Title: Student Material to Victim Empowerment: Bridging The Systems Mental Health and Victim Service Providers

                              STUDENT MATERIAL
     
                                     TO
                                
     VICTIM EMPOWERMENT: BRIDGING THE SYSTEMS
     MENTAL HEALTH AND VICTIM SERVICE PROVIDERS                       TABLE OF CONTENTS
     
           INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . 3 
     
          UNDERSTANDING AND RESPONDING TO THE TRAUMA OF VICTIMIZATION. . 12
                    Identifying and Assessing Signs of Crisis . . . . . . . . 14
                    Secondary Victimization . . . . . . . . . . . . . . . . . 29
                    Cross Cultural Issues in Crisis . . . . . . . . . . . . . 34
                    
     POST TRAUMATIC STRESS DISORDER, RAPE TRAUMA SYNDROME AND
     BATTERING. . . . . . . . . . . . . . . . . . . . . . . . . . . 43
                    Trauma and Post Traumatic Stress Disorder . . . . . . . . 44
                    Diagnostic Criteria for Post Traumatic Stress Disorder. . 46
                    Rape Related Post Traumatic Stress. . . . . . . . . . . . 49
                    Ten Warning Signs of Mental Illness . . . . . . . . . . . 55
                    Depression. . . . . . . . . . . . . . . . . . . . . . . . 56
                    Hostage in the Home . . . . . . . . . . . . . . . . . . . 58
     
          CLINICAL PERSPECTIVE: THINKING BEYOND THE OFFICE . . . . . . . 74
                    Thinking Beyond the Office. . . . . . . . . . . . . . . . 75
                    Integrating Awareness of Victimization into Treatment . . 77
                    Therapy in the Context of the Survivor's Life . . . . . . 88
                    The Therapy Relationship. . . . . . . . . . . . . . . . . 95
                    Caring for Ourselves and Each Other . . . . . . . . . . .109
     
          RESOURCES. . . . . . . . . . . . . . . . . . . . . . . . . . .113
                    Outline for Interagency Agreement . . . . . . . . . . . .114
                    Interagency Agreement Example . . . . . . . . . . . . . .116
     
          BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . .118
     
          RESOURCES. . . . . . . . . . . . . . . . . . . . . . . . . . .127
     
     
     
                                     
     
     
     
     
     
                                INTRODUCTION
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     Although the world is full of suffering, it is also full of the overcoming of it.
          Helen Keller
     
     This project was supported by Grant No. 95-MU-GX-K003 awarded by the Office for Victims of
     Crime, Office of Justice Programs, U.S. Department of Justice. The Assistant Attorney General,
     Office of Justice Programs, coordinates the activities of the following program offices and
     bureaus: Bureau of Justice Statistics, National Institute of Justice, Office of Juvenile Justice and
     Delinquency Prevention, and the Office for Victims of Crime. Points of view in this document
     are those of the author and do not necessarily represent the official position or policies of the
     U.S. Department of Justice.     
     Introduction
     
     
     "There is nothing more isolating than the pain of violation. It forces victims to question
     themselves and their world because it destroys two essential beliefs:  (1) their sense of
     trust and (2) their sense of control over their lives. After the crime is over, victims begin
     to struggle with their reactions...they are often overcome with fear, anger, guilt and
     shame. They may feel contaminated and unworthy of help.  Their relationships with
     family and friends can be seriously disrupted, and if they become involved with the
     police and the courts, they may come to believe that no one understands or cares about
     what has happened to them."  (The Crime Victim's Book, Bard and Sangrey, 1986)
     
     A victim of a serious personal crime as well as significant others, family members and
     friends, go through a difficult adjustment period, often experiencing the impact of the
     crime in varying degrees for the remainder of their lives.
     
     
     Purpose
     
     
     This curriculum and participant's resource manual were produced with a grant from the
     Office for Victims of Crime. The resource manual contains a collection of articles and
     information written from either a mental health or a victim services perspective. Because
     these perspectives are not always in agreement, there may be conflicting points of view
     which participants can use as discussion starters. 
     
     Individuals with diverse backgrounds, expertise and experience in victim services and
     mental health served as an advisory panel and assisted the Pennsylvania Coalition
     Against Rape with the development of this curriculum. The panel members of Victim
     Empowerment: Bridging the Systems - Mental Health and Victim Services Providers saw
     the project as essential and vital to the provision of quality support services and
     treatment for victims of crime and their significant others. They also saw this project as
     an opportunity to develop a collaborative systems approach to victim services between
     mental health and victim services providers.
     
     The Pennsylvania Coalition Against Rape wishes to thank the advisory panel members
     for their time and expertise in the development of the curriculum outline.
     
     Advisory Panel Members
     
     Panel Chair:
     Dr. Ida Marie Gentzler, Assistant Professor of Sociology and Community Psychology, Penn
     State Harrisburg, Middletown, PA 
     
     Training Development Coordinator: 
      Donna Johnson, Consultant, Norristown, PA  
     
     Author, Thinking Beyond the Office:  
     Mary Margaret Hart, Licensed Psychologist,  Bellefonte, PA 
     
     Project Manager and Editor: 
     B. J. Horn, Training Coordinator, Pennsylvania Coalition Against Rape, Harrisburg, PA 
     
     Additional Panel Members:
     Beverly Andrews, Counseling Supervisor, The Sexual Assault Resource & Counseling Center of
     Lebanon County, Lebanon, PA 
     
     Rosalie Danchanko, PA State Director, Neighbors Who Care, and President, Coalition of
     Pennsylvania Crime Victims Organizations, Johnstown, PA
     
     Susan Jensen, Child Therapist, Bethel Park, PA 
     
     Bernadine P. Lasher, Director, Council on Domestic Violence and Sexual Assault,  Midland, MI 
     
     Grace S. Mattern, Director, New Hampshire Coalition Against Domestic & Sexual Violence,
     Concord, NH 
     
     Dawn McKee, Project Coordinator, Pennsylvania Commission on Crime and Delinquency,
     Pleasant Gap, PA 
     
     Beth Resko, Women's Program Therapist, The Meadows Psychiatric  Center, Centre Hall, PA 
     
     Judith Rex, Coordinator, Vermont Network Against Domestic Violence and Sexual Assault,
     Montpelier, VT 
     
     Jamie Snyder, Director, Center for Sexual Assault & Domestic Violence Survivors, Columbus,
     NE 
     
     
          Advisory Panel Recommendations 
     
     For this curriculum to be utilized to its maximum potential, the panel made the following
     recommendations:
     
               The training curriculum will be provided to individuals only as part of a training
          program.
     
               A 'train the trainers' program will be conducted to ensure that the manual and its
          information are used consistently.
     
               Trained teams, representative of victim services and mental health professionals,
          will be sought.
     
               Trainees or participants will be selected with the advice and input of local
          community leaders.  
     
               Trainees are to be representative of the victim services and mental health fields.
     
               Trainees are to be motivated individuals who are committed to change and willing
          to promote change in their respective communities.
     
               Funding and resources should be available to address the recommendations as
          stated.
          Core Beliefs and Concepts
     The material in this manual has been selected based on these core beliefs: 
               We need  a violence-free culture
               Victims should be the focus of the system(s)
               The victim empowerment as the model includes:
               
               Victims
                    Having the right to be believed and owning their stories
                    Being in control of the healing process
               
               Service Providers
                    Acknowledging the rights and responsibilities of victims
                    Respecting the choices of victims
                    Providing victims with options for choices
                    Avoiding inappropriate labeling of victims
                    Working collaboratively with other systems to support victims
     
               Victims are not to blame for their victimization
               People are responsible for the effects of their behavior
               The trauma of victimization is not mental illness but victimization is trauma and
          needs to be addressed
               Confidentiality is important
     
     
     Why Build a Bridge?
     
     
     A mental health professional who has not received any training on the unique emotional
     and psychological issues of trauma may not be able to appropriately respond to a crime
     victim or even make a suitable referral. For example, to someone not trained in
     victimization issues, a burglary might be seen as a minor loss of possessions, something
     to be dealt with quickly by the police and insurance company, with perhaps the added
     security of new locks. However, to burglary victims, there has been a violation of an
     extension of themselves. For many, the loss or damage to money and/or possessions
     are not nearly as harmful as the intrusion into the privacy of the home, the place where
     people are supposed to feel safe.
     
     Historically, mental health counselors, psychologists, and psychiatrists have not
     received extensive training in victimization issues. In a recent survey by the Mental
     Health Association of more that 175 mental health professionals in Berks County,
     Pennsylvania: 
     
               Less than one-third of the 130 respondents were willing to and/or had experience
          in working with victims of violent crime
               Only a handful indicated they had more than limited experience
               There were very few mental health professionals who indicated knowledge of
          sexual assault issues
     
     At the Erie County Rape Crisis Center in Pennsylvania:
     
               Approximately 25% of its clients, who were victims of sexual assault/abuse or 
          victims of other crimes, were also receiving services at one or more mental health
          service providers
     
     It is important to note that not all crime victims require treatment by a mental health
     professional. If a victim is regarded as having functioned adequately or "normally" prior
     to the victimization, then the crime is seen as a crisis or a disruption to the life of the
     victim. While a victim's response may not "look" normal to those who do not have an
     understanding of trauma issues, it could be a normal response to an abnormal event.
     
     Victim service providers use crisis intervention techniques, including empowerment
     counseling, to restore the victims to their previous level of functioning. They address
     issues unique to the victimization such as:
     
               - Safety
               - Body boundaries
               - Self-esteem
               - Regaining power and control
               - Re-establishing trusting relationships
     
     Studies such as Rape in America (NVC, 1992) show that many victims do not
     successfully regain control over their lives after their victimization.  Although many crime
     victim programs provide victims with long term counseling, including support groups,
     numerous individuals are concurrently and appropriately seen by mental health
     professionals. For those programs that are limited to crisis services and for those clients
     who should be referred for further treatment for mental health issues, victim services
     providers must learn when and where to refer clients:
     
               Victim services counselors must learn the warning signals to make referrals, such
          as those offered by the American Psychiatric Association, which include:
          - Prolonged depression or apathy
          - Suicidal ideations
          - Substance abuse
          - Inability to cope with daily activities after an appropriate period of time
     
               Victim programs must develop referral lists of mental health providers who
          understand trauma and victimization issues, are willing to accept clients who do
          not have insurance coverage or funds and are available without prolonged
          waiting periods.
     
               Through coordinated appropriate releases with mental health practitioners, victim
          services staff can continue to address the victimization needs such as court
          accompaniment, and specific victimization counseling. 
     
     Ten years ago, the American Psychological Association Task Force on the Victims of
     Crime and Violence, chaired by Morton Bard, Ph.D., made the following
     recommendations:
     
               Psychologists involved in service delivery should acquire specific, identifiable
          skills in direct intervention with victims.
     
               More psychologists should acquire specialized consultative skills to increase the
          capacity of indigenous workers to help victims.
     
               More psychologists should become involved in initiating and evaluating changes
          in the criminal justice system to ameliorate the problems victims experience in
          that system.
     
               More psychologists who are prepared to do so should actually provide service
          directly to victims, to indigenous helping systems, and in the criminal justice
          system.
     
               Psychologists should be more involved in gaining knowledge about the victim 
          experience and about helpful intervention for victims.
     
               There should be greater public awareness about the mental health needs of
          victims and the roles psychologists can serve in helping victims.
     
               The APA should endorse laws and legal arrangements that facilitate the
          realization of  victims' interests and encourage the formal evaluation of these
          arrangements.
     
     Dr. Bard made recommendations for the mental health community in The Crime Victim's
     Book, which include:
     
               Establishing training programs that enable practitioners to treat crime victims and
          their families
     
               Establishing and maintaining direct liaisons with victim services agencies
     
     These comments were echoed by Shelly Neiderbaum, one of the founders of the International
     Association of Trauma Counselors, Inc., at the National Organization for Victim Assistance
     1995 Conference. 
     
     
     
     
     
          
     
                                
                                
                                
                 UNDERSTANDING AND RESPONDING 
                                
                         TO THE TRAUMA
                                
                               OF
                                
                         VICTIMIZATION
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     To experience anguish and anxiety in the face of the perils that threaten us is a healthy reaction.
     Far from being crazy, the pain is testimony to the unity of life. The deep interconnections that
     relate us to other beings.
          Joanna Macy
     
     
     Trauma of Victimization
     
     
     Victims of personal crimes are dealt a severe blow to their view of reality:
     
         They have been deliberately violated by another human being
         The crimes may range from having a pocket picked to murder
         The issues involved with each type of crime are unique
         The personal abilities of victims to deal with the specific type of crime are also
       unique
     
     
     Extent of Victimization
     
     
         Every 2 seconds a property crime is committed
         Every 15 seconds a woman is battered
         Every 46 seconds someone is robbed
         Every minute 1.5 adult women are raped
         Every minute approximately 6 American children are reported as abused and
       neglected
         Every 21 minutes someone is murdered
         Every day 55 Americans are killed in alcohol-related traffic crashes
       (from National Victim Center 1994 Crime Clock)
     
     
     Stages of Crisis
     
     
     Most victims experience a common series of emotional reactions. This parallels the grief
     process outlined by Elisabeth Kubler-Ross in On Death and Dying, or rape trauma
     syndrome described by Ann Burgess in Rape and its Victims.  It consists of three basic
     stages:
     
     STAGE ONE:   Crisis/Acute Stage
         Denial - "This cant' be happening to me, it must be a dream."  
         "I feel like an observer, watching and reliving someone else's experience."
     
