Association Task Force on
Victims of Crime and Violence examined the field of psychology and its
allied professions. Its final report reviewed the state of psychological
knowledge on victimization, surveyed theory and approaches to helping
victims, and made recommendations for the mental health community.7

Major advances have been made in our understanding of crime-related
psychological trauma and the best ways to provide treatment to crime
victims. Research on the scope of criminal victimization and its
psychological impact has grown substantially. In 1994, the fourth edition
of the Diagnostic and Statistical Manual pointed out differences between
acute traumatic stress disorderreflecting what is known in the field as the
crisis reaction to victimizationand post-traumatic stress disorder.8 It
further recognized the impact of the subjective perception of victims in
understanding traumatic events, which opened the way for further research
on the effects of culture and environment on victim responses and healing.
Research has led to a growing acknowledgment of the differences between the
types of trauma reactions that occur after a sudden, random, arbitrary
event and the reactions that occur when one is repeatedly traumatized over
time in situations such as domestic violence, child abuse, hostage taking,
or war.9 Other studies have provided new understanding of stress reactions
of crisis intervenors, victim assistance providers, and mental health
professionals when they work with crime victims.10 Although less
well-developed, the research literature on efficacy of treatments for
crime-related psychological trauma also has expanded.

Prior to 1982, there was virtually no systematic training available for
mental health professionals on effective treatments for crime victims. The
Society of Traumatic Stress Studies developed the first interdisciplinary
curriculum on responding to traumatic stress in 1989.11 This information is
now included in the training curricula of some mental health and medical
professionals, and postgraduate inservice training through workshops is
much more available.

The passage of the Victims of Crime Act (VOCA) in 1984 had an important
impact on improving mental health services for crime victims because state
crime victim compensation programs were required to provide payment for
mental health counseling in order to qualify for VOCA funding. Within a few
years, most states amended their compensation statutes to include mental
health counseling as an eligible benefit, providing considerable incentive
for mental health professionals to learn how to provide effective treatment
to crime victims.

The Office for Victims of Crime (OVC) has supported expanding mental health
services for crime victims by funding important initiatives in education
for mental health professionals and counseling for crime victims. These
initiatives range from supporting assessment and counseling services for
child sexual abuse victims on Native American reservations to funding
crisis response teams to assist victims of major mass crimes such as the
1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City. In
1995, OVC provided funding to the Pennsylvania Coalition Against Rape to
develop a curriculum on collaborative approaches to victim services for
mental health and victim service providers.12 In the critical area of
financial support for victim counseling, OVC funded the National
Association of Crime Victim Compensation Boards in 1991 to develop
state-of-the-art guidelines on evaluation and payment of mental health
counseling claims.

In addition, the National Institute of Justice provided substantial funding
for the 1994 National Conference on Family Violence cosponsored by the
American Medical Association and the American Bar Association. Important
recommendations were made at the conference to improve multidisciplinary
criminal justice and health care approaches to family violence, including
developing mental health referral sources and a communitywide assessment
process that maximizes safety for all family members.

The Importance of Understanding and Treating Crime-related Psychological
Trauma

Crime-related psychological trauma is a major public health and mental
health problem for our nation. Because violent crime has been shown to
increase both morbidity and mortality, violence and its aftermath have
become mainstream public health issues.13 Violent crime puts a large number
of Americans at risk of debilitating mental health problems that can
severely limit their ability to live productive, emotionally healthy lives.
Victims with a history of victimization suffer more crime-related
psychological trauma after experiencing a new crime than do victims without
prior victimization.14 Because of the sheer number of Americans suffering
from crime-related mental health problems, their treatment is one of the
most pressing issues facing the mental health community today.

Crime-related psychological trauma impairs the ability and willingness of
many victims to cooperate with the criminal or juvenile justice system. At
every key stage of the justice processfrom contemplating making a report to
police to attending a parole hearinginteracting with the system is
stressful for victims and often exacerbates their trauma. When victims do
not report crimes to police out of fear or are too terrified to testify, it
is extremely difficult for the justice system to accomplish its mission.

Crisis Reactions and Short-term Trauma

Most crime victims suffer crisis reactions after serious crimes. They often
experience shock and a sense of disbelief, thinking, this cant be happening
to me. Many describe high levels of physiological anxiety such as rapid
heart rate and hyperventilation as well as emotional reactions such as
feeling helpless, terrified, and extremely angry. These are common flight
or fight responses that occur in dangerous situations. They may be
accompanied by disorientation, confusion, shame, guilt, and grief.

Some victims survive the crime and the accompanying reactions with few
lingering effects. More continue to experience the reverberations of crisis
over the next few weeks or months. This is particularly true if the crime
has substantially disrupted their day-to-day lives. Victims of violent
crime may feel high levels of fear, anxiety, and general distress,
disrupting their ability to concentrate on simple mental activities. Some
become preoccupied with the crime, worry constantly about their safety and
the safety of their family members, and become concerned that other people
will not believe them or will think that they are responsible for what
happened. Even more distressing for these victims, especially those who are
harmed by members of their family, is that violent criminal acts destroy
their belief that their world is safe and that the people they live, work,
and go to school with can be trusted.

Acute traumatic stress disorder is one description of short-term trauma and
reflects findings that indicate that for many people such symptoms subside
within a month after victimization.15 It is not unusual for memories of the
event to disrupt victims thoughts and sleep. They may have recurrent
nightmares, become irritable, suffer outbursts of tears, feel estranged and
isolated from loved ones, or be wary of any sudden, intrusive sensation.

With the help of strong social support and pre-existing lifetime coping
skills, the intensity of traumatic reactions is likely to decrease over
time. But it is not unusual for reactions to continue until individuals
feel that their lives have stabilized and that they have regained a sense
of safety and security in their world. Crisis reactions can also reappear
at later times in their lives when another event triggers their memory of
the original trauma.

Long-term Psychological Trauma

For some victims of violent crime and their families, psychological trauma
may last for months or years. Research demonstrating that violent crime can
produce long-term psychological harm has grown enormously since the
publication of the President's Task Force Report in 1982.

Many victims of and witnesses to violent, highly stressful events develop
symptoms that are referred to by the American Psychiatric Association as
post-traumatic stress disorder, or PTSD. For victims of crime, these events
may include sexual assault, physical attack, robbery, mugging, kidnaping,
child sexual assault, observing the serious injury or death of another
person due to violent assault, and learning about the violent assault or
death of a family member or close friend.16 Reactions to these events can
be a destructive force in a persons life for a long time. They include:

 Persistent re-experiencing of the event, including distressing
recollections, flashbacks, and dreams, and emotional and physiological
reactions to anything that triggers an association.

 Persistent avoidance of things associated with the traumatic event and
reduced ability to be close to other people and have loving feelings.

 Persistent symptoms of increased arousal, including sleeping disorders,
outbursts of anger, an inability to concentrate on simple tasks, wariness,
and highly sensitive startle responses.