     STAGE TWO:   Intermediate Stage (24 hours to 6 weeks):  
         A series of different emotions intrude and fade with varying intensity:  fear, anger,
       guilt, frustration, embarrassment. They are often accompanied by disruptions in
       eating/sleeping patterns and a change in lifestyle. Victims can fluctuate between
       feeling able to cope to feeling out of control. One minute they will blame
       themselves and the next rage against the individual(s) who harmed them.
     
     STAGE THREE:   Reintegration (one week to one year):  
         Victims resume normal life. The intrusive memories lessen and the victims
       integrate the crime into their total life experiences. As one victim commented, "I
       have it in perspective now and don't think of it very often anymore."
     
     While these are the primary stages of crisis, victims react differently.  Many victims are
     amazingly resilient and can cope easily in the aftermath of a crime.  In some cases, it
     takes longer for the bruises to heal than the emotional scars. Much depends on how the
     crime is perceived by the victim, family and friends, and the community. Victims'
     reactions do not take place in an isolated environment, but are influenced by other
     circumstances. 
     
                                      
     Identifying and Assessing Signs of Crisis*
     
     
     
     Crisis Invervention
     
     
     With the gift of listening comes the gift of healing, because listening to your brothers or
     sisters until they have said the last words in their hearts is consoling.  Someone has said
     that it is possible "to listen a person's soul into existence."  I like that.
            -Catherine de Hueck Doherty
     
     
     
     Overview
     
     
     Natural caregivers have known for centuries the value of listening with great care and little
     judgment to a person's sorrow and pain. Though some people have a natural gift for
     providing that kind of help, most people need some assistance in learning the basics of
     crisis intervention -- it is, to a degree, "contra-instinctual" -- and everyone can, with study,
     improve their crisis intervention skills.
     
     In the aftermath of a catastrophe, most victims must deal with the physical and emotional
     shockwaves of the event but also, in short order, with the sense of helplessness,
     powerlessness, and a loss of control.
     
     For many victims, the physical and emotional reactions which describe crisis are not severe,
     and recede after a few hours or days. For others, the crisis is put on hold while they
     mobilize their survival skills, and only days, even years, later, are they slapped with a sense
     of the enormity of the event, now vividly remembered. Even victims who do not develop the
     symptoms of long-term stress reactions face the risk that certain "triggers" will reproduce
     the old feelings of panic, helplessness, anger, and the like.
     
     "Crisis Intervention" is obviously a humane effort to reduce the severity of a victim's crisis,
     to help the victim win as much mastery over the crisis experience as possible. To
     understand the potential benefits of crisis intervention, it is worth emphasizing that these
     are a battery of skills that victim advocates should possess -- but so should others whose
     professional work brings them into contact with victims in crisis.
     
     A common response in the shock of the moment is for the victim to retreat into a childlike
     state, and when the immediate danger is passed, to turn to someone nearby who is
     perceived as an authority figure for help-- a law enforcement officer, teacher, nurse, a
     friend, anyone who offers a sense of "parental" comfort. Anyone whose job constantly puts
     them in that role discovers how "accessible" the victim is at the moment. The helper is now
     invested with extraordinary influence in the life of the victim in crisis. In these
     circumstances, the helper is a crisis intervenor -- perhaps a gifted one, perhaps one whose
     talents have been forged by experience, or far more likely, a conscientious professional with
     no training or skills in how to interact with people in crisis, to the detriment of both the victim
     and the professional.
     
     "Crisis" encompasses a number of intense, tumultuous emotions; it can be a continuing
     condition, or alternatively flare and recede; any stressful, post-crime event, such as going
     to a battered women's shelter, or to a lineup, or to a trial, may put the victim back into crisis.
     While there are  no predictors about who will experience crisis, or when the onset will be,
     or how severe it will be in the intensity or duration, a working presumption for most crisis
     intervenors is that the sooner the service is offered, the better. Indeed, there is a conviction
     among many practitioners that on-scene intervention, when the victim is in the early stages
     of distress, may prove to prevent or greatly reduce the crisis symptoms that might otherwise
     afflict the victim.
     
     
     
     Techniques
     
     
     A.     Safety and Security
     
              1.   The first concern of any crisis intervenor should be for the physical safety of
            the victim. Until it is clear that the victim is not physically in danger or in need
            of emergency medical aid, other issues should be put aside. This is not
            always immediately obvious. Victims who are in physical shock may be
            unaware of the injuries they have already sustained or the dangers they still
            face.
     
                   For the crisis intervenor who is responding to a telephone crisis call, the
            question should be posed immediately, "Are you safe now?" Intervenors who
            are doing on-scene or face-to-face intervention should ask victims if they are
            physically harmed.  That question alone may cause the victim to become
            aware of a previously undiscovered injury.
     
              2.    A parallel concern should be whether the victim feels safe.  The victim may
            not feel safe in the following circumstances:
     
                                       The victim can see and hear the assailant being interviewed by law
                      enforcement officers.
                                       The victim is being interviewed in the same area where the attack took
                      place.
                                       The victim is not given time to replace torn clothes.
                                       The victim is cold and uncomfortable.
                                       The assailant has not been apprehended and he has threatened to
                      return.
     
                   Any of these may make the victim feel unsafe even if there are law
            enforcement officers present. In the aftermath of Edmond, Oklahoma, post
            office mass murders in 1986, one of the survivors of the attack said that he
            would not feel safe until the assailant, Patrick Sherrill, whose final killing was
            of himself, was physically in his grave.
     
              3.   A priority for some victims and survivors is the safety of others as well.  If a
            couple has been robbed in a street crime, each may be more worried for the
            other person than himself or herself. Parents are often more concerned about
            the safety of their children than their own.
     
              4.    Survivors of victims of homicide may not focus on safety but rather seek a
            sense of security through the provision of privacy and nurturing. Their
            anguish and grief can be made more painful if there are unfamiliar and
            unwanted witnesses to their sorrow.
     
                   They, too, will suffer feelings of helplessness and powerlessness. The shock
            of the arbitrary death of a loved one is usually not assimilated immediately
            and survivors may not understand questions or directives given to them. One
            mother did not realize that she had said yes when she was asked if she
            wanted to identify the body of her son. When she was taken to the morgue,
            she became hysterical and distraught because she was not properly
            prepared.
     
              5.     All victims and survivors need to know that their reactions, their comments,
            and their pain will be kept confidential. If confidentiality is limited by law or
            policy, those limits should be clearly explained.
     
              6.   Security is also promoted when victims and survivors are given opportunities
            to regain control of events. They cannot undo the crime or the death of loved
            ones, but there may be opportunities for them to take charge of things that
            happen in the immediate aftermath.
     
              7.   Hints for Helping.
     
            a.  Make sure the victims/survivors feel safe or secure at this point in time.
     
                             Sit down to talk.
                             Ask the victims/survivors where they would feel safest when you talk
                 to them, and move to that location.
                             If it is true, reassure them with the words "You are safe now."
                             Identify yourself and your agency clearly, and explain your standards
                 of confidentiality.  You might say, "Our program's standards require
                 me to keep all information that you tell me confidential unless you give
                 your permission to me to release it..."  
                             If possible, keep media away from victims/survivors or help them in
                 responding to media questions. If the case involves a sensational
                 crime and there are media representatives approaching the survivors,
                 try to ensure that the victims/survivors understand that they do not
                 have to answer questions unless they want to, and under
                 circumstances of their own choosing.
                             If they have loved ones about whom they are concerned, try to find out
                 as much information as possible about the safety of the loved ones.
                 For instance, a mother who has been a victim on the way home from
                 work might not be as worried about the victimization as the safety of
                 a child who is home alone awaiting her arrival.  
                             If victims are to be interviewed by law enforcement officers, try to
                 ensure that they understand questions by asking them to repeat the
                 question back to the interviewer.
                             Provide victims with information that may help to assure them of their
                 safety.  For instance, if they have been survivors of a massacre, it
                 may help if they are assured that the gunman is dead, or that he has
                 been apprehended.
                             If they are not safe, keep them informed about the extent of additional
                 threat.  For instance, if the gunman is still at large, try to get
                 information about his whereabouts. If possible, find them an alternative
                 location at which to stay for a few hours or a few days. In the
                 aftermath of the serial killings of five co-eds in Gainsville, Florida, the
                 victim/witness program and the community arranged for students to
                 sleep together in dormitory-like conditions in a large auditorium
                 surrounded by guards, all to restore a sense of safety.
                             Give victim permission to express any reactions and respond non-
                 judgmentally.  Say:  "You have a right to be upset over this tragedy,
                 so don't be afraid to tell me what you are thinking."
     
                        b.   Respond to the need for nurturing -- but be wary of becoming a
                 "rescuer" on whom the victim becomes dependent.  The "rescuer" who
                 ends up months later making decisions for the victim has subverted
                 the primary goal of crisis intervention; that is, to help the victim restore
                 control over his or her life.  
     
                                       An apt analogy for the role of the crisis intervenor at this stage is as
                      follows:  when a person breaks his leg, a doctor sets it and puts it in
                      a cast. While it heals, the patient uses crutches to get around, and
                      when the cast is removed, the leg still needs exercise and care to
                      become strong again. When someone survives a violent crime or the
                      death of a loved one, they survive with a fractured heart. The crisis
                      intervenor becomes like the doctor. The initial intervention helps the
                      survivor by protecting that heart as much as possible against further
                      harm. Later, the crisis intervenor provides support, understanding, and
                      a few crutches while the survivor begins the long process of healing
                      a broken heart.
     
                        c.   Help survivors to re-establish a sense of control over the small things,
                 then the larger ones, in their lives.
     
                             While it is important to assist survivors with practical activities, it is
                 also important to allow them to make decisions for themselves and to
                 take an active role in planning their future.
                             The crisis intervenor initially can offer survivors a sense of control by
                 asking them simple questions involving choices that are easily made.
                 For instance, "What name would you like me to use in talking with
                 you?" "Where would you like to sit while we talk?" "Would you like a
                 glass of water?"
                             Often the recovery of a physical object that is important to the survivor
                 helps to re-establish a sense of control. For instance, after an arson
                 burned down much of one family's home, the entire family was
                 strengthened when a law enforcement officer found their cat in the
                 bushes nearby. The family had thought the cat had died in the fire.
     
     
     B.  Ventilation and Validation
     
              1.   Ventilation refers to the process of allowing the survivors to "tell their story."
            While the idea of "telling your story" seems a simple concept, the process is
            not easy. Victims need to tell their story over and over again. The repetitive
            process is a way of putting the pieces together and cognitively organizing the
            event so that it can be integrated into the survivor's life. The first memory of
            the event is likely to be narrowly focused on, say, a particular sensory
            perception or a particular activity that occurred during the event. Victims
            usually see the criminal attack with tunnel vision. They know intuitively that
            other things are happening around them, but they may focus on an assailant's
            knife, their struggle to get away, their first impression of a burglarized room.
     
                   As time goes by, memory will reveal other parts of the event. These bits of
            memory will come back in dreams, intrusive thoughts, and simply during the
            story-telling process. The victimization story will probably change over time
            as they learn new things and use the new information to reorganize their
            memories.
     
                   For example, a victim who reported a burglary first told the crisis intervenor
            that he heard a noise and he went downstairs to see what was wrong, finding
            a burglar in his front room. The burglar grabbed something and struck him in
            the stomach before running out the front door. There was a crash and then
            everything went silent.
     
                   When the man repeated the story the second time, he said that he
            remembered that it was just a noise, but it sounded like some whispering and
            rustling. On a later telling, he remembered that when he came downstairs, he
            saw a brief flash of light toward the back of the house.
     
                   Upon investigation, it was discovered that there had probably been two
            burglars and one had exited through the kitchen window in the rear of the
            house.
     
                   This process of reconstructing a story results in inconsistent or contradictory
            stories, which undermine an investigation or a prosecution. However, from a
            crisis intervention perspective, it is perfectly normal for the process of
            ventilation to reveal a more complete story over time. Realistically, a victim
            will tell his story over and over again, with or without a crisis intervenor, in
            order to reconstruct the event, so that the story will often change anyway.
            The difference is that the crisis intervenor will provide a sounding board for
            the victim's distress as the review process unfolds.
     
                   For victims, the replaying of the story over again helps them get control of the
            real story. The "real" story is not only the recitation of the event itself, but
            usually includes the story of various incidents in the immediate aftermath; the
            story of ongoing traumatic incidents related to the crime; the story of families'
            or friends' involvement in the event; and so forth. Each of these stories must
            be integrated into the victim's final mental recording of the event.
     
              2.    A part of the ventilation process is finding words or other ways that will give
            expression to experiences and reaction. In this aspect, ventilation is often
            culturally-specific. Some cultures may express their reactions through
            physical or various artistic forms rather than words. In most of the United
            States, words are the most comfortable form of expression.
     
                   The power found in putting words to feelings and facts is tremendous. There
            is often a depth of emotion in telling another person that a loved one has
            died, even in finding the name of the loved one. The power is also illustrated
            in the release that many victims find when an intervenor responds to their
            ventilation with a word that expresses what victims feel. For instance, victims
            may feel intense anger towards an assailant and find the word "anger"
            insignificant to express their intensity.  When an intervenor offers a word like
            "outrage" or "fury" to describe their feelings, victims often feel a sense of
            liberation -- a sense of permission to feel such intense emotions.
     