 Significant distress or impairment in social, occupational, or other
important areas of functioning.

While PTSD reactions generally have been acknowledged as common among
victims throughout the world, it should be emphasized that cultural
perceptions of threat and response to danger may affect how people respond
to violent crime.

Research has indicated that rates of PTSD are much higher among those who
have been victims of violent crime than among those who have been victims
of other types of traumatic events. One such study found that the lifetime
prevalence of PTSD was significantly higher among crime victims than among
victims of other traumatic events. The same study found that crime victims
who believed they would be killed or seriously injured during the crime
were much more likely to develop PTSD than were victims whose crimes did
not involve life-threatening injury.17 Rates of PTSD appear to be higher
among victims who report crimes to the criminal justice system than among
nonreporting victims.18 Importantly, research indicates that many crime
victims with PTSD cannot recover without treatment and that some crime
victims have PTSD for years after their victimization.19

Long-term crime-related psychological trauma is not limited to PTSD.
Compared to people with no history of criminal victimization, victims of
violent crime have significantly higher rates of major depression, suicide
thoughts and attempts, alcohol and drug abuse problems, and anxiety
disorders or dissociative disorders. While the complexities of
psychological trauma are not completely understood, the interrelationship
between symptoms of PTSD and other mental health concerns is reflected in
the research surrounding Complex PTSD or the Diagnosis of Extreme Stress
Not Otherwise Specified (DESNOS).20 The symptoms of PTSD are included in
the description of this phenomenon but it also includes symptoms relating
to dissociation, anxiety, depression, and suicide. Victims of chronic abuse
and violence may be more likely to exhibit these reactions than simple
PTSD.

Counseling and Mental Health Interventions

The differences between immediate crisis reaction, short-term trauma, and
long-term trauma are the foundation of the major types of interventions
used by mental health providers when treating victims of crime. The
interventions are not mutually exclusive, and the need for crisis
intervenors, victim service providers, mental health professionals, and
other healers to work together is critical in many cases.

Crisis intervention refers to the immediate counseling response to victims
in the aftermath of a crime or traumatic event. The goals of crisis
intervention are to reassure victims of their immediate safety and
security, allow them an opportunity to express their reactions, assist them
in reducing their immediate emotional distress, and provide them with
information and assistance on what they can expect to happen next in their
lives.

Posttrauma counseling describes interventions that provide longer term
support to victims to help them better understand the psychological effects
they are dealing with. Posttrauma counseling also helps victims develop
skills and social or spiritual support to begin to cope with the
victimization. The methods and tools mental health providers use in
posttrauma counseling include cognitive-behavioral techniques, peer support
groups, ritual and meditation, education, and physical and mental activism.

Posttrauma therapy refers to psychological or psychiatric interventions
that typically involve clinical sessions with a mental health professional.
Mental health professionals are trained in trauma-related reactions and may
employ a number of therapeutic interventions.

Complex trauma therapy is still in its infancy stage. With new information
and research emerging on the impact of chronic victimization, multiple
victimization, and victims who have coexisting mental health problems,
diagnosis, treatment, and interventions have become increasingly
complicated. However, research being conducted by the Department of
Defense-Health Services to identify the interrelationship between
individual coping capacities, ordinary stress, latent and acute trauma
reactions, and effective trauma treatment plans may create opportunities in
the future.

Cultural Competency in Mental Health Counseling

According to Erwin Parsons, All ethnically focused clinical, sociological,
anthropological, and experimental studies converge to one central
conclusion regarding ethnic America: Ethnic identification is an
irreducible entity, central to how persons organize experience, and to an
understanding of the unique cultural prism they use in perception and
evaluation of reality. Ethnicity is thus central to how the patient or
client seeks assistance (help-seeking behavior), what he or she defines as
a problem, what he or she understands as the causes of psychological
difficulties, and the unique, subjective experience of traumatic stress
symptoms. Ethnicity also shapes how the client views his or her symptoms,
and the degree of hopefulness or pessimism towards recovery. Ethnic
identification, additionally, determines the patient's attitudes toward his
or her pain, expectations of the treatment, and what the client perceives
as the best method of addressing the presenting difficulties.21

Trauma, suffering, recovery, and healing are defined differently in
different cultures. Asian cultures, for example, emphasize character
building and purposeful and responsible behavior, rather than gaining
insight or reducing symptoms. Native cultures emphasize restoring harmony
among relations with the Great Spirit and Mother Earth when someone is
victimized or harmed. The individual in these cultures does not strive for
independent accomplishment, selfhood, or personal fulfillment apart from
being a part of a family, clan, or community.

Many cultures do not isolate physical, emotional, and spiritual factors in
health and illness. Trauma affects the whole person. Cultures therefore
have different idioms of distress. Southeast Asian refugees, for example,
often complain about body dysfunction such as headaches or chest pains when
experiencing depression. Asians in general experience and report
psychosomatic stress.

Many cultures, including American Indian, Asian, Pacific Islander, and
Latino cultures, depend upon shamans for healing. The concept of shaman is
at least 20,000 years old and encompasses the idea of priest and healer.
Shamanistic approaches are radically different from the dominant beliefs of
Western physicians and mental health practitioners. Indigenous holistic
healing practices are not alternative approaches but the traditional
approaches of the majority of the world's people. In a nation as
pluralistic and multicultural as the United States, it is crucial to
recognize cultural differences in addressing the needs of crime victims.

Emerging Mental Health Issues for Victims of Crime

A number of issues of importance to meeting the mental health needs of
crime victims have emerged over the past decade. These issues either were
not addressed by the Presidents Task Force or have become more salient in
todays society.

Repeat Victimization, Chronic Victimization, and the Cycle of Violence

In 1982, there was little acknowledgment that many people are victimized
repeatedly during their lifetime, increasing their risk for crime-related
psychological trauma and complex mental health problems. Studies show that
a substantial number of crime victims have been victimized more than once,
and that a history of victimization is associated with risk of subsequent
violent assault.22 Other research suggests that the risk of developing PTSD
and substance abuse problems is higher among repeat victims of violent
assault than among those who have experienced only one violent assault.23
Evidence also suggests that a history of victimization in youth increases
their risk of involvement with delinquent peers and delinquent behavior.24
Moreover, the involvement of youth with delinquent peers and substance
abuse appears to increase their risk of victimization.25 Another line of
research has found that a history of child abuse and neglect increases risk
of delinquent behavior during childhood and adolescence as well as the risk
of being arrested for violent crime as an adult.26

Chronic victimization as a result of domestic violence, child abuse, or
hostage taking also contributes to higher risks of mental health problems.
Victims of chronic violence present particularly complex histories when
they have not only been abused by loved ones or intimates but also been
victims of stranger crimes. They, too, may present coexisting mental health
problems, including problems developed during an individual's attempt to
survive and to cope with the chronic violence.

The High Prevalence of Crime Perpetrated by Acquaintances

Since the release of the Presidents Task Force report in 1982, it has
become increasingly clear that violent assault by a stranger is much less
common than assault by people known to the victim. Child abuse victims,
rape victims, physical assault victims, and homicide victims are all more
likely to be attacked by someone they know well than by someone they do
not.27 Being attacked by a family member, friend, or acquaintance poses
particular problems for victims in the criminal and juvenile justice system
and creates special issues for them in counseling.

Victimization of Children and Adolescents

The focus of the President's Task Force report was on the adult crime
victim. The extent to which Americas youth are disproportionately victims
of violence was not fully appreciated. Violence is a major problem for
children and adolescents,28 and research shows that a history of violent
assault during childhood or adolescence increases risk for a host of major
mental health problems such as PTSD29 and substance abuse.30 Treating
violence-related mental health disorders in young victims requires special
expertise, and because young people face unique problems in the criminal
and juvenile justice systems, therapists should understand their special
needs.

Other issues should be considered when treating the mental health needs of
child victims. First, the complexity of problems child victims face often
means that treatment must extend beyond brief intervention. This is
particularly true if the goals of treatment are to support victims
throughout the justice systems and child protective services process and to
address prevention and other developmental issues. Second, crime-related
psychological trauma is likely to be exacerbated at key developmental
milestones in a childs life, and child victims require more treatment at
those times. Third, although more research is needed on this issue, it
appears that victimized girls are more likely than victimized boys to be
victimized in the future, and victimized boys appear to be more likely than
victimized girls to become physically aggressive. These important findings
suggest the need for slightly different treatment approaches for girls and
boys.

Confidentiality of Communications Between Victims and Their Counselors

A provision of the 1994 Violence Against Women Act directed the Attorney
General to study and evaluate the manner in which states have taken steps
to protect the confidentiality of communications between sexual assault or
domestic violence victims and their counselors. The Act also required the
development of model legislation that provides maximum protection within
constitutional limits for the confidentiality of such communications. In
1995, the director of the Violence Against Women Office within the
Department of Justice wrote about the need for such protection in a report
to Congress entitled The Confidentiality of Communications Between Sexual
Assault or Domestic Violence Victims and their Counselors:31

A successful prosecution depends on the cooperation of the crime victim.
Yet in many cases of sexual assault and domestic violence, a woman who has
been attacked frequently finds herself victimized a second time when her
case goes to court. This is particularly true when the victim receives
counseling from a domestic violence or rape crisis counselor who often is
not a licensed psychologist or psychotherapist, and lacks the testimonial
privilege afforded to other professionals such as psychotherapists or
psychologists in most states.

In far too many cases, defense attorneys subpoena counseling records and
call counselors as witnesses. The attorneys use the records to shift the
courts focus from the crime to the victims thoughts and comments regarding
the emotionally devastating incident. Often, victims face the threat that
their most intimate feelings will be disclosed in open court and become a
matter of public record.

Sexual assault and domestic violence victims must be able to communicate
freely with their counselors, secure in the knowledge that the private
thoughts and feelings they reveal during counseling will not be publicized
as a result

of reporting the crime.

According to the report, as of December 1995, 27 states and the District of
Columbia had enacted statutes that protect, to differing degrees,
confidential communications that arise from the relationship between sexual
assault and domestic violence victims and their counselors. Some state
statutes provide an absolute privilege in which disclosure is not permitted
under any circumstances. Others provide a semi-absolute privilege in which
disclosure is permitted only under specified circumstances that serve the
public interest. Still others provide a qualified privilege in which
disclosure is permitted after certain requirements are met or balancing
tests are employed. State courts have reached different conclusions about
the constitutionality of statutes providing absolute or semi-absolute
privilege in these cases.

Federal legislation to protect the confidentiality of victim-counselor
communications has not been enacted, and the United States Supreme Court
has not addressed the issue of whether absolute testimonial privilege is
constitutional.32

Impact of Health Care Reform on Availability of Mental Health Counseling
for Crime Victims

Massive changes are occurring in health care financing and health care
delivery systems. These changes include reduced direct federal and state
funding for mental health services such as mental health centers, increased
managed care in the private sector, proposed reductions in Medicaid
reimbursement for health care services including mental health, and the
formation of large health care networks that emphasize primary care and
de-emphasize specialty care. These changes are generating enormous
financial pressures to reduce costs, which is most often accomplished by
reducing services. This trend is likely to continue.

Until comprehensive health care reform is achieved that specifically
includes coverage of mental health counseling for crime victims, the
availability of quality mental health services for crime victims is likely
to be reduced, putting more pressure on mental health counselors to seek
funding from crime victim compensation and other financial resources.

Recovered Memories

Much controversy has been generated about the extent to which memories of
abuse during childhood can be repressed, sometimes for long periods, and
later recovered. In a few cases, therapists have been accused of falsely
implanting repressed memories, which some refer to as false memory
syndrome.33 However, other professionals object to the term, saying that
there is no evidence to suggest that the syndrome exists. This controversy
has resulted in attacks on the legitimacy of certain types of therapy
conducted with adults who disclose that they have been physically or
sexually abused as children. Some therapists whose adult clients remembered
having been assaulted as children during the course of treatment have been
sued by parents accused of assault.

Evidence of repressed memory exists outside the crime victims field. For
example, scientific data on memory repression during World War II
documented hundreds of cases of repressed memories in troops returning from
battle. In many of the cases, psychologists diagnosed soldiers with what
would now be classified as PTSD. The psychologists historic reports show
that many of the soldiers could not remember traumatic experiences that
others in their platoon described. Once they were able to recall the
traumatic experiences, their PTSD symptoms disappeared.34

Judith Herman, author of Trauma and Recovery, points out that people
subjected to prolonged, repeated trauma develop an insidious, progressive
form of post-traumatic stress disorder that invades and erodes the
personality . . . . Through the practice of dissociation, voluntary thought
suppression, minimization, and sometimes outright denial, they learn to
alter an unbearable reality. She goes further with the concept of
suppression, pointing out that clinicians who work with severely
traumatized patients often become suspect among their colleagues.
Regression, dissociation, and denial, she writes, are phenomena of social
as well as individual consciousness.35

A survey about child abuse was sent to 500 American Psychological
Association members and practitioner-oriented divisions; 330 members (56
percent women) returned the questionnaire. Childhood abuse (sexual or
nonsexual) was reported by 22 percent of the sample and 41 percent of those
reported a period of forgetting. Overall, 47 percent of the participants
who had experienced forgetting were able to corroborate the abuse. Those
who recovered their memories in therapy were just as likely as those whose
memories were triggered outside of therapy to be able to corroborate their
abuse.36

The courts have varied reactions to repressed memory. In three high-profile
cases decided in 1997, one court found the theory of repressed memory to be
validated and generally accepted by recent scientists. But in the other two
cases, the courts expressed reservations given the state of scientific
knowledge and controversy in the area.37

Promising Practices in Crime-Related Mental Health

Innovative programs have been developed that provide excellent mental
health services to victims with crime-related psychological trauma. Crime
victims involved with the criminal and juvenile justice systems face
special problems, and effective mental health programs for them must do
more than just provide counseling services. Most of the programs discussed
in this section use a multidisciplinary approach to ensure that victims are
informed about how the system works and are prepared to deal with the
stress of participating in the system. These programs work closely with
crime victim compensation programs and victim assistance agencies to help
victims access other services, and they make a special effort to ensure
that mental health professionals serve victims as advocates, helping them
get the information and assistance they need.