     
                   The exact words to describe events and experiences are often vital. For
            example, Mothers Against Drunk Driving (MADD) is adamant about the
            importance of calling the collision of a car driven by someone drunk a drunk-
            driving "crash," a term often used to describe a mechanical or human error.
     
              3.   Validation is a process through which the crisis intervenor makes it clear that
            most reactions to horrific events are "normal."
     
                                  a.   Validation should be content-specific. Example: rather than saying "I
                      can't imagine how upset you are," it is preferable to say "I can't
                      imagine how upset you are about your son's death in the car crash."
     
                                  b.   Care should be taken in the words that are used to validate. For
                      instance, many survivors do not want to hear their reactions are
                      "normal reactions to an abnormal situation" - a common summation of
                      what crisis and trauma produce - because survivors want to have their
                      experience validated as unique. Telling them that their reactions are
                      "not common" seems to be more effective.
         
                                  c.   Where possible, repetition of the actual phrases that the survivors use
                      to describe experiences is useful. Example, if someone says, "I can't
                      sleep at night, I am so afraid that someone will break in and kill me
                      and my family," an appropriate response would be, "It's not unusual for
                      you to be afraid after such a terrifying experience. If you can't sleep at
                      night, that only shows how afraid you are."
     
              4.   The focus of validation should be that most reactions of anger, fear,
            frustration, guilt, and grief do not mean that the victim is abnormal, immoral,
            or a bad person. They reflect a pattern of human distress in reaction to a
            unique criminal attack.
     
                        a.   While most reactions are normal, there are some people with pre-
                 existing mental health problems who have harmful reactions. There
                 are also some who react to personal disasters in a dangerous way -
                 to themselves or others. In the aftermath of crisis, the intervenor
                 should always be alert to any words or other signs of suicidal thoughts
                 or threatening behavior towards specific individuals. If these arise,
                 seek immediate professional help - a mental health professional, a
                 suicide hotline, even a law enforcement agency if there is an imminent
                 threat to someone else.
     
                        b.    While most reactions are normal, most people have not experienced
                 such intense feelings, so they think they are "going crazy." Survivors
                 should be reassured that while the crisis has thrown their lives into
                 chaos, they are not, as a consequence, crazy.
     
              5.   Hints for Helping.  The following introductory questions will help the victim
            focus on the crime in an objective way. It will help the victim impose an order
            on the event and begin to take control of the story. It may help to ask the
            victim to recall that day from the beginning, so that the "normal" parts become
            part of the crisis story.
     
            a.   Ask the victim to describe the event.
     
                        b.   Ask the victim to describe where he or she was at the time of the
                 crime, who he or she was with, and what he or she saw, heard,
                 touched, said, or did.
     
                        c.   Ask the victim to describe his or her reactions and responses. As the
                 victim begins the description, remember to validate the reactions and
                 responses. If she says: "I remember turning stone cold when I felt the
                 hand on my back and a tug at my purse," say, "Some people have
                 called that a `frozen fright' reaction."
     
                        d.   Ask the victim to describe what has happened since the crime,
                 including contact with family members, friends, the criminal justice
                 system, and so on. Responses to this question will help reveal
                 whether the victim has suffered additional indignities as a result of the
                 crime or whether the victim has been treated with dignity and
                 compassion.
     
                        e.   Ask the victim to describe other reactions he or she has experienced
                 up to now.  Again, validate reactions.
     
                        f.   Let the victim talk for as long as you can. If you are running out of
                 time, give the victim at least a fifteen-minute warning, such as, "Mrs.
                 Jones, I really want to hear more about your experience and reactions,
                 but I have to leave in about fifteen minutes. If we don't finish up this
                 part by then, I want to do that tomorrow, at a time that is good for you.
                 If I don't hear from you, I'll give you a call, if that's okay."
     
                        g.   Don't assume anything - even the apparent pattern of the crisis
                 reaction is suspect. So, for example, the victim's controlled calm of the
                 moment may yield to tears in a few minutes, or a few weeks. Indeed,
                 if the victim is experiencing crisis, it is safe to bet that his or her
                 reactions will take new form over time.
     
                        h.     Don't say things like: I understand.
                                          It sounds like...
                                            I'm glad you can share those feelings.
                                            You're lucky that...
                                                                          It'll take some time but you'll get over it.
                                            I can imagine how you feel.
                                            Don't worry, it's going to be all right.
                                            Try to be strong for your children.
                                            Calm down and try to relax.
     
                                                      Do say things like:      You are safe now (if true).
                                            I'm glad you're here with me now.
                                            I'm glad you're talking with me now.
                                            I am sorry it happened.
                                                                               It wasn't your fault (if there was no   
                                          attributable blame to the victim).
                                                                               Your reaction is not an uncommon response
                                          to such a terrible thing.
                                                                               It must have been really upsetting to see
                                          [hear, feel, smell, touch] that.
                                                                               I can't imagine how terrible you are feeling.
                                                                               You are not going crazy.
                                                                               Things may never be the same, but they can
                                          get better.
     
     
     To improve communication with the victim, avoid words like:
     
         Feelings - although this chapter is concerned with victims' feelings, in practice it is
       better to stick with the word "reactions" to describe "feelings." Many people are
       uncomfortable with being asked to talk about their feelings or emotions.
         
         Share or sharing - ask people to tell you about their experiences. Don't ask them to
       "share" those experiences or thank them for "sharing." No one can literally share
       another person's experience, even    if they have suffered through the same event.
       Many people resent the presumption implicit in this term, or the "social work"
       connotation it carries.
         
         Client or Victim or Survivor - when talking to or about a person for whom you are
       providing crisis intervention, use the victim's preferred name.
     
         Incident or Event - when referring to the crime or the criminal attack. While such
       words may be used in other settings, they are inappropriate in talking with the person
                                          who has survived such an "event."    
     
         Alleged - when referring to a victim. Let the lawyers speak of alleged victims and
       offenders if they need to. Victim advocates should assume that people who describe
       themselves that way are what they say - victims of crime.
     
     C.  Prediction and Preparation
     
              1.   One of the potent needs that most victims have is for information about the
            crime and what will happen next in their lives. Remember, their lives have
            typically been thrown into chaos and they feel out of control. A way to regain
            control is to know what has happened and what will happen - when, where,
            how.
     
              2.   The information that is most important to victims is practical information.  The
            following are examples. Note that some topics may raise scary possibilities
            that the victim has not even considered; the intervenor may tactfully touch on
            such issues or defer them. However, never duck any unpleasant surprise if
            there is reason to believe that the victim will find out about it soon.
     
                                  a.   Will the victim have to relocate? Many burglary victims need to move
                      temporarily because their homes are no longer secure. If relocation is
                      necessary or recommended, what are the victim's options?
     
                                  b.   Does the victim have adequate financial resources to pay for any
                      immediate needs caused by the crime? The robbery victim may not
                      have money to pay for food or rent, even if a compensation program
                      may reimburse a victim at a later date, the need for immediate money
                      is sometimes overwhelming.
         
                                  c.   What legal issues confront the victim? Will the case be processed in
                      the criminal justice system? Will there be an investigation? What are
                      the chances that there will be an arrest - and then prosecution, trial,
                      conviction, and sentencing? Does the victim have civil litigation
                      options? Might it be feasible for the victim to sue the offender or a third
                      party who might be held responsible for factors leading up to the
                      attack? Note that honest answers and estimates are essential; to the
                      victim of a "cold" burglary with no immediate suspects, the bad news
                      is that fewer than one such case in fifty results in an arrest in most
                      jurisdictions - and giving a rosier picture will undermine your future
                      credibility. By the same token, there may be many questions that arise
                      which are beyond the intervenor's expertise; note them, and help the
                      victim to get expert answers.
         
                                  d.   What immediate medical concerns face the victim? An injured victim
                      needs information about the extent of those injuries. A sexual assault
                      victim may need information to make informed decisions on testing for
                      pregnancy or sexually-transmitted diseases, including HIV. The
                      survivor of a victim of homicide or catastrophic injury may need
                      detailed information about the cause of death or extent of injuries.
         
                                  e.   What will be expected of the survivors of a homicide victim in the
                      immediate future? Will they be asked to identify the body? If so, what
                      is the condition of the body? Is there a need to address immediately
                      funeral considerations? (Some religions call for immediate burial.) Do
                      the survivors know their loved one's body will be given an autopsy?
         
                                  f.   What does the victim need to know about the media? As indicated
                      above, if the case is sensational or has a "newsworthy" face to it, it is
                      likely that there will be media coverage. Does the victim know his or
                      her rights? Is the victim prepared for a full media intrusion? Has the
                      victim been warned that what appears in the media may not have any
                      relation to the truth as he or she has experienced it?
     
              3.   The second priority is the information on possible or likely emotional reactions
            that the victims might face over the next day or two, and over the next six
            months or so - emphasizing that there is no particular timetable when victims
            can expect to experience crisis reactions, or which of the intense emotions
            may surface. In many ways, this review will become as important as anything
            else they learn. In the initial stages of dealing with the crime, practical issues
            are their priority.  Some of the emotional concerns that should be outlined,
            however, are the following:
       
                        a.   Immediate physical and mental reactions to crisis. These reactions
                 may include inability to sleep, lack of appetite, anxiety, numbness,
                 estrangement from the world, a sense of isolation, anger, fear,
                 frustration, grief, and an inability to concentrate.
         
                                  b.   Long-term physical and mental reactions. These reactions may include
                      intrusive thoughts, nightmares, terror attacks, continued sense of
                      isolation, inability to communicate with others, sleep disturbances,
                      depression, inability to feel emotion, disturbance of sexual activity,
                      startle reactions, irritability, lack of concentration, and so forth.
         
                                  c.   Reactions of significant others. While some friends or family members
                      serve as the most important source of emotional support for victims,
                      many cause as much harm as good. Three common reactions that
                      may cause victims distress are: over-protectiveness; excessive anger
                      and blame directed toward the victim; and an unwillingness to talk
                      about or listen to stories of the crime.
         
                                  d.   Victims should expect that everyday events may trigger crisis
                      reactions similar to the ones they suffered when the crime occurred.
                      Thus, the birthday of the son who was murdered may trigger
                      overwhelming feelings of grief and anger about the murder.  A sunset
                      of a particular shade and color may trigger a panic attack in a victim
                      who was robbed during such a sunset. The smell of alcohol on the
                      breath of a young man may trigger an outburst of rage in a young
                      woman who had been raped by a man who had been drinking.
     
              4.   In addition to needing predictable information, victims need assistance in
            preparing for ways in which they can deal with the practical and emotional
            future.  The following are some hints for helping.
     
                                  a.   Take one day at a time. Suggest that the victim plan each day's
                      activities around needed practical tasks. Help the victim list the tasks
                      that need to be done and set a goal for accomplishing a certain
                      number each day. Victims who have been severely traumatized may
                      want to check in with you after each day to report their progress and
                      to receive positive feedback on any successes.
         
                                  b.   Problem-solving. Show the victim how to use problem-solving
                      techniques to address the overwhelming problems that he might face.
                      Suggest that the victim list the three most important problems
                      confronting him for the next day. After he makes his list, have him
                      analyze whether all three really need to be done in the next twenty-
                      four hours. If he thinks so, ask him to sort the list in priority order.
                      Take the first problem he has listed and ask him to think about all the
                      possible ways he might deal with the problem. After he has discussed
                      such ideas, ask him to choose the option that he thinks is most
                      feasible.
     
                                       Example: Jim is a robbery victim. The robber stole his wallet and the
                      contents of his pockets, which included all of his cash, his bank card,
                      his driver's license, his car and apartment keys, and a pocket watch.
                      Jim is panicky because it's 9 at night and he doesn't have any money
                      and doesn't know how to get home. Even if he is able to get there, he
                      doesn't have keys to get into his apartment or to drive to work in the
                      morning.
         
                                       You ask Jim to list his three biggest problems. He says: getting home,
                      getting in his apartment, and getting to work in the morning, in that
                      priority order. You ask him to think of all the possible ways he might
                      be able to get home. After some thought, he decides that he can
                      borrow a quarter from you and call a friend to come get him.  He then
                      realizes that his friend would probably let him stay at his house
                      overnight, if needed. He also realizes, as he is thinking, that he might
                      be able to call his landlord from his friend's house and arrange to get
                      into his apartment. As he begins to think calmly and carefully about the
                      problem he remembers he has an extra set of keys to both his
                      apartment and his car at home... and so the problem-solving begins
                      and may continue.
         
                                  c.   Talk and write about the event. Suggest to victims that they use
                      audiotapes or write a journal to tell their unfolding stories. Even if no
                      one else sees or hears these stories, it is a way of expressing oneself
                      and a way of processing thoughts.
         
                                  d.   Plan time for memories and memorials. It can be predicted that certain
                      things will be trigger events for future crisis reactions. Urge victims to
                      try to think through what those trigger events might be and allow
                      themselves time to deal with those reactions. For example, a woman
                      who had been sexually assaulted on October 14 routinely took that
                      day off from work to do something nice for herself and to think about
                      her pain.
         
                                  e.   Encourage victims to identify a friend or family member on whom they
                      can rely for support during times when they must confront practical
                      problems. If they are able to name that person, suggest that they call
                      and explain their need for support and help. If this is done in advance,
                      it makes it easier to request certain help when the time comes.
         