Several programs include an educational component in which student mental
health professionals receive specialized training in how to provide
effective mental health treatment to crime victims. This training is
important because of the shortage of mental health professionals with
specific expertise in assessment and treatment of crime-related
psychological trauma. By providing training to student mental health
professionals and continuing education to practicing clinicians, these
programs are increasing the cadre of mental health professionals who can
provide competent care to crime victims.

A final attribute of these programs is that most have a research component.
Research is important because it provides

new knowledge about the scope of violent crime, the nature of crime's
impact on mental health, and the effectiveness of mental health
interventions.

 The National Crime Victims Research and Treatment Center (NCVC) at the
Medical University of South Carolina in Charleston, South Carolina,
provides specialized mental health services for crime victims of all ages
and their families. NCVC trains mental health professionals about effective
mental health treatment for crime victims and works closely with local
police agencies, prosecutor's offices, rape crisis centers and battered
womens shelters, the state crime victim's assistance network, and the state
crime victims compensation agency. NCVC staff identify physically injured
crime victims hospitalized in the medical center and provide them with
information about the criminal justice system, typical psychological trauma
experienced by crime victims, crisis counseling, and referrals for
outpatient treatment. NCVC also conducts research on the scope and mental
health impact of violent crime.

 Among the comprehensive array of programs developed by Victim Services in
New York City are several mental health services. Its licensed mental
health center provides goal-focused individual counseling and trauma
reduction and supportive group services for victims of violent crime,
including domestic violence, sexual assault, incest, and robbery, as well
as homicide survivors. At precincts and in courts and community offices,
the agency offers crisis intervention and stress education and management
services to victims shortly after the crime is committed. Counseling is
also available in schools and shelters for children who witness crimes,
including domestic violence, and a crisis response team has been
established to respond to victims of natural and community disasters. At
one of the agencys nine community offices, the counseling services are
provided by social work students and other mental health professionals who
work for free in exchange for the opportunity to train with victims. At all
sites and in every setting where mental health services are offered, staff
are available to address the practical needs of victims by, for example,
helping them navigate the court system, obtain crime victim compensation,
arrange for child care, or repair or replace locks.

 The Harborview Sexual Assault Treatment Center in Seattle, Washington,
one of the oldest treatment and research programs in the nation, has been a
national leader in developing comprehensive mental health services for
sexually abused children and adults. The program has improved the quality
of mental health services for victims of sexual assault through training to
physicians and mental health professionals.

 The Rape Treatment Center (RTC) at Santa Monica-UCLA Medical Center
provides comprehensive services for sexual assault victims 24 hours a day,
7 days a week. In the 1970s, RTC pioneered a model for victim care that
integrated psychological interventions into the emergency medical care
process. This model was disseminated throughout the United States via a
training film produced by the National Institute of Mental Health. RTC also
offers long-term counseling for victims and their significant others, as
well as advocacy, accompaniment, information and referrals, and other
support services. To enhance the treatment of victims wherever they turn
for help, RTC provides professional training for medical, mental health,
law enforcement, criminal justice, judiciary, and school personnel,
including a course on victim issues for every new recruit at the Los
Angeles Police Department Training Academy. Stuart House, RTCs facility for
child victims, enhances collaboration with other victim service providers.
The facility has an onsite multidisciplinary team, including police,
prosecutors, and child protection personnel, who investigate abuse
allegations and minimize system trauma to child victims. Stuart House also
provides comprehensive treatment services and expert pediatric forensic
examinations.

 The Crime Victim Recovery Project at the University of Missouri at St.
Louis works closely with police and victim assistance agencies to address
crime-related psychological trauma. Through the program, crime victims are
provided with state-of-the-art cognitive-behavioral treatment. Similar to
NCVC and the Harborview Center, the program operates specialized training
programs for mental health professionals.

 In New Haven, Connecticut, the Child Study Center at the Yale University
School of Medicine and the New Haven Department of Police Services have
developed a collaborative program to address the psychological impact on
children and families of chronic exposure to community violence. The Child
Development-Community Policing program brings together mental health
professionals and police officers to intervene with children who are
victims, witnesses, or perpetrators of violence. The program also
emphasizes cross-training by police and mental health professionals.

 The National Organization for Victim Assistance (NOVA) has trained mental
health providers all over the country as part of their crisis response
training. NOVAs crisis response teams include trained mental health
providers who work together with law enforcement, medical professionals,
victim advocates, religious leaders, and others to provide assistance to
communities in the aftermath of major crimes and acts of terrorism.

Victim Support Groups

Many victims who have participated in victim support groups have found that
interaction is an important part of their healing process, as the voices of
four support group members indicate:

I dont know what I would have done without them. . . . I was in the pits of
depression for weeks . . . [and] thought seriously of suicide. They
literally saved my life.

You can only pretend so long. . . . You act as if you can deal with it when
you really cant. . . . They were there when I needed them. . . . They made
me feel the reality of it.

Its a wonderful experience to be around those you know can truly understand
how you feel because they feel the same.

It seemed as though no one could really understand what was happening to me
until I became involved with the group. . . They know because theyve been
through it.

Support groups for all types of victims have emerged during the past 15
years. Sometimes these groups are facilitated by trained mental health
professionals; other groups are led by crime victims themselves. Many
victims say that participation in victim support groups was a significant
factor in their healing process.

Parents of Murdered Children (POMC) and Mothers Against Drunk Driving
(MADD) have hundreds of chapters throughout the country, and many of them
offer victim support groups. In a survey of nearly 300 MADD members whose
loved ones were killed or seriously injured in a drunk driving crash, the
survivors said that support groups aided their emotional recovery by
providing a setting to share their feelings, keep the memory of their loved
one alive, and exchange vital information about assistance and compensation
programs with others who were experiencing similar trauma.38

Victim Activism

Taking part in efforts to make their communities and nation safer and more
just may also help victims recover from the emotional trauma of violent
crime. Victims of crime have found many ways to become active in the
aftermath of crime. On the community, state, and national levels, victims
are working to change the justice system and raise public awareness about
the consequences of crime and violence. For many victims who have fought to
enact the thousands of victims rights laws, the opportunity to stand up for
the rights of other victims of crime has helped them overcome feelings of
helplessness. By participating in Neighborhood Watch and sexual assault
prevention programs, warning parents and their children about the dangers
of drunk driving, or helping to educate children and incarcerated offenders
about the impact of crime through participation in victim impact panels,
victims feel a sense of greater control. Their actions help to ensure that
what happened to them will be less likely to happen to others.

Recommendations from the Field for the Mental Health Community

Mental Health Community Recommendation from the Field #1

The mental health community should develop linkages with crime victim
compensation, victim assistance programs, and criminal and juvenile justice
agencies to ensure that victims have access to adequate counseling or
mental health treatment at each stage of the justice process, from the time
the crime occurs through incarceration, pardon, parole, and appeals.
Federal and state laws should be amended to ensure that government covers
mental health counseling costs for crime victims throughout the criminal
justice process and beyond in cases of long-term psychological trauma.

The Presidents Task Force identified key stages of the criminal justice
process but did not specifically address crime victims needs for counseling
at each stage of the process. An offenders parole, probation, and release
can be as stressful for victims as the trial itself, and many jurisdictions
have overlooked counseling services during these traumatic periods.

The Victims of Crime Act should be amended to clarify that compensation and
assistance programs can be used to fund mental health counseling for crime
victims at all key stages of the criminal justice process. States should
ensure that victims are able to receive services or reimbursements from
state compensation programs to cover counseling costs related to their
participation in the criminal and juvenile justice process. Victims may
need to re-enter counseling many months or even years after the crime to
help them deal with the sentencing or release of an offender.

Model programs provide excellent examples of how mental health
professionals can work closely with justice system and victim assistance
agencies. Information about these programs should be widely disseminated
with descriptions of how they are organized and staffed, the services they
provide, how they are financed, and how they have addressed the practical
issues of interacting with the criminal justice system and victim
assistance agencies. Exchange programs should be established to encourage
mental health providers to visit model programs and observe how they work.

Mental Health Community Recommendation from the Field #2

Legislation should be enacted in every state and at the federal level to
ensure that designated victim counseling is legally privileged.

Crime victims are much less likely to be candid with their counselor or
seek counseling at all if they know that anything they confide is
discoverable by defense attorneys. Without candid discussion, good therapy
for victims is difficult, if not impossible.

The 1995 Report to Congress of the Violence Against Women Office offers two
model statutes that present alternative privileges in recognition of the
differences in state constitutions, case law, and statutes. Governors,
state legislatures, and Congress should give serious consideration to these
model statutes and adopt appropriate legislation.

Mental Health Community Recommendation from the Field #3

Research on the mental health consequences of victimization and treatment
of crime-related psychological disorders should be expanded.

Although a great deal is known today about the psychological impact of
crime victimization, more research is needed. To provide valuable data on
an important consequence of criminal victimization, the National Crime
Victimization Survey should be modified to include brief measures of
psychological trauma that individuals suffer in response to violent crime.
This information will help victim service providers, mental health
practitioners, and justice officials better understand and meet the many
needs of victims caused directly by trauma.

Considerably more is known about effective mental health treatment of
adults than about what works with child victims and their families. More
research is needed to give therapists a solid foundation of knowledge about
which techniques are most effective with child victims and witnesses.
Leading child abuse experts David Finkelhor and Lucy Berliner have strongly
recommended that further studies be conducted to establish clearly the
efficacy of treatment for sexually abused children and to learn more about
the optimal length of treatment, the problem of treatment dropouts, and
other important treatment-related issues that have not been researched
sufficiently.39 (For more discussion of this topic, see chapter 5.)

In addition, more research is needed regarding effective treatment methods
for children who witness violence. A recent study found that 43 percent of
male adolescents and 35 percent of female adolescents had witnessed some
form of violence firsthand, and that 15 percent of youth who had witnessed
violence developed PTSD, compared to 3.3 percent of surveyed youths who had
not.40 In the 1997 report, Family Violence in AmericaBreaking the Cycle for
Children Who Witness, the International Association of Chiefs of Police
(IACP) points to numerous studies indicating the alarming number of
children who witness violence in their homes and in the larger community.
In one recent study, 40 percent of students in the 6th, 8th, and 10th
grades in low-income areas of New Haven, Connecticut, reported witnessing
at least one violent crime in the previous year.41 Nearly one-third of
students in the 5th and 6th grades from low-income areas of Washington,
D.C. reported having witnessed a shooting, while 17 percent reported having
witnessed a murder.42 The IACP report also reported that more than 3
million children in the United States each year are at risk of witnessing
domestic violence in their homes.43

Mental Health Community Recommendation from the Field #4

Initial and continuing education programs for mental health professionals
should include education on the crisis, short-, and long-term trauma issues
arising from victimization and appropriate mental health treatment for
crime victims and their families, including counseling options available to
them. Training also should include information regarding the cultural
diversity of victims, stressing the importance of responding with
sensitivity to ethnic and cultural differences.

Addressing educational needs was one of the key recommendations of the 1982
Task Force for mental health professionals. Although some progress has
occurred in the past 15 years, there is still a need for education in two
critical areas: (1) academic curricula to educate student mental health
professionals in psychology, social work, psychiatry, nursing, and
counseling in appropriate mental health treatment for crime victims and
their families, and (2) inservice continuing education for practicing
mental health professionals about effective treatment for crime victims.

Counseling and other kinds of physical, emotional, and spiritual support
interventions should be available to meet the specific needs of individual
victims. Victims should be given options for counseling, including support
groups, traditional healing, supportive or trauma counseling, and mental
health therapy, depending on their needs and desires. Mental health
professionals should also be identified who have proficiencies in dealing
with the special issues of repeat victimization, chronic victimization, and
coexisting mental health problems. Mental health professionals need to be
encouraged to make their services available to victim service providers in
emergencies as well as during standard office hours.

Training programs should include information that will help practitioners
work more effectively with culturally and ethnically diverse populations.
Research studies, treatment programs, and professional education on the
impact of crime on victims should address the various ways cultures respond
to trauma, including mental health intervention and counseling, healing and
purification rituals, shamanistic and holistic practices, and indigenous
and transcultural approaches.

Mental health providers should be aware that techniques other than
traditional Western methods are being utilized in the counseling of crime
victims. One such technique is Morita Therapy, an Eastern psychotherapy
that has been used in the United States for the past 30 years to assist
crime victims. The Victim Services Unit of the Waco, Texas, Police
Department trains its crisis intervention teams in Morita methods, and
domestic violence counselors and shelter staff in Georgia, sexual assault
therapists in Florida, and child abuse workers in Texas are using Morita to
better understand and respond to victim trauma.

Mental Health Community Recommendation from the Field #5

Interventions and counseling services should be developed for victims with
multiple mental health problems. Special attention should be given to
individuals suffering from repeat or chronic victimization and individuals
with limited access to financial, social service, and health care
resources.