                                  f.   Good nutrition, adequate sleep, and moderate exercise can
                      significantly help victims survive times of crisis. That underestimated
                      triad is, in fact, the basis for virtually all stress reduction programs.
                      Help victims set up their own regular routine of health.  At first it may
                      be difficult, but if they keep trying they will readily realize some
                      benefits.
         
     
     ... Charles Dickens said, "No one is useless in this world who lightens the burdens of
     others."
     
     * Reprinted with permission of National Organization for Victim Assistance 
     
     
          Secondary Victimization*
     
     After the trauma of a crime, many report being victimized by the very systems that were
     designed to help them. The media, health services and criminal justice system can respond
     to victims of crime in ways that make them feel traumatized again. A counselor can help to
     reduce the chances of secondary victimization by helping victims to understand their rights. 
     
     
     Crime Victims' Rights
     
     
     While the American criminal justice system is primarily modeled after the English system,
     there is an important difference in criminal prosecutions. Historically, criminal prosecutions
     in England were private actions brought by the victim or a representative of the victim. In
     the American tradition, a crime is deemed to have been committed against the state or
     against society as a whole. An unfortunate outcome of this is the victim's assignment as a
     witness. Since the crime is viewed as being committed against the state, it is the state's job
     and right to prosecute. In criminal cases, it is not the victim who decides if the case will go
     to court. The victim has little or no control over the process of bringing the offender to
     justice.
     
     In recent years, America's victims' rights movement has advocated to up-grade the victim's
     role in the criminal justice process. It has sought to balance the rights of victims and the
     accused. During the past two decades, all states have passed laws affirming the rights of
     crime victims. Almost every state has enacted "victims' bills of rights." A quarter of the
     states have passed constitutional amendments for victims' rights.
     
     Today, victims are frequently categorized - sexual assault victims, domestic violence
     victims, child abuse or neglect victims, elderly victims of abuse, victims with disabilities,
     victims of hate-motivated crimes, and even Good Samaritans. Many states have included
     surviving family members of homicide victims in their definition of "victim." These groups
     often have rights and remedies that are unique and distinct, such as protection from abuse
     orders for domestic violence victims, videotaped testimony and testimonial aids for child
     victims, and protective services for elderly victims.
     
     
     
     
     
     
     
     
     
     All states have rights for crime victims, but the scope varies greatly from state to state. 
     Victims' rights can include:
     
     
     
                         The right to attend and/or participate in criminal justice proceedings
                         The right to notification of the stages/proceedings in the criminal process
               and of other legal remedies
                         Protection from intimidation and harassment
                         The right to confidentiality of records
                         Speedy trial provisions
                         The right to prompt return of the victim's personal property seized as
               evidence from offenders
                         The availability of offenders' profits from the sale of the stories of their
               crimes
                         Victim compensation and restitution
     
     
     
     
     
     
     Victim Impact Statements*
     
     
     Courts in every state are permitted to consider or even to request a victim impact
     statement. These statements provide a way for those deciding a case to factor in the
     human cost of the crime and for victims to participate in the criminal justice process.
     
     Almost all states provide for victim input at sentencing. Impact statements can be mandated
     by law, or left to the judges' discretion. Most victim impact statements normally written, and
     become part of the pre-sentence report. They may be drafted by the official preparing the
     pre-sentence report, the victim, or survivors of the victim, depending on the law. In some
     states, the parent or guardian of a minor or incompetent victim can prepare the statement.
     The Child Protection Act of 1990 permits child victims of Federal crimes to submit victim
     impact statements in ways that are "commensurate with their age and cognitive
     development," which could include drawings, models, etc.
     
     A state may allow written or oral statements at sentencing. The oral statements may be
     made by the victim, survivors of a victim, or in some states, a representative of the victim
     or victim's estate.
     
     Victim impact statements can include the financial, physical, psychological or emotional
     harm that the victim or victim's family suffered.  State law might specify what can be
     included in the statement, or it may simply permit a "description of the impact of the
     offense." Victims may be permitted to state what sentence they wish the offender to receive
     or voice their opinions about the proposed sentences. In more than half of the states,
     victims can submit impact statements even if the offender was sentenced prior to the
     passage of an impact statement law. The majority of states also permit victim input at the
     parole hearing.
     
     In 1990, the California legislature passed a law which permits the use of videotaped victim
     impact statements at parole release hearings. Acknowledging that many victims are unable
     to travel to parole release hearings, more states are permitting video impact statements.
     Some states are permitting the use of audiotaped victim impact statements for the same
     reasons.
     
     Victim impact statements that are submitted to the court at the time of sentencing should
     also be included in an offender's file. This assists the paroling authorities in understanding
     how the crime affected the victim(s) soon after it occurred, rather than its impact at the
     time(s) of parole release hearings. In over half of the states, the original victim impact
     statement is kept on file by corrections authorities, and reviewed as part of the parole
     process. Many states solicit updated impact statements for parole hearings as well.
     
     
     
     
     Crime Victims and the Media*
     
     
     In its rush to be the first with the news, the media can often inflict a "second victimization"
     upon crime victims or survivors. Common complaints that victims have include: interviewing
     survivors at inappropriate times; filming and photographing gruesome scenes; searching
     for the "dirt" about the victim; seeking interviews with friends or neighbors', interviewing or
     photographing child victims; printing victims' names, addresses or places of employment;
     and scrutinizing victims' past. After a crime, victims are frequently physically and mentally
     numb.  They are confused and disoriented.
     
     A recent study shows that television news directors agree in principle that crime victims
     have privacy rights and the individual's right to privacy is not outweighed by the public's
     desire to know.  However, directors are less likely to adhere to this principle if they know
     a competitor is going to break the story. 
     
     While victims have rights when dealing with the media, many yield to media pressures and
     answer questions that they would not consider answering under other circumstances. In
     most cases, there are no legal remedies if his or her rights are violated.
     
     The National Victim Center developed this list of rights for victims: 
     
     
     
     
                         To say "no" to an interview
                         To select the spokesperson or advocate of the victim's choice
                         To select the time and location for media interviews
                         To request a specific reporter
                         To refuse an interview with a specific reporter even though he or she
               has granted interviews to other reporters
                         To say "no" to an interview even though the victim has previously
               granted interviews
                         To release a written statement through a spokesperson in lieu of an
               interview
                         To exclude children from interviews
                         To refrain from answering any questions with which the victim is
               uncomfortable or that the victim feels are inappropriate
                         To avoid a press conference atmosphere and speak to only one reporter
               at a time
                         To demand a correction when inaccurate information is reported
                         To ask that offensive photographs or visuals be omitted from airing or
               publication
                         To conduct a television interview using a silhouette or a newspaper
               interview without having a photograph taken
                         To completely give the victim's side of the story related to the
               victimization
                         To refrain from answering reporters' questions during a trial
                         To file a formal complaint against a reporter
                         To grieve in private
     
     
     
     
     
     Medical Issues*
     
     
     Twenty-eight percent of rape victims report some degree of physical injury as a result of the
     rape (Rape in America, 1992).
     
     Every year, domestic violence results in almost 100,000 days of hospitalizations, almost
     30,000 emergency department visits, and almost 40,000 visits to physicians (American
     Medical Association, 1991).
     
     Every year hospitals spend millions of dollars treating victims -- including victims of physical
     abuse, homicide, terrorism, aggravated assault, rape and domestic violence. Even though
     hospital staff see many victims of trauma and in many cases are one of the first to respond
     to victims, hospitals are frequently understaffed and personnel undertrained to deal
     effectively with the emotional needs of victims.
     
     Individuals whose physical wounds do not appear to be severe may be forced to sit and
     wait while others are treated. In some cases the victim and the offender may be brought to
     the same hospital for treatment. The victim may be forced to be in close proximity to the
     offender while awaiting or receiving medical treatment. 
     
     Staff who deal with victims of crime on a daily basis may respond to victims in ways that
     seem to minimize their pain and emotional trauma. Because treating victims of crime is
     routine, hospital staff may fail to explain procedures with sensitivity and care and thereby
     cause secondary victimization.
     
     
     
     Fear of HIV
     
     
     With the HIV/AIDS epidemic, the trauma of a sexual assault has evolved into a potentially
     life threatening concern. To date, there have been no documented cases of HIV
     transmission in adult victims as a result of a sexual assault. This does not mean that
     transmission is impossible. The physical trauma to the body increases the susceptibility to
     infection. Child or elderly victims are at increased risk of infection.   
     
     Although there is no prescribed way to introduce the topic, a discussion about the rape
     exam or general health concerns may provide a natural opening to insert the topic. A
     counselor can also wait for the victim to raise the issue.  
     
     A victim's desire to have an offender tested for HIV is understandable, but the results rarely
     relieve the fear and anxiety. Knowing the results of an offender's present HIV test does not
     guarantee that the victim is free from exposure to HIV. Current research indicates that a
     person could be exposed to the virus, yet not test positive for months or years. This
     individual could transmit it to another even though test results are negative. Additionally,
     in many cases the offender may never be apprehended. Although a number of states have
     mandated testing of alleged and/or convicted offenders, not all provide for immediate
     testing or automatic notification to victims.
     
     Due to the high-risk behaviors of numerous sexual offenders, and the frequency with which
     some children are assaulted by the same offender, the risk of infection for children, when
     compared with adults, is higher. While the risk is higher, the incidence of HIV infection in
     children is so low that testing is not recommended unless a strong belief or evidence exists
     that the offender engages in high-risk behaviors or the child exhibits symptoms of sexually
     transmitted diseases. If testing is deemed advisable, the parent(s) or legal guardian(s) must
     give permission.
     
     Most people consider sexual assault victims as the victim group at highest risk for HIV
     infection. However, domestic violence victims should also be considered. Women whose
     partners use drugs are at risk. Victims may be coerced into using intravenous drugs with
     shared needles, and consequently exposed to the virus. Most battered women are not
     powerful enough to convince their partners to use a condom. Sexual assault may be part
     of the battering cycle.
     
     
     Cross Cultural Issues in Crisis*
     
     I. Understanding Cultural Contexts
     
              A.   CULTURE (cul' tur):   "the totality of socially transmitted behavior patterns,
            arts, beliefs, institutions, and all other products of human work and thought
            characteristic of a community or population."  The American Heritage
            Dictionary of the English Language 
     
                                  1.   Issues that help define culture identity include attitudes towards
                      spirituality, birth, dress and other factors.
     
                                  2.   Sources of cultural identity include not only race, ethnicity, nationality
                      and religion but also such attributes as age, gender, language, sexual
                      orientation.
     
                        B.   Placing yourself in your own cultural context.  It is important to know your own
                 values and cultural references before trying to interact with others with
                 different values and references.
     
     II. Issues Of Cultural Perspective
     
              A.   Culture and crisis
     
                        1.   Most literature on trauma and appropriate intervention strategies is
                 based on theoretical and philosophical paradigms drawn from a white,
                 Anglo-Saxon, Judeo-Christian perspective in the United States. Yet it
                 is clear that people with different cultural backgrounds, including those
                 backgrounds that are drawn outside of race, ethnicity, nationality or
                 religion, may perceive trauma and appropriate treatment differently.
     
                             "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."
                 E.R. Parsons, "Ethnicity and Traumatic Stress: The Intersecting Point
                 in Psychotherapy," in Trauma and Its Wake, ed. Charles R. Figley,
                 Brunner/Mazel: New York, 1985.
     
                        2.    Several different conceptual schemes provide some insight into how
                 different cultures may need different types of intervention or strategies
                 for service delivery.
     
                                            a.   The Axis of Control describes the degree to which individuals
                           feel in personal control of their lives, and the degree to which
                           they may feel personal responsibility for what happens to them,
                           or their community.  
     
                                            b.   The Axis of Conflict describes how people tend to react to
                           conflict in their lives and the goals they seek in resolving that
                           conflict.
     
                                            c.   The Axis of Life attempts to illustrate different perspectives on
                           life and death issues and whether individuals seek to resolve
                           their concerns about life and death through communing with
                           nature, God or technology.
     
                                  3.   Each perspective described through these suggests differences in
                      attitudes, philosophies and values when providing outreach and
                      service to different cultural groups.
     
              B.   Cultural assessment
     
                        1.   That analysis can be based on any dominant and uniting characteristic
                 of a population. For instance, if a crisis response effort was being
                 planned for an intervention at Gallaudet University, the only four-year
                 liberal arts university for deaf people in the United States, it would be
                 important to think of the frame of reference of the hearing impaired or
                 deaf populations. It would be critical to think about the integration into
                 the hearing impaired culture, or lack thereof, of any particular group or
                 individual within the college.
     
                        2.   For purposes of illustration on how an assessment might be made, the
                 following is a "checklist" for helping counselors determine the level of
                 ethnic identification that a victim may have.
     
                                            a.   Determine the extent that the ethnic language is spoken in the
                           home.
     
                                            b.   Determine how well English (or the dominant language or
                           dialect in a country) is spoken.
     
                                            c.   Determine the stresses of migration on the ethnic group as a
                           whole and how long the individual or community has been in
                           the United States.
     
     
     
                                            d.   Determine the community of residence and the opportunities
                           the individual has for linking with people of a similar ethnic
                           origin.
     
                                            e.   Determine the educational attainment and socio-economic
                           status of the individual and the community.
     