New knowledge about repeat victimization, chronic victimization, and the
cycle of violence has several implications for providing appropriate mental
health counseling for crime victims. One implication is that mental health
professionals should include crime prevention and substance abuse
prevention in their work with victims to decrease the risk that new
victimization or substance abuse problems will occur. A second implication
is that mental health professionals should not assume that the crime they
are treating is the only one the victim has experienced. To be sure that a
victim is being treated appropriately, mental health providers must
construct a careful crime victimization history. A third implication is
that providing effective mental health counseling to victims may well be an
effective way to reduce the risk of future victimization, substance abuse,
delinquency, and violent behavior.

Victims with multiple mental health problems pose particular challenges for
the criminal justice, juvenile justice, mental health care, and health care
communities. Because these victims often have few resources and are
difficult to treat, they tend to fall between the cracks. Brief mental
health treatment can help them with their short-term crime-related
problems, but these victims require comprehensive interventions to help
them achieve long-term recovery. More programs should be established that
offer coordinated, intensive, multiagency services that include case
management as well as

mental health treatment.

Mental Health Community Recommendation from the Field #6

Greater emphasis should be placed on mental health treatment for child
victims and witnesses, including preventive interventions that focus on
reducing the risk of subsequent mental health problems, antisocial and

violent behavior, substance abuse, and revictimization.

Victimization increases childrens risk of a host of mental health problems
including anxiety disorders, major depression, antisocial behavior,
substance abuse, and violent behavior. It also increases their risk of
revictimization. Mental health professionals who work in schools or with
children should be trained about the impact of victimization and effective
treatment approaches.

Treating the mental health needs of child victims requires mental health
professionals taking their unique situation into consideration. Child
victimization cases often involve protective services in addition to the
criminal or juvenile justice system. Counselors must understand these
systems well and be able to interact with them in the childs best
interests.

Mental Health Community Recommendation from the Field #7

Insurance companies and managed health care companies should provide
coverage for targeted mental health treatment for crime victims.

Insurance companies and managed health care companies need to understand
the benefits of specialized mental health treatment for crime victims and
should provide special coverage for such treatment. Cognitive behavioral
procedures and other therapies have been successful in treating victims
with crime-related psychological trauma. These treatment methods should be
recognized by service providers in the mental health, victim assistance,
crime victim compensation, and criminal justice communities.

Mental Health Community Recommendation from the Field #8

Mental health providers should recognize the healing benefits that
participation in support groups can provide for many crime victims and
provide referrals to these programs when appropriate.

In reconstructing their lives in the aftermath of victimization, many
victims join support groups composed of individuals who have experienced a
similar trauma. Support groups provide a mutually supportive atmosphere for
victims to discuss their feelings. By talking with others, victims work to
overcome their feelings of low self-esteem, isolation, powerlessness, fear,
and anger. They also demonstrate to each other that they are neither
abnormal nor

guilty for the crime.

There are many outstanding victim support and activism programs across the
nation, including those offered by such respected organizations as Parents
of Murdered Children, Mothers Against Drunk Driving, and the Stephanie
Roper Committee. Domestic violence shelters, rape crisis programs, and
child abuse treatment programs also offer support groups, as do Parents
Anonymous and Parents United, who offer support for families who want to
break the cycle of abuse.

Mental Health Community Recommendation from the Field #9

Mental health providers should help victims of crime become involved in
community service programs when this type of work can assist in the victims
healing process.

For many victims of crime, community activism plays a major role in
facilitating their healing. Studies have shown that community involvement
by victims not only provides important opportunities to educate school
children as well as criminal justice and allied professionals, but also
helps many victims to heal. It should be noted, however, that activism is
not useful for every victim. Opportunities for community service include
working in schools to help decrease victimization, assisting other victims
by supporting self-help groups, advocating for reforms in public policy,
and speaking on victim impact panels to educate others about crimes impact
on individual lives.

The Mothers Against Drunk Driving Victim Impact Panel Program, for example,
was designed to encourage victims of drunk driving crashes to tell
offenders about the devastating physical and emotional injuries their
actions have inflicted. A formal research evaluation of this program funded
by the National Institute of Mental Health (NIMH) showed that participation
has reduced victims psychological trauma and improved their well-being.
Further research is needed to determine which aspects of the program are
most beneficial to healing: giving victims the ability to share their
stories with others, giving victims the opportunity to share their stories
with an audience they feel needs to hear it, or both.

Mental Health Community Recommendation from the Field #10

Mental health professionals should assist in identifying secondary victims
of crime and ensure that they receive appropriate counseling and mental
health services.

Many people dramatically affected by crime are overlooked. Sometimes
referred to as secondary victims of crime, they include individuals in the
background of traumatic events such as police officers and firefighters and
classmates of children who have been kidnaped or murdered.

A recent example of secondary victims were the more than 12,000 rescue
workers and volunteers who responded to the bombing of the Alfred P. Murrah
Federal Building in Oklahoma City, 85 of whom were injured and one of whom
died. Two-thirds reported handling bodies or body parts; one-third felt
that they were in much or extreme danger; and one-half spent 10 days
working in the carnage, the majority of that time directly at the bomb
site. The mental health community estimated that as many as 20 percent of
the rescuers would eventually need mental health care. Indeed, one police
officer who responded to the bombing committed suicide on the first
anniversary of the tragedy.

Moreover, much of the Oklahoma City community suffered as secondary
victims. An estimated 387,000 people knew someone who was killed or
injured, and 190,000 people attended funerals. A survey projected that
60,000 people were at risk for developing mental health problems and 15,000
more were at high risk.

Public education is lacking about the impact of crime on secondary victims.
As a result, many secondary victims do not seek assistance for their
serious psychological problems. The mental health community should help to
provide crucial education about the needs of secondary crime victims and
establish programs to help them heal.

Mental Health Community Recommendation from the Field #11

Mental health professionals should work with multidisciplinary teams of
other trained crisis interveners, including victim service providers, law
enforcement officers, emergency medical responders, and clergy, to respond
to violent incidents and help communities prepare crisis response
protocols.

Mental health professionals have unique skills and training that enable
them to play a leadership role in helping to prepare communities to respond
to incidents of mass violence. They should use this training to help
schools and other institutions and businesses to prepare action plans for
responding to victims in the aftermath of a major criminal incident. The
importance of establishing a crisis response capability is highlighted in
several other sections of this report.

Mental Health Community Recommendation from the Field #12

Reciprocal referral systems should be established among victim service
providers, crisis intervenors, counselors, mental health professionals, and

justice practitioners.