                                            f.   Determine the degree of religious faith of the individual or the
                           community and whether that faith reflects the religion of the
                           ethnic group.
     
                                            g.   Determine the presence of intermarriage in the community, by
                           the individual, within the individual's family, or within the
                           community as a whole.
     
     
                        C.    Understanding Cultural Competence
     
                        1.   A long-held theory of cross-cultural assistance has been that it is best
                 if members of the same cultural, racial or ethnic group assist each
                 other. That is, an Hispanic/Latino victim theoretically would best be
                 served by an Hispanic/Latino counselor. While this is still a useful goal
                 in some cases, it has not been practical in application since there has
                 often been a shortage of helpers from different cultures in the
                 communities where they are needed most.
     
                        2.   James Green offers the following definitions of ethnic competence that
                 could be utilized as well to explain a more generic definition of cultural
                 competence.  (Source:  James Green, Cultural Awareness in the
                 Human Services.  Prentice Hall, 1982.)
     
                                            a.   "Ethnic competence as awareness of one's own cultural
                           limitations. One of the implications of the model of help-seeking
                           behavior is that the more similar the cognitive and affective
                           characteristics of the client and the worker, the greater chances
                           for effective communication...cultures are in fact different."
     
                                            b.   "Ethnic competence as openness to cultural differences. The
                           belief that underneath we are all the same and that we all share
                           a basic understanding of what is good and valuable in life might
                           well be added to our list of common American values. These
                           beliefs derive from the melting pot ideology, with its assumption
                           (and hope!) that the cultural differences that separate people
                           are less important than the things that unite them, and that
                           manifestations of differences are best under-emphasized in
                           order to assure tranquillity in social relation... The acceptance
                           of ethnic differences in an open genuine manner, without
                           condescension and without patronizing gestures is critical for
                           the development of an ethnically competent professional
                           style..." (While Mr. Green accurately refers to the traditional
                           belief about a melting pot society -- more and more people
                           currently subscribe to the "tossed salad" description of the
                           mixture of ethnicities.)
     
                                            c.    "Ethnic competence as a client-oriented systematic learning
                           style. All cross-cultural encounters are potential learning
                           experiences. They may result in the discovery of new
                           information or an enhanced understanding of something not
                           fully appreciated before. Systematic learning depends on
                           whether the worker-as-health-provider is willing to adopt the
                           role of worker-as-learner."
     
                                            d.   "Ethnic competence as utilizing cultural resources. To do so,
                           the worker must know the resources available to the client and
                           how they may best be used. "Resources" here mean not only
                           community agencies but also institutions, individuals and
                           customs indigenous to the client's own community."
     
                                            e.   "Ethnic competence as acknowledging cultural integrity. In
                           catch phrases such as "culture of poverty," "cultural
                           deprivation" or "the black problem" the prejudicial view is
                           expressed.  Yet all cultural traditions and extant communities
                           are by definition rich, complex and varied."
     
     
     III. Recommendations For Cross-Cultural Service Delivery
     
              A.    Preparation for providing cross-cultural victim assistance
     
                        1.   Take advantage of as many cross-cultural educational opportunities
                 as possible.
     
                        2.   Consider the following possibility. Most people who think of
                 themselves as members of a dominant cultural group spend less time
                 learning about minority groups than do minority groups within the
                 same population. Minorities need to learn about dominant cultural
                 values in order to survive or succeed.
     
                        3.   Be aware of institutional and latent cultural bigotry. Such bigotry
                 includes racism, sexism, ageism, homophobia, and so forth. While it
                 is easy to identify obvious indicators of bigotry, subtle signs of
                 discrimination, ignorance and prejudice may be more difficult to
                 observe.
     
                                  a.   Language often carries inherent messages of prejudice.
     
                                  b.   Stereotypes also often are indicators of bigotry.
     
                                  c.   Educational programs can carry implicit biases in favor of the
                      dominant culture.
     
                                  d.   Symbols, traditions, and behaviors may be implicitly
                      discriminatory.
     
                                  e.   It is wise for crisis responders to spend time thinking about the
                      difference between bigoted words, phrases, or humor, and
                      what constitutes non-bigoted or discriminatory speech.
     
                                  f.   Racism is one of the most important factors in cultural
                      experiences.  Some have suggested that the more people of
                      one race are exposed to people of other races the less likely
                      either race will be racist. However, others suggest that if people
                      lack any exposure to a different race they may also be non-
                      racist.  People become racist when exposed to negative
                      experiences or stereotypes about other races.  When those
                      experiences or stereotypes are reinforced by media, friends
                      and family, language or formal education, racism becomes
                      entrenched.
     
                        B.   The following action plan for working in a cross-cultural context is based on
                 further work of Erwin Parsons.
     
                        1.   Prior to doing cross-cultural intervention, find out about a culture's
                 routines, traditions and impact of family relationships. Routines such
                 as regular mealtimes or mode of dress can affect when and how
                 interventions are made. Crisis responders should be prepared to
                 participate in traditions to the extent possible.
     
                        2.   The orientation: Have an open discussion about difficulties of working
                 with individuals or groups who come from a different cultural context
                 than yours.
     
                                  a.   Express a willingness to learn about the ethnic group involved.
     
                                  b.   Communicate some appreciation and respect for the
                      individual's culture.
     
                                  c.   Acknowledge your differences and your limitations.
     
                        3.    Address practical problems first.
     
                                  a.   Deal with immediate environmental problems such as financial
                      loss, secure shelter, family conflict and the like that the
                      individual is having difficulty handling by himself.
     
                                  b.   Build trust.
     
                                  c.   Assist the survivors or victims with financial resources or
                      compensation if possible.
     
                                  d.   Help the survivors focus on something tangible that they can
                      accomplish over the next few days.
     
                        4.   Crisis intervention with cultural focus.
     
                                  a.   Search for the meaning of suffering and pain relevant to the
                      dominant cultural group involved.
     
                                  b.   Search for the meaning of death in the culture.
     
                                  c.   Search for the meaning of life.
     
                                  d.   Make an effort to acknowledge your limitations with language
                      or other communication concerns, and ask the survivors to tell
                      you if you say something wrong or do something offensive.
     
                                  e.   Ask survivors to tell their story and talk to them about the crisis
                      reaction.
     
                                  f.   Ask survivors if their families should be present during
                      discussions or if they would like to have clergy members
                      present.
     
                                  g.   Ask survivors if they would like to go to a place or worship or if
                      there are any ceremonies or rituals that are particularly directed
                      at crisis in the culture.
     
                                  h.   Ask survivors to describe what they would like you to do to be
                      of assistance to them and then tell them truthfully what you can
                      or can't do.
     
                                  I.   Useful cross-cultural intervention includes: reduction of
                      isolation, relaxation techniques, meditation, education about
                      crisis and trauma reactions, neuro-lingual programming,
                      reframing the crisis in culturally relevant terms, helping
                      individuals to develop control, increase self-esteem and self-
                      regulation.
     
                                  j.   Be aware of culturally specific communication techniques such
                      as the use of eye contact, the integration of food and drink in
                      discussion, the pace of conversation, body language and so
                      forth.
     
     IV. Different Ethnic-Cultural Contexts
     
     Crime victimization is often more prevalent within minority populations than between the
     dominant population group and minorities; therefore, crime victimization is included as a
     context for understanding cultural environments.  While ethnic groups suffer victimization,
     they often also become victims of the system when accused of crimes.
          
     Victims Who Are Disabled
     
     Individuals with a physical disability are more likely to be unemployed, under-employed and
     less well educated. Women who are disabled are less likely to be married than men who
     are disabled. People of color who are disabled are more likely to be negatively impacted
     both economically and socially. Persons with disabilities are not only misunderstood by
     society as a whole but often by their families as well. They are frequently discouraged from
     expressing themselves sexually.  When working with an individual who has a disability:
     
     
     
                         Ask how to best handle any situation of which you are unsure.
                         Remember that the victim is a person who happens to be disabled, rather than
               a disabled person who happens to be a victim.
                         An attendant or family member may not be able to communicate with the
               victim any better then you.
                         It is not appropriate to talk to family members without the permission of the
               victim or instead of the victim.
                         The victim should decide if another individual should be present for the
               interview.
                         A care-taker may be the one abusing the victim.
                         A victim who at some point lived in an institution or residential facility may have
               rigid ways of thinking, been encouraged to be friendly to everyone or
               experienced abuse by staff or other residents.
                         An inability to speak does not equal an inability to hear.
                         If an interpreter is needed, always speak to the victim, not the interpreter.
                         Learn the shorthand, such as "GA" for go ahead, and the protocol for
               telephone relay services.
     
     
     
     
     
     When working with a victim who is blind or sight impaired:
     
     
     
                         Allow the victim to take your arm when walking rather than taking his/her arm.
                         If there is a guide dog, do not comment about the dog's inability to protect the
               victim. Asking about a dog's behavior is a form of victim blaming.
                         Introduce yourself every time you enter the room; announce when you are
               leaving.
     
     
     
     
     
     
                POST-TRAUMATIC STRESS DISORDER,
                                
                    RAPE TRAUMA SYNDROME AND
                                
                           BATTERING
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     Powerlessness is a political condition, while passivity is a strategy adopted by the powerless to
     survive...The process of victimization consists of (1) first putting the victim in a position of
     powerlessness relative to the victimizer, and then (2) repeatedly impressing the victim with his or
     her powerlessness, including the powerlessness to escape, until the victim adopts passive and
     compliant behavior to stay alive.
       Anne Jones
     
     Trauma and Post Traumatic Stress Disorder
     
     In her book, Trauma and Recovery, Judith Herman (1992) reminds us that the ordinary
     response to the horrors that occur in our lives is to expel them from our consciousness.
     There are certain violations that are unspeakable. While they are unspeakable, they refuse
     to be buried because there is an equal but opposite conviction that denial does not work.
     Herman tells us "remembering and telling the truth about terrible events are prerequisites
     both  for  the restoration of the social order and for the healing of individual victims."
     However, since atrocities are frequently shrouded in secrecy, evidence of a traumatic event
     initially appears as a symptom, not a story.
     
     The distress symptoms of traumatized people concurrently call attention to the existence
     of an unspeakable secret while deflecting attention from it. We see this clearly in the way
     people who experienced a trauma alternate between feeling numb and reliving the event.
     Mental health professionals call this dissociation.  
     
     "People who have endured horrible events suffer predictable psychological harm. There is
     a spectrum of traumatic disorders, ranging from the effects of a single overwhelming event
     to the more complicated effects of prolonged and repeated abuse. Established diagnostic
     concepts, especially the severe personality disorders commonly diagnosed in women, have
     generally failed to recognize the impact of victimization" (Herman, 1992, p. 3).
     
     Traumatic syndromes as well as the recovery processes have basic features. The primary
     stages of recovery are: 
     
                   establishing safety 
                   reconstructing the trauma story 
                   restoring the connection between survivors and their communities
     
     The challenge is to help survivors reconnect the pieces, rebuild history and make meaning
     of their current symptoms in the light of prior events. The traditional sphere in which this
     occurs for women is within the  experiences of domestic and sexual life; while for men it is
     within the experiences of war and political life.
     
     Studying psychological trauma means coming face to face with human vulnerability to
     natural acts or disasters and the evil deeds of humans. We witness horrible events. When
     the events are natural disasters, witnesses are readily inclined to sympathize with the
     victim. Conversely, when the traumatic events are of human creation, witnesses are caught
     in the struggle between victim and perpetrator. Morally, it is impossible to remain impartial.
     Witnesses take sides. The side that many choose is the side of the perpetrator because
     all that the perpetrator asks is for witnesses or society to do nothing. To side with a victim,
     requires the witnesses to share the burden of the victim's pain.  
     
     Ask Vietnam veterans if people want to know what really happened during the war, and
     they will say  "no." Society, without individuals or groups willing to hear and report the pain,
     prefers to look the other way. It happens even more frequently when the victim is already
     devalued by society (a woman, a child). Devalued individuals find that the most traumatic
     events of their lives take place outside the range of socially validated reality. Their
     experiences are unspeakable.
     
     In the field of psychological trauma, there has been debate about whether individuals with
     post-traumatic conditions should be treated with care or contempt. Are they genuinely
     suffering or are their stories products of their imagination? Despite the literature
     documenting the occurrence of psychological trauma, debate still centers on the basic
     question of whether these incidents are credible and real. Those who spend too much time
     treating victims of traumatic events are viewed with suspicion by many of their colleagues.
     
     There have been three periods during the past century when a particular form of
     psychological trauma has become a public concern. Each time, the study of trauma has
     flourished in association with a political movement. The first of these was hysteria, the
     archetypal psychological disorder of women. Its study grew out of a  political movement of
     the late nineteenth century in France. The second was shell shock. Its study began in
     England and the United States after World War I and reached its peak after the Vietnam
     War. The political setting was the disillusionment with the Vietnam war and the growth of
     an antiwar movement. The last and most recent traumas to come to public awareness are
     sexual and domestic violence. The feminist movement brought them to public view. Today's
     understanding of psychological trauma is built upon a synthesis of these three areas of
     inquiry.
     
     Not until the women's liberation movement of the 1970's was it recognized that women in
     civilian life had post-traumatic disorders. The real but private conditions of women's lives
     were hidden. The privacy created powerful obstacles to consciousness and made women's
     reality practically invisible. Those who spoke about sexual or domestic abuses were subject
     to public humiliation, ridicule and disbelief.  Women remained silent out of fear and shame,
     and silence permitted sexual and domestic exploitation.
     
     This confirmed what Freud had dismissed as fantasies. Sexual assaults against women and
     children were pervasive. A survey conducted in the early 1980's by Dianna E. H. Russell,
     a sociologist and human rights activist, concluded one woman in four had been raped and
     one woman in three had been sexually abused in childhood. 
     
     For the first time, women designated rape as an atrocity. Feminists redefined rape as a
     crime of violence - of power and control - rather than a sexual act. Feminists also redefined
     rape as a method of political control, forcing the subordination of women through terror.
     
     In 1980, psychological trauma became a "real" diagnosis for the first time. In that year the
     American Psychiatric Association included in its official manual of mental disorders a new
     category called Post Traumatic Stress Disorder (PTSD).  PTSD occurs in war and peace,
     as the result of natural disasters or planned attacks, in single or repeated episodes and at
     the hands of strangers and loved ones.
     
     
     
     Diagnostic Criteria for Post Traumatic Stress
     Disorder*
     
     
            A.     The person has been exposed to a traumatic event in which both of the following
            were present:
       
              1.   The person experienced, witnessed, or was confronted with an event or
            events that involved actual or threatened death or serious injury, or a threat
            to the physical integrity of self or others.
       
              2.   The person's response involved intense fear, helplessness, or horror.   Note: 
            In children, this may be expressed instead by disorganized or agitated
            behavior.
     
            B.     The traumatic event is persistently re-experienced in one (or more) of the following
            ways:
     
              1.   Recurrent and intrusive distressing recollections of the event, including
            images, thoughts, or perceptions.   Note: In young children, repetitive play
            may occur in which themes or aspects of the trauma are  expressed.
       
              2.   Recurrent distressing dreams of the event.   Note: In children, there may be
            frightening dreams without recognizable content.
       
              3.   Acting or feeling as if the traumatic event were recurring (includes a sense of
            reliving the experience, illusions, hallucinations, and dissociative flashback
            episodes, including those that occur on awakening or when intoxicated). 
            Note: In young children, trauma-specific reenactment may occur.
       
              4.   Intense psychological distress at exposure to internal or external cues that
            symbolize or resemble an aspect of the traumatic event.
       
              5.   Physiological reactivity on exposure to internal or external cues that
            symbolize or resemble an   aspect of the traumatic event.
     
            C.     Persistent avoidance of stimuli associated with the trauma and numbing of general
            responsiveness (not present before the trauma), as indicated by three (or more) of
            the following:
     
              1.   Efforts to avoid thoughts, feelings, or conversations associated with the
            trauma
     
              2.   Efforts to avoid activities, places, or people that arouse recollections of the
            trauma
     
              3.   Inability to recall an important aspect of the trauma
     
              4.   Markedly diminished interest or participation in significant activities
     
              5.   Feeling of detachment or estrangement from others
     
              6.   Restricted range of affect (e.g., unable to have loving feelings)
     
              7.   Sense of a foreshortened future (e.g., does not expect to have a career,
            marriage, children, or a normal life span)
     
            D.     Persistent symptoms of increased arousal (not present before the trauma), as
            indicated by two (or more) of the following:
     
              1.   Difficulty falling or staying asleep
     
              2.   Irritability or outbursts of anger
     
              3.   Difficulty concentrating
     
              4.   Hyper-vigilance
     
              5.   Exaggerated startle response
     
            E.     Duration of the disturbance (symptoms in Criteria B, C and D) is more than one
            month.
     
            F.     The disturbance causes clinically significant distress or impairment in social,
            occupational, or other important areas of functioning.
     
       Acute: if duration of symptoms is less than 3 months
       Chronic: if duration of symptoms is 3 months or more
       With Delayed Onset: if onset of symptoms is at least 6 months after the stressor
     
       * from Desk Reference to the Diagnostic Criteria from DSM-IV, American Psychiatric Association
     
     At the moment, the study of psychological trauma seems to be firmly established as a
     legitimate field of inquiry. Twenty years ago, the literature consisted of a few out-of-print
     volumes. Now there are new books, new research findings and new discussions every
     month.
     
     Traumatic events are extraordinary, not because they are rare, but rather because they
     overpower normal human adaptations to life. Unlike ordinary misfortunes, traumatic events
     generally involve threats or perceived threats to life. Victims encounter feelings of
     helplessness and terror.
     
     Long after danger is over, victims experience the event as though it were continually
     recurring in the present. They are unable to return to "normal," for the trauma repeatedly
     intrudes. It is as if time stops at the moment of trauma. The traumatic moment breaks into
     consciousness in the form of  flashbacks and nightmares. Small, seemingly insignificant
     reminders can trigger these memories, which return with the vividness and emotional force
     of the original event. As a result even normally safe encounters may feel dangerous.
     
     Traumatized people who cannot spontaneously dissociate may attempt to produce similar
     numbing effects by using alcohol or narcotics. It has become clear that traumatized people
     run a high risk of compounding their difficulties by developing dependence on alcohol or
     other drugs.
     
     Although dissociation, or even intoxication, may be adaptive defense mechanisms at the
     moment of total helplessness, they cease to be once the danger is past. They prevent the
     integration necessary for healing. Unfortunately, dissociation, like other symptoms of the
     post-traumatic stress syndrome, is persistent.
     
     Traumatic events place enormous stress on basic human relationships. They can sever ties
     of family, friendship, love and community. They can shatter the self image that is formed
     and sustained in relation to others. They can undermine belief systems. They can violate
     the victim's faith in a natural or divine order and cast the victim into a state of crisis.
     Traumatic events destroy victims' fundamental assumptions about the safety of the world,
     the positive value of the self and the meaningful order of creation.
     
     The damage to relational life is not a secondary effect of trauma. Traumatic events destroy
     victims fundamental assumptions about the safety of the world, the positive value of the
     self, and the meaningful order of creation. 
     
     Support from other people may temper the impact of the event, while blame or a hostile
     response may compound the damage and intensify the traumatic syndrome. After traumatic
     life events, survivors are highly vulnerable. Their sense of self is shattered. That sense can
     be rebuilt only as it was built initially, in connection with others.
     
     Sharing the traumatic experience with others is an element of recovery. In this process, the
     survivors seek assistance not only from those closest to them but also from their
     communities. The response of these communities has a powerful influence on the ultimate
     resolution of the trauma. Re-establishing the bonds between the traumatized person and
     their communities depends upon public acknowledgment of the traumatic event and some
     form of community action. Once communities acknowledge that a person has been harmed,
     they must assign responsibility for the harm and repair the injury. These two responses -
     recognition and restitution - are necessary to rebuild the survivor's sense of order and
     justice.
     
     Rape-Related Post-Traumatic Stress
     
         Nearly one-third of all rape victims develop Rape-related Post-traumatic Stress
       Disorder (RR-PTSD) sometime in their lifetimes, and more than 11 percent suffer
       from RR-PTSD at the present time. 
     
         Thirteen percent of American women surveyed had been raped and 31 percent of
       these rape victims developed Rape-Related-PTSD.  
     
         Of the 683,000 women raped each year in this country, approximately 211,000 will
       develop RR-PTSD each year.    
     
         Rape victims are three times more likely than non-victims of crime to have a major
       depressive episode.  
     
         Rape victims are 4.1 times more likely than non-crime victims to contemplate
       suicide. Thirteen percent of all rape victims actually attempt suicide.
     
         Compared to non-victims of crime, rape victims are: 13.4 times more likely to have
       two or more major alcohol problems; and 26 times more likely to have two or more
       major serious drug abuse problems.
     
            from Rape in America:  A Report to the Nation, National Victims Center, 1992.
     
     
     
     Rape Trauma
     
     
     An acute and long-term emotional reorganization process that occurs as a result of
     completed or attempted rape, and lasts for months or years after the actual rape has
     occurred.
     
     
     
     Stages
     
     
            A.     Acute/Impact Reaction
       
              1.   Immediately and several days after the rape
       
       2.   Ways of showing anger
     
            a. Expressed style - fear, crying, smiling, restlessness, tenseness        
     
            b. Controlled style - feelings hidden by calm, composed attitude
       
       3.   Somatic Reactions
     
                        a.   Physical: soreness and bruising from the physical attack, irritation and throat
                 infections for women forced into oral sex
            
                        b.   Skeletal muscle tension: inability to sleep or restlessness while asleep, edgy
                 and jumpy over minor incidents
     
                        c.   Gastrointestinal Irritability: stomach pains, appetite affected, nausea
     
                        d.   Genital Disturbances: vaginal discharge, an itchy, burning sensation on
                 urination, chronic vaginal infections, rectal bleeding/pain
     
       4.   Emotional Reactions
     
                        a.    Fear of: how friends will react, not being believed, rapist retaliation
     
                        b.   Shock/disbelief
     
                        c.   Agitation/anger
     
                        d.   Shame/self-blame
     
                        e.   Confusion/bewilderment
     
                        f.   Extreme sense of guilt
     
       5.   Her needs
            
                        a.   Someone to believe her
     
                        b.   Emotional support/acceptance       
     
                        c.   Reassurance about how she handled the attack
     
       6.   Additional needs
            
                        a.   Examination by physician even if it is several days after the attack
     
                        b.   Aid in reporting the crime
     
            B.     Outward Adjustment Phase
     
              1.   Lasts from weeks to months
     
       2.   Emotional reactions
     
                        a.   Intense fear: pregnancy, V.D., physical violence or death, crowds, being
                 approached from behind, intercourse, fear of the unexpected (because the
                 rape may have been unexpected)
     
                        b.   Anxiety: anticipating medical exams, court hearing in which she'll face the
                 rapist, prospect of losing partner
     
                        c.   Denial - refusing to believe the rape happened
     
                        d.   Lost sense of security
     
                                            1.   Nightmares in which
     
                                            a.   Victim is in danger and wants to do something but wakes
                           before acting
     
                                            b.   Victim succeeds in fighting off assailant
     
                                            c.   Humiliation, embarrassment
     
                                            d.   Self-blame
     
                                            e.   Feelings of wanting revenge
     
                      f.   Fear of sexual things
     
                                            g.    All problems become intensified
     
            3.   Physical signs
     
                                  a.   Antipregnancy medicine - causes nausea.  Consist of 25-50 mg. of
                      diethylstilbestrol (DES) administered per day for five days
     
                                  b.    Anti-venereal disease medicine - causes nausea.  Consists of 4.8
                      million units of aqueous procaine penicillin administered
                      intramuscularly
     
                                  c.   Burning sensation when urinating and itching or burning discharge
                      from vagina
     
                                  d.   Tension headaches
     
            4.   Her needs
     
                                  a.   Counselor to be patient as she retells her story; time and time again,
                      if necessary
     
                                  b.   Aid in approaching family and friends
     
                                  c.   Counseling with partner about her fear of sexual intercourse
     
                                  d.   Meet with other rape victims so she won't feel as isolated and helpless
     
     C.  Depression Phase
     
            1.   Lasts days to months
     
            2.   Her emotions
     
                                  a.   Loss of self-esteem as her defenses break down
       
                                  b.   Obsessive memories
       
                                  c.   Uncertain about being able to control her life and environment
     
            3.   Her needs
     
                                  a.   Support through the sentencing of her rapist and any possible end to
                      intimate relationship
     
                                  b.   Overcome her guilt feelings
     
                                  c.   Help in re-establishing intimate relationships 
     
     D.  Integration and Resolution Phase
     
       1.   Lasts months to years
     
       2.   Her emotions
     
                                  a.   Lack of trust in men
     
                                  b.   Anxious and depressed when something reminds her of the rape
     
       3.   Her needs
     
                                  a.    Support and someone to listen
     
                                  b.   Guidance in steps to make her feel more safe
     
                                            1.   Obtain unlisted phone number
     
                                            2.   Move to another location
     
                                                      3.    Extended vacation to get away for a awhile
     
     
     
     Reactions Above and Beyond Rape-Related PTSD That May Require 
     Different Kinds of Intervention
     
               Depressed for an extended period of time (several weeks)
               Demonstrated psychotic behaviors
               Talk of or attempts at suicide
               Use of alcohol or drugs to self medicate
               Abrupt/dramatic changes in sexual behavior; confusion about sexuality
               Expresses a hatred of sex
     
     
     
          Ten Warning Signs of Mental Illness*
     
     
     1.   Marked personality change.
     2.   Inability to cope with problems and daily activities.
     3.   Strange or grandiose ideas.
     4.   Excessive anxieties.
     5.   Prolonged depression and apathy.
     6.   Marked changes in eating or sleeping patterns.
     7.   Thinking or talking about suicide.
     8.   Extreme highs and lows.
     9.   Abuse of alcohol or drugs.
     10. Excessive anger, hostility or violent behavior.
     
       * from the American Psychiatric Association
     
     A person displaying one or more of these warning signs may have a mental illness and
     should be evaluated by a mental health professional as soon as possible. If the individual
     has experienced trauma due to crime or abuse, the behavior may be a normal response to
     an abnormal event.
     
          Depression
     
     The most common complaints that patients tell their physicians are the common symptoms
     of depression. In 1990, the American Psychological Association reported that depression
     annually afflicts about 7 million American women and is responsible for 30,000 suicides.
     This is twice the rate of depression found in American men. The rate of depression and
     victimization in women may be linked.
     