Victims often find it useful to have access to different types of
assistance in their efforts to reconstruct their lives. Supportive
counseling may be helpful, but victims may also need therapeutic
intervention. Victim service providers should work with mental health
professionals to identify professionals who are trained, available, and
willing to provide therapy to victims. Mental health professionals may find
that some victims respond to therapy but would also benefit from support
groups or additional crisis intervention at critical points in the criminal
justice process. Mental health professionals should work with victim
service providers and others to identify what programs and services are
available to meet the needs of victims. Communities and the justice system
should establish referral systems with protocols and procedures and keep
them updated on a continuing basis.

Mental Health Community Recommendation from the Field #13

Community mental health centers should participate in communitywide
networks of victim services and crisis response planning, protocols, and
services.

Many community mental health centers are designed to primarily assist
clients with chronic mental health and substance abuse problems. However,
many centers also maintain crisis hotlines and may be a natural point of
contact for crisis response efforts in times of emergencies. Community
mental health centers can also be a valuable source of referral information
for victims with trauma issues and coexisting mental health problems.

Endnotes

1 Davis, R.C. and L.N. Friedman, The Emotional Aftermath of Crime and
Violence, in, Trauma and its Wake: the Study and Treatment of
Post-traumatic Stress Disorder ed. C.R. Figley, New York: Brunner/Mazel,
1985:90-112.

2 Lurigio, A.J. and P.A. Resick, Healing the Psychological Wounds of
Criminal Victimization: Predicting Postcrime Distress and Recovery, in
Victims of Crime: Problems, Policies, and Programs, eds, A. Lurigio, W.
Skogan, Vol. 25, 1990:50-67; Riggs, D.S. and Kilpatrick, D.G., Families and
Friends: Indirect Victimization by Crime, in A.J. Lurigio, W.G. Skogan, and
R.C. Davis, eds., Victims of Crime: Problems, Policies, and Programs,
Newbury Park, CA: Sage, 1990:120-138.

3 Davis, R., B. Taylor, and S. Bench, The Impact of Sexual and Non-Sexual
Assault on Secondary Victims, New York: Victim Services, 1994.

4 Ochberg, F., M., ed., Post-Trauma Therapy and Victims of Violence, New
York: Brunner/Mazel, 1988.

5 Presidents Task Force on Victims of Crime, Final Report, Washington,
D.C.: U.S. Government Printing Office, December 1982.

6 American Psychiatric Association, Diagnostic and Statistical Manual of
Mental Disorders, Washington, DC: American Psychiatric Association, 3rd
ed.,1980.

7 American Psychological Association, Final Report of the APA Task Force on
the Victims of Crime and Violence, American Psychological Association,
November, 1994.

8 American Psychiatric Association, Diagnostic and Statistical Manual of
Mental Disorders, Washington, DC: American Psychiatric Association, 4th
ed., 1994.

9 Herman, J. L., Trauma and Recovery, 1992.

10 Figley, Trauma and its Wake, 1985.

11 The Society for Traumatic Stress Studies, Initial Report of the
Presidential Task Force on Curriculum, Education and Training, Washington,
D.C.:1989.

12 Pennsylvania Coalition Against Rape, Victim Empowerment: Bridging the
Systems - Mental Health and Victim Services, Washington, D.C.: Office for
Victims of Crime, U.S. Department of Justice, 1996.

13 Mercy, J.A., M.L. Rosenberg, K.E. Powell, C.V. Broome, and W.L. Roper,
Public Health Policy for Preventing Violence, Health Affairs, Vol.12 No.4,
1993:7-29; Rosenberg, M.L., and J.A. Mercy, eds., Assaultive Violence,
Violence in America, Vol. 2, 1991:12-50.

14 National Victim Assistance Academy, National Victim Assistance Academy
Text, Alexandria, VA, 1997:Chapter 10, 9.

15 American Psychiatric Association, Diagnostic and Statistical Manual of
Mental Disorders,4th ed.

16 Id.

17 Resnick, H.S., D.G. Kilpatrick, B.S. Dansky, B.E. Saunders, and C.L.
Best, Prevalence of Civilian Trauma and PTSD in a Representative National
Sample of Women, Journal of Clinical & Consulting Psychology, Vol.61,
1993:6.

18 Kilpatrick, D.G. and H.S. Resnick, The Importance of Being
Epidemiological: Implications for Study of Rape-related PTSD Etiology,
Paper presented at the 25th annual meeting of the Association for the
Advancement of Behavior Therapy, New York: November 1991; Freedy, J.R.,
H.S. Resnick, D.G. Kilpatrick, B.S. Dansky, and R.P. Tidwell, The
Psychological Adjustment of Recent Crime Victims in the Criminal Justice
System, Journal of Interpersonal Violence, Vol.9 No.4, 1994:450-468.

19 Kilpatrick, D.G., and R.K. Otto, Constitutionally Guaranteed
Participation in Criminal Proceedings for Victims: Potential Effects on
Psychological Functioning, Wayne State Law Review, Vol.34 No.1, 1987:7-28;
Resnick, Prevalence of Civilian Trauma and PTSD in a Representative
National Sample of Women.

20 Herman, Trauma and Recovery.

21 Parsons, E., Ethnicity and Traumatic Stress: the Intersecting Point in
Psychotherapy, in, Trauma and its Wake: the Study and Treatment of
Post-traumatic Stress Disorder, C. Figley, ed., 314-37.

22 D.G. Kilpatrick, et al., Rape, Other Violence Against Women, and
Posttraumatic Stress Disorder: Critical Issues in Assessing the
Adversity-Stress-Psychopathology Relationship, in Adversity, Stress, &
Psychopathology, B.P. Dohrenwend, American Psychiatric Press, forthcoming;
Resnick, Prevalence of Civilian Trauma and PTSD in a Representative
National Sample of Women, Kilpatrick, D.G., C.N. Edmunds, and A.K. Seymour,
Rape in America: A Report to the Nation, National Victim Center & Medical
University of South Carolina, 1992; Reiss, A.J., and J.A. Roth,
Understanding and Preventing Violence, National Academy Press, 1993; Wyatt,
G.E et. al., Differential Effects of Womens Child Sexual Abuse and
Subsequent Revictimization, Journal of Consulting and Clinical Psychology,
Vol. 60, 1992:167-173.

23 Breslau, N., et. al., Epidemiologic Findings on PTSD and Comorbid
Disorders in the General Population, forthcoming; Kilpatrick, D.G., et.
al., Violent Assault and Alcohol Dependence Among Women:Results of a
Longitudinal Study, Research Society on Alcoholism, June 1994:433, Abstract
No. 80.

24 Ageton, S.S., Sexual Assault Among Adolescents, Lexington Books, 1983;
Dembo, R., A Structural Model Examining the Relationship Between Physical
Child Abuse, Sexual Victimization, and Marijuana/Hashish Use in Delinquent
Youth: A Longitudinal Study, Violence and Victims, Vol. 7, 1992:41-62 ;
Straus, M.A., Family Violence and Non-family Crime and Violence, in Crime
and the Family, eds., A.J. Lincoln and M.A. Straus, Thomas:1984; Widom,
C.S., The Cycle of Violence, Science, Vol. 244, 1989:160-166; Widom, C.S.,
The Cycle of Violence, Research in Brief, Washington, D.C.: U.S. Department
of Justice, National Institute of Justice, 1992, NCJ 136607.

25 Ageton, Sexual Assault Among Adolescents; Kilpatrick, Violent Assault
and Alcohol Dependence Among Women: Results of a Longitudinal Study;
Cottler, L.B. et. al., Posttraumatic Stress Disorder Among Substance Users
From the General Public, Journal of Consulting and Clinical Psychology,
Vol.56, 1992:843-850.

26 Widom, The Cycle of Violence; Widom, C.S, Family Violence Across the
Life Cycle, Paper presented at the proceedings of the American Medical
Associations National Conference on Family Violence, Health and

Justice, 1994.

27 Finklehor, D., and J. Dziuba-Leatherman, Victimization of Children,
American Psychologist, Vol.49, No. 3, 1994:173-183 (child abuse victims);
Siegel, J.M., et. al., The Prevalence of Child Sexual Assault: The Los
Angeles Epidemiologic Catchment Area Project, American Journal of
Epidemiology, Vol. 126 No. 6, 1987:1141-1153 (child abuse victims);
Kilpatrick, Rape in America: A Report to the Nation, (rape victims); Koss,
M.P. et. al., The Scope of Rape: Incidence and Prevalence of Sexual
Aggression and Victimization in a National Sample of Higher Education
Students, Journal of Consulting and Clinical Psychology, Vol. 55, 1987
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Murder: Gender Specific Differences in Rates of Fatal Violence and
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Amick-McMullan, A., Homicide as a Risk Factor for PTSD Among Surviving
Family Members, Behavior Modification, Vol.15 No.4, 1991:545-559 (homicide
victims).

28 Finklehor, Victimization of Children; Kilpatrick, Rape in America: A
Report to the Nation; Bastian, L.D. and B.M. Taylor, School Crime: A
National Crime Victimization Survey Report, Washington, D.C.: U.S.
Department of Justice, 1991, NCJ-131645; Finkelhor, D. et. al., Sexual
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Gelles, R.J. and M.A. Straus, Is Violence Toward Children Increasing?: A
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Violence,Vol. 9 No.4, 1994:450-468; McCurdy, K. and D. Daro, Current Trends
in Child Abuse Reporting and Fatalities: The Results of the 1992 Annual
Fifty State Survey, National Committee for Prevention of Child Abuse, 1993;
Saunders, B.E. et. al., Child Sexual Assault as a Risk Factor for Mental
Disorders Among Women: A Community Survey, Journal of Interpersonal
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Mental Disorders in a Community Population, Journal of Consulting and
Clinical Psychology, Vol. 6, 1988:843-850; Whitaker C.J. and L.D. Bastian,
Teenage Victims: A National Crime Survey Report, Washington, D.C.: U.S.
Department of Justice, 1991.

29 Browne, A., and D. Finkelhor, Impact of Child Sexual Abuse: A Review of
the Research, Psychological Bulletin, Vol. 99, 1986:66-77; Burnam, Sexual
Assault and Mental Disorders in a Community Population; Saunders, et. al.,
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Publishing, 1990; Lanktree, C.B., et. al., Incidence and Impact of Sexual
Abuse in a Child Outpatient Sample: The Role of Direct Inquiry, Child Abuse
and Neglect, Vol.15, 1991:447-453.

30 Ageton, Sexual Assault Among Adolescents; Burnam, Sexual Assault and
Mental Disorders in a Community Population; R.J. Gelles & M.A. Straus, The
Medical and Psychological Cost of Family Violence, in Physical Violence in
American Families: Risk Factors and Adaptations to Violence in 8,145
Families, M.A. Straus & R.J. Gelles, Transaction, 1990:425-430; Saunders,
B.E., et. al., Prevalence, Case Characteristics, and Long Term
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at the annual meeting of the American Orthopsychiatric Association in
Toronto, Ontario, March 1991; Stein, J.A. et. al., Long-term Psychological
Sequelae of Child Sexual Abuse: The Los Angeles Epidemiologic Catchment
Area Study, in Lasting Effects of Child Sexual Abuse, G.E. Wyatt & G.J.
Powell, Sage Publications, 1988:135-154; Kilpatrick, Rape in America: A
Report to the Nation.

31 The Confidentiality of Communications Between Sexual Assault or Domestic
Violence Victims and Their Counselors, Report to Congress, Washington,
D.C.: U.S. Department of Justice, Violence Against Women Office, 1995.

32 Id. at 3-5.

33 Williams, L.M., Recall of Childhood Trauma: A Perspective Study of
Womens Memories of Child Sexual Abuse, Journal of Consulting and Clinical
Psychology, Vol. 62 No.6, 1994:1167-1176.

34 American Psychological Association, Professional Psychology: Research
and Practice, American Psychological Association, Vol.28 No.4,
1997:338-340.

35 Herman, J., Trauma and Recovery, New York: Basic Books, 1992: 9, 86-87.

36 Feldman-Summers, S., The Experience of Forgetting Childhood Abuse: A
National Survey of Psychologists, Journal of Consulting and Clinical
Psychology, 1994: 62, 636-639

37 See Shahzade v. Gregory (Civil Action No. 92-2139-EFH), U.S. District
Court for Massachusetts, May 8, 1997; S.V. v. R.V. (Civil Action No.
94-0856), Texas Supreme Court, March 14, 1997; Borawick v. Shay, U.S. Court
of Appeals for the Second Circuit (68 F.3d. 597, 1995. Decision affirmed by
the U.S. Supreme Court, May 28, 1997.)

38 Lord, J.H., Survivor Grief Following a Drunk Driving Crash, Death
Studies, 11, 413-435.

39 Finkelhor, D. and Berliner, L, Research on the Treatment of Sexually
Abused Children: A Review and Recommendations, CHILD, November 1995.

40 Kilpatrick, D. and B. Saunders, Prevalence and Consequences of Child
Victimization, Research Preview, Washington, D.C.: National Institute of
Justice, April 1997.

41 New Haven Public Schools, Report on the SAHA, 1991-92: Final Report, New
Haven, Connecticut: Social Development Project Evaluation, 1992.

42 Richters, J.E., and P. Martinez, The NIMH Community Violence Project II:
Childrens Distress Symptoms Associated with Violence. Psychiatry, Vol. 56:
22-35.

43 Carlson, B.E., Childrens Observations of Interparental Violence, in
Battered Women and Their Families, A. R. Roberts, Ed., New York: Springer,
1984.

44 Miller, T.R., M.A. Cohen, B. Wiersema, Victim Costs and Consequences: A
New Look, Washington, D.C.: U.S. Department of Justice, National Institute
of Justice, 1996, NCJ 155282.