     
     Symptoms 
     
     
         unusual weight gain or loss of weight
         either sleeping too much or insomnia
         inability to enjoy pursuits which formerly gave pleasure
         brooding over the past
         pessimism about the future
         loss of interest in sex
         extreme irritability
         overreaction to trivial events
         trouble with concentration or memory
         neglect of appearance
         frequent thoughts of death or dying
         social isolation
         low self esteem
         feelings of helplessness
     
     A common feature of depression includes the tendency to over generalize the meaning of
     events. Instead of dealing with adversities as isolated incidents, people with depression see
     incidents as part of a larger pattern. They are inclined to see things as black or white. For
     example, a mother trying to solve family problems, realizes that some solutions will work
     well while others will not. But the mother who is depressed tends to feel there are no
     solutions.
     
     
     
     Recovery 
     
     
     Depression can often be successfully treated. Depression can be caused by sudden
     changes in brain chemistry (endogenous) or by personal tragedy or trauma (exogenous)
     which trigger chemical changes. Serotonin and norepinephrine are chemicals that affect
     mood. When confronted with trauma or tragedy, a person may become depressed. The
     amounts of serotonin and norepinephrine in the brain plummet. After about three weeks,
     the levels of the chemicals usually rise and the person begins to feel better. For some
     people, the levels of serotonin and norepinephrine do not return to normal. With low levels
     of the chemicals, the person may feel continually "blue."  But if the quantity drops further,
     it could lead to clinical depression.
     
     There are drugs which can restore the levels of serotonin and norepinephrine. In the last
     few years several drugs have been approved by the FDA for the treatment of depression
     that have fewer side effects and begin to work more rapidly.
     
     For people who suffer from depression as a result of a traumatic event, medication may
     help them to focus and process what has happened. It can help them sleep, increase their
     energy levels, and reduce feelings of hopelessness. In addition to medications, talk therapy
     and support groups are used to treat depression. Frequently they are used in combination.
     
     
     
     
     
     
     
                                
                                
                                
                                
                                
                                
                                
                                
                                
                                
     Hostage in the Home*
     
     Domestic Violence Seen Through Its Parallel, The Stockholm
     Syndrome
                                                               
     When most people hear the term domestic violence, they think of punches, bloody noses,
     black eyes, broken ribs.  So people invariably react by saying, "I wouldn't take that!  The
     very first time he hit me, I'd be out the door!"  Thinking that one becomes an abuse victim
     at the moment of the first assault, they imagine how they would react to an assault by a
     stranger and blame the abuse victim for not reacting to her1 partner's assault as they think
     they would.
     
     People who work with abuse victims are often frustrated and angered by decisions victims
     make which they consider bizarre and inexplicable.  For example, abuse victims often:
     
                   minimize their injuries
                        refuse to participate in the prosecution of their assailants
                        put up bail to get their abusers out of jail
                        stay with or return to the men who abuse them
     
     Because physical abuse is concrete and is all that outsiders can see, and because people
     do not think that just physical assaults would make someone do the "crazy" things abuse
     victims do, they conclude that the victim is mentally unbalanced.
     
     In fact, the victim's mental state is altered as a result of her relationship with the abuser. 
     Her perceptions of herself, her abuser and life in general have been altered.  Not solely due
     to the physical abuse she may have suffered, but due to years of psychological assaults,
     the unremitting use of tactics defined by Amnesty International (1973) as "psychological
     torture."  The abuse victim's very different view of her situation is the result of a lengthy
     process.
     
     
     1  Although it is clear that there are men abused by female and male partners, and there are women abused
     by female partners, because "[a]nalyses of police and court records in North America and Europe have
     persistently indicated that women constitute 90-95% of the victims of those assaults in the home reported
     to the criminal justice system," (Dobash, et al., 1992), herein the victim will be referred to as female and the
     perpetrator as male.  The bottom line is that pain has no gender, and, as this analysis shows, human beings
     exposed to psychological torture will react similarly, regardless of sex.  Therefore, the author asks readers
     to mentally translate the term "battered women" into "battered women or men."
     
     The abuse victim being subjected to her first assault is a very different person from those
     who judge her.  Prior to that first assault, the abuser has spent months or years using
     escalating tactics of mental abuse and intimidation, using "minor" physical aggression to
     control her before moving to actual physical assault.  He undermines her psychologically
     before he ever lays a hand on her.  By the first time the abuser strikes her, the victim is no
     longer like unvictimized people, and simply cannot react like them.  Living in fear while
     undergoing constant psychological degradation each and every day changes her far beyond
     what outsiders can imagine.
     
     One way to make the complex process of victimization that abusers use to gain and
     maintain control over victims understandable to the average person, is to look at domestic
     violence through its parallel:  the Stockholm Syndrome.
     
     The Stockholm or Hostage Syndrome is a "conversion" that occurs when an individual is
     terrorized while being held in captivity. Given certain specific circumstances, a hostage's
     view of his/her captor and his/her relationship to him changes 180 degrees from hatred to
     adulation.
     
     The best way to illustrate this psychological turn-around is through the 1985 terrorist
     takeover of Flight 847 in Europe. (Walker, 1989)  After capturing the plane, the terrorist
     released the women and children - presumably to show what good guys they were.  Left on
     the plane were two sailors and a group of wealthy American businessmen.
     
     The terrorists took the plane to the Beirut airport and held the men captive on the tarmac
     for ten days.  During the ten days of captivity, the hostages had guns held to their heads
     and put in their mouths, and had their lives threatened.  They watched their captors beat
     one of the sailors to death and dump his body out of the tail section of the plane.  Most
     people remember this hijacking from that detail because the image was so vivid in the
     newspapers and on TV.
     
     During their captivity, one of the hostages was forced to read a political statement to the
     media from the cockpit of the plane.  After their rescue, the hostages were flown to the U.S. 
     When they got off the plane, waiting reporters rushed over to interview the man who had
     read the statement earlier in the week.  They asked him only three questions:
     
     
               "Is it good to be home?"
     "Yes, it's wonderful."
     
     
               "What was it like?"
     "It was hell."
     
     
               "What were the kidnappers like?"
     "It's funny you asked that.  They weren't bad
     people.  They let me eat, they let me sleep,
     they gave me my life."
     
     
     Then he said something advocates and police officers have heard from hundreds of victims
     of abuse:  "They have such potential to be good people."
     
     He went on to talk about how the terrorists had to do what they did to get publicity for their
     cause and how America mistreats third world countries.  Within minutes, a government
     spokesperson appeared on camera to say that the kidnappers were not really "good people"
     -  that the man who had been interviewed was a victim of the Stockholm Syndrome. 
     (Walker, 1989)
     
     The Stockholm Syndrome was named for the terrorist take-over of a bank in Stockholm,
     Sweden, in August 1973 when three women and one man were held hostage for six days
     by two men.  (Cooper, 1978)  During that incident, when the police stormed the bank to
     rescue the hostages, the captives fought police at the side of the captors. Afterwards they
     blamed the police for endangering them, and one of the freed hostages became engaged
     to a jailed terrorist. This last occurrence led to the investigation and definition of the
     Stockholm Syndrome.
     
     Since then, following numerous hostage-takings, the world has seen former hostages:
                   minimize their injuries
                   refuse to participate in prosecuting terrorists
                   visit their captors in jail
                   recommend and pay for defense counsel
     
       ...  ALL THE SAME THINGS BATTERED WOMEN DO.
     
     While hostages sometimes refuse to prosecute terrorists, hostages receive compassion
     and understanding.  But all too often, when a battered woman is afraid to prosecute her
     batterer -- who, unlike terrorists, is out on the street knowing where the victim and her loved
     ones live -- her "refusal" to prosecute is used as an excuse by some members of the
     criminal justice system to refuse to protect her and prosecute him.
     
     The bond of interdependence between captive and captor called the Stockholm Syndrome
     develops "when someone threatens your life, deliberates, and doesn't kill you."  (Symonds,
     1980)  The relief arising from the removal of the threat of death generates intense feelings
     of gratitude as well as fear, which combine to make captives reluctant to display negative
     feelings toward the terrorist.  This is pathological transference, a kind of "conversion." 
     Recognition that the terrorist/abuser has the power of life and death over them, combined
     with gratitude that he has let them live, causes a unique change in perspective -- the
     hostage/abuse victim and children come to see the captor/abuser as a "good guy," even a
     savior.  "The victim's need to survive is stronger than his impulse to hate the person who
     has created his dilemma."  (Strentz, 1980)
     
     Overwhelmingly grateful to terrorists for giving them life, hostages focus on their
     perceptions of their captors' kindness, not their brutality.  Similarly, battered women
     convince themselves that the abuser is a good man whose violence stems from problems
     they can help him solve.
     
     Stockholm Syndrome develops when an individual is subjected to four conditions (Graham,
     et al., 1988)
     
     
     Condition One
     
     
     A person is held captive and cannot escape, so her or his life depends on the captor.
     The reality of captivity is easy to understand in the context of hostages or prisoners
     because the walls which confine them are made of brick or stone or wood.  However, the
     walls which confine the abuse victim are built from societal attitudes and practical barriers,
     as well as the psychological pressures she is subjected to every day by her abuser.
     
     A now-familiar example of isolation while living in the public eye is Nicole Brown Simpson. 
     That the beautiful, wealthy wife of a famous public figure could actually be a victim of
     domestic violence -- the clich being a low-income, downtrodden hag -- electrified America
     and blasted open the stereotypical image of battered women.  Because her image and
     circumstances are now firmly engraved in the public consciousness, it is easier to evoke
     thoughts of captivity in the midst of everyday "freedom."
     
     Societal Barriers - Many victims ask family, friends, police and/or the courts for protection
     or help to escape, only to be refused and find that nothing stopped the abuser from
     punishing them for the attempt.  Often it is not only the abuser, but his family and friends,
     who threaten, harass, intimidate and harm the victim seeking help.  Victims all too
     frequently learn that no one will treat their situation seriously, and they feel as though they
     have run into a brick wall when they hear:
     
         "What did you do to deserve it?"
         "Give him another chance.  Stand by your man."
         "You made a vow before God to stay with him 'in sickness and in health until death do 
       you part."
         "Clearly he's sick, so it's your duty to stay with him and help him."
         "It's only a family argument -- I'm not going to arrest him."
         "We're releasing him on his own recognizance."
         "We don't prosecute first-time batterers -- we send them to diversion."
     
         
       These responses to her appeals for help, repeated over and over, teach the victim that she
       cannot escape.  Her situation is very similar to that of a dog being trained to stay within a
       certain area through the use of a shock collar.  Every time the dog reaches the edge of the
       designated area, the collar shocks it.  Eventually, after enough shocks, in the animal's mind
       there is an invisible wall around the property.  After that training, when the electricity is
       turned off, the dog will still not go beyond the border.  Invisible to the outside observer, the
       wall of pain and fear is very real to the animal.
     
     Financial Barriers - Another brick in the wall preventing victims from escape is lack of
     access to money.  Abusers control the family finances to more effectively control victims
     because their financial dependence gives him power.  If the victim has a job, the abuser's
     harassment may cause her to lose it.  "Battering, not pregnancy, is the main reason women
     leave the workforce altogether."  (Jones, 1991)  Lack of access to money makes it
     extremely difficult, if not impossible, for even a middle-class woman to be able to afford to
     take care of herself and the children if she leaves.
     
     Even in the 1990's, a woman faces major barriers when seeking a way to support herself
     and her children if she leaves her abuser:
     
                   According to the U.S. Bureau of Labor Statistics, women still earn only 66 for every
            dollar in annual salary an American man earns - even female college graduates. 
            (Faludi, 1991)
         
                   More than 80% of full-time working women earn less than $20,000 a year -- nearly
            double the male rate.  (Newton, 1989)
     
     One of the prevalent myths about divorce is that women receive generous alimony and child
     support from former husbands.  While this may be true for some, it is far from true for the
     majority:
     
                   In the first year after a divorce, the women and children suffer a 33% drop in their
            standard of living, while the man enjoys a 10% to 15% rise in his.  (Duncan &
            Hoffman, 1988)
         
                   One year after going to court and being awarded support, 88% of women with full
            restraining orders and 81% of those without had not received any money to support
            themselves, and 64% of those with orders and 49% of those without full orders had
            never received any child support from the abuser.  (National Center on Women and
            Family Law, 1993)
         
                   "Divorced men are now more likely to meet their car payments than their child
            support obligations -- even though, as one study in the early '80s [sic] found, for 2/3
            of them, the amount owed their children is less than their monthly auto loan bill." 
            (Hewlett, 1986)
         
     
     Children - When the couple has children, the situation becomes extraordinarily
     complicated.  The children, who dare not confront their father, often blame their mother for
     not pleasing him and avoiding the violence that terrifies them:  "Why did you do that, Mom? 
     You knew it would make him mad."  Having no safe release for their fear, they may take the
     side of the parent they perceive to be the stronger, wanting to be on his side to escape his
     violence themselves.
     
     The mother worries that their lower standard of living after separation or divorce will result
     in increased danger to her children from a new environment:  exposure to drugs, gangs,
     etc.
     
     Most horrifying of all to the victim is the abuser's most common and most dreadful threat: 
     he will win custody of the children, or simply snatch them.
     
     Chesler (1991) found that:
                   Fathers who fought for custody won 70% of the time, whether or not they were
                                     absentee or violent fathers.    
                   12% of the mothers and 37% of the fathers she studied kidnapped their children.
                   All of the maternal kidnappers were primary caretakers and had been prevented by
            the fathers from seeing their children.
                   14% of the paternal kidnappers had been involved in primary child care.  None had
            been prevented by the mothers from seeing their children.
                   None of these fathers was economically, legally or custodially punished.
                   Of the smaller number of maternal kidnappers, 80% were both found and punished.
         
     The abuser's threat to gain custody through the legal process can be seen as easily
     plausible.  Since he has spent years denying his violence to his partner, the children, and
     their families, he is well practiced at denying his abuse. So he behaves precisely in
     accordance with the criteria judges use in assessing a witness' veracity. He makes good
     eye contact with the judge, speaks calmly and tells a coherent story. In contrast, the victim,
     often unrepresented, has also spent years denying the violence. Her testimony may be the
     very first time she has spoken in public about the degrading abuse to which she has been
     subjected. So she doesn't make a very good witness. She may avoid eye contact, break
     down on the witness stand, and omit details.
     
         More than 40 children are abducted by a parent each hour in this country.  Most of these
       abductions are perpetrated by fathers or people acting on their behalf, including step-
       mothers and relatives.  Fifty-four percent of these abductions are short-term
       manipulations around custody orders, but 46% involve concealing the whereabouts of
       the child or taking the child out of state.  Fully 82% occur between the couple's
       separation and two years after the parents have separated or divorced.  (Finkelhor, et
       al., 1990)
         
         In 1988, an estimated 163,200 children abducted by parents or family members were
       taken across state lines, concealed from or prevented from having contact with the
       custodial parent, or taken with the intention of being kept indefinitely or changing their
       custody.  (Finkelhor, et al., 1990)
         
         More than 54% of abductions occur in the context of domestic violence.  (Greif & Hegar,
       1992)
     
     "Each publicized custody battle terrorizes married, divorced, and unwed mothers in non-
     measurable and unknown ways."  (Chesler, 1991)
     
     Scarcity of Available Services - Services for abuse victims are poorly funded by state and
     federal governments, and thus are not available everywhere, and are generally offered by
     networks of volunteers.
     
         Between 1983 and 1987, one-third of the 1 million battered women in the U.S. who
       sought shelter were turned away due to lack of space.  (Women and Housing Task
       Force, 1988)
         
         In 1991 there were 3,200 animal shelters in the U.S., but only 1,200 shelters for abuse
       victims.  (Washington Post, 1991)
                   
         "There are no governmental protective services for battered women.  Furthermore, over
       one half of all counties in the U.S. have no battered women's programs."  (Jackson,
       1990)
     
     If his victim does succeed in escaping, the abuser often resorts to even more serious
     violence because he has lost the very people his abuse is aimed at keeping and controlling
     -- his partner and children.
     
     Some men would rather kill "their" women and/or themselves than see women make a new
     life. We, and victims, see these stories in the press and on television regularly. Victims
     know full well that their escape may end in their death. Statistics verify that battered
     women's lives do indeed depend on their batterers.
         
         Approximately 70% of murdered women are killed by a husband, lover or estranged
       same.  Approximately 2/3 of those murdered by intimate partners or ex-partners have
       been physically abused before they were killed."  (Campbell, et al., 1992)
         
         The most common type of homicide-suicide episodes, representing fully 50% to 75% of
       all murder-suicides in the U.S., typically involved a male between the ages of 18 and 60
       years who physically abused his girlfriend or wife, feared her infidelity or estrangement,
       murdered her, and committed suicide, usually by firearm.  (Marzuk, et al., 1992)
     
     
     Condition Two
     
     
     The captive is isolated from outsiders so that the only other perspective available
     to her or him is that of the captor.
     Hostage-takers routinely keep information about the outside world's response to their
     kidnapping from captives to keep them totally dependent.
     
     Like terrorists, abusers isolate their victims.  Isolation is the back-drop against which the
     entire drama is played because in isolation, all the victim hears is the negative messages
     of the abuser.  Abuse victims are isolated in many ways:
     
     Geographical Isolation - In rural areas, she may be isolated because she lives at the end
     of a road or in the back woods.  There are few things more terrifying than living with
     someone violent, knowing that no matter how loudly you scream, no one will hear you.  No
     one will come.  No one will call 911 when the batterer rips out your phone.
     
     Social Isolation takes many forms:
     
     Family/Friends/Work - Many batterers control who the victim's friends are and who she
     spends time with, determining who the couple will socialize with, or whether they will
     socialize at all.  If he is angry, threatening, violent, or is even merely argumentative in front
     of others, they avoid associating with the couple.  Thus the woman is left even more alone
     so the abuser's demeaning messages become her reality because they are all she hears. 
     Kept totally under his thumb, she cannot bond with anyone else.
     
     Many abusers are obsessively jealous and possessive. They conduct surveillance on their
     partners, "following [them] around, interrogating the children, eavesdropping on telephone
     conversations, and making frequent telephone calls to monitor [their] activities... Closely
     related to this is extreme possessiveness which is often manifested by the abuser's
     unwillingness to accept the end of the relationship."  (Adams, 1990)
     
     "Women ... are subjected to ongoing harassment and pressure tactics including multiple
     phone calls, homicide or suicide threats, uninvited visits at home or work, and manipulation
     of children.... Some abusers use their children as emissaries who are responsible for spying
     on mom's activities or for convincing mom to 'let Daddy come home'."  (Adams, 1990)
     
     Often when a victim has separated from her abuser, his harassment in the workplace leads
     to her losing her job.
     
         Abusive husbands and lovers harass 74% of employed battered women at work, either
       in person or over the telephone, causing 56% to be late for work at least five times a
       month; 28% to leave early at least five days a month; 54% to miss at least three full
       days of work a month; and 20% to lose their jobs.  (New York Victim Service Agency,
       1987; Schechter & Gray, 1988)
     
     Religion - Most organized religions are based on the premise that suffering on earth is the
     prerequisite for eternal life in Heaven.  Christians are taught, "God never gives you a
     burden greater than you can bear."  They are told to carry the cross of their pain and
     suffering just as Christ did, that suffering on earth is the price you pay to earn eternal life
     in Heaven.
     
     Romantic Relationships - The batterer repeatedly tells his victim, "If you leave me, no one
     will want you."  Over time, she comes to believe that and, when considering whether to
     leave, she has to confront the very real possibility that she will never have another
     relationship -- and accept that perhaps she will never have sex again.  Never again will a
     man touch her with love and caring.
     
     The Isolation of Stereotypes - Society's stereotypes reinforced by the abuser's
     psychological brainwashing form a powerfully effective section in the wall of isolation.  In
     an effort to evade a realization of their personal vulnerability to being victimized, the public
     accepts victim-blaming stereotypes about crime victims in general (Bard & Sangrey, 1986),
     and abuse victims in particular.  One of the most widespread stereotypes about battered
     women is:  Women are masochists -- they ask for it -- they stay because they like
     being beaten.  This myth is repeated as truth by people who know little or nothing about
     the reality of violent relationships.
     
     Battered women who are still hiding the violence of their home lives hear this "common
     wisdom" from friends, family, co-workers and the public so often that many become
     convinced of its truth, and believe that people will look down on them and be unwilling to
     help them.  Taught first by batterers and then by the stereotype that the violence is their
     fault, shame and fear keep victims silent.  So they stay in the relationship, afraid to turn to
     anyone for help for fear of being rejected and despised.
     
         "The propensity to fault the character of the victim can be seen even in the case of
       politically organized mass murder.  The aftermath of the Holocaust witnessed a
       protracted debate regarding the 'passivity' of the Jews and their 'complicity' in their
       fate.  But the historian Lucy Dawidowicz points out that 'complicity' and 'cooperation'
       are terms that apply to situations of free choice.  They do not have the same meaning
       in situations of captivity."  (Herman, 1992)
     
     Another common stereotype about battered women is the "Bad Faith" Stereotype.  This
     stereotype is described by members of the justice system as the woman who uses and
     abuses the abuse prevention process to manipulate and punish her male partner.
     
     The danger of this stereotype is illustrated by the Thurman vs. Torrington case.  Because
     the Torrington Police Department saw Tracey Thurman as a stereotype rather than an
     individual, they were blinded to her real danger -- which led to her being disfigured and
     partially paralyzed for life -- and to their having to pay her $1.9 million in damages.
     
     While some women, abused and not abused, certainly do "abuse" the system, and while
     one finds evil among some members of any group, the generally held stereotypes about
     battered women are not true of the vast majority of victims.
     
     Isolation strengthens and enforces abusers' use of the following tactics to demoralize and
     brainwash their victims because the victim has no one to turn to for a "reality check."  The
     tactics used by abusers have been defined by Amnesty International (1973) as
     psychological torture. Yet while world opinion can be mobilized and concrete sanctions
     imposed against countries which treat prisoners and dissidents in this way, even though
     they use these same tactics against women, abusers are rarely prosecuted or receive
     meaningful sentences. These tactics are the cornerstone of the brainwashing and
     manipulation used on P.O.W.'s, political dissidents and hostages as well as battered
     women:
     
     Verbal Humiliation and Degradation - This is not simply the use of foul language. It is
     unrelenting criticism and constant attacks on the victim's worth as a human being.  Who
     she is and what she does are never good enough.  It is not only the viciousness of these
     attacks that makes this tactic so effective -- it is the constant repetition of the batterer's
     denigrating messages.  Repeated humiliation is the abuser's strongest weapon. The
     messages that she is utterly worthless, and the cause of his anger and violence become
     part of the victim's self-image due to constant repetition of the same theme -- which he
     delivers verbally and reinforces with his fists.
     
     Self-blame is a common reaction to being victimized. (Bard & Sangrey, 1986)  But in
     addition to natural feelings of self-blame (it is easier to deal with guilt than the fear of
     reccurrence [Miller & Porter, 1983]), the abuse victim's self-blame is actively stimulated by
     her abuser, and her suffering minimized:
     
                   "'If we had a problem, it's because I loved her so much... Like all long-term
            relationships, we had a few downs and ups.... All this press talk about a rocky
            relationship was no more than what every long-term relationship experiences... At
            times I have felt like a battered husband or boyfriend but I loved her.'"  (Simpson,
            1994)
     
     Each of us forms our self-image from how others respond to us.  The more important a
     person is to us, the more we value and rely upon their opinion of us.  Women in our society
     are taught to believe that a partner's love is supposed to be the most important thing in their
     lives.  Success, financial gain, status and prestige are supposed to be secondary to finding
     a partner and keeping his love.  So, when the abuser rejects her, the victim has to admit
     to herself that she has failed in making what society has taught her was the single most
     important choice in her life, that of a husband or lover.  Thus, she has to overcome the
     socialization of a lifetime as well as her love for her partner, to reject his importance in her
     life, in order to discount his opinion of her.
     
     Threats of Harm - The abuser threatens to harm the victim, the children, her family, pets,
     treasured personal belongings; he threatens to abandon her and the children, to further
     isolate them, to snatch the children or to kill her, the children or himself.  These threats
     often include detailed descriptions of how he will harm or torture her loved ones.  In the
     beginning, the abuser's threats are usually ominously vague, and he may not carry them
     out.
     
     Gradually, "mere" threats alone become insufficient to maintain control over partner and
     children, so he begins carrying some of them out.  When he does act on his threats of
     physical violence, studies show that his victim's likelihood of injury is great:
     
         "Women suffering violent victimizations were almost twice as likely to be injured if the
       offender was an intimate (59%) compared to offenders who were strangers (27%). 
       Women were also [almost twice] more likely to receive injuries requiring medical care
       if the attacker was an intimate (27%) compared to a stranger (14%)."  (Bachman, 1994)
         
         "Domestic violence is the largest single cause of injury among women seen at hospital
       emergency rooms, more common than auto accidents, muggings, and rapes combined." 
       (Stark & Flitcraft, 1985)
         
         "[A]s many as half of the domestic 'simple assaults' actually involved bodily injury as
       serious as or more serious than 90% of all rapes, robberies, and aggravated assaults." 
       (Langan & Innes, 1986)
     
     Eventually the victim is constantly off balance -- a key factor in brainwashing -- because she
     never knows whether or when he will act on his threats.
     
     Enforcement of Trivial Demands - This tactic forces the victim to develop the habit of
     complying with whatever demands the abuser chooses to make.  Her life is governed by
     long lists of demands and rules:  how clean the house must be, how the children are to be
     disciplined or dressed or fed, having to account for how she spends her time, where she
     goes, whom she sees, etc.  Whatever an individual abuser's demands, when they are not
     met, he demonstrates his power with a variety of physical and psychological punishments. 
     The victim lives in a continual atmosphere of impending doom.
     
     Monopolizing Perceptions - The abuser  creates an atmosphere so dangerous that the
     victim becomes totally focused on remaining safe here and now.  Monopolization of
     perception is the psychological state which results from living in an atmosphere of fear and
     impending punishment created through the use of the psychological manipulative tactics
     discussed above by themselves or in combination with physical assaults.
     
     Because the outpouring of the abuser's rage is so unpredictable, the victim protects herself
     and the children by maintaining the family and the home in accordance with his ever-
     changing demands. Her time and energy are focused on the abuser and his impending rage
     over anything that may turn out to be "wrong."  She becomes exhausted by her constant
     efforts to totally control the home environment to pacify him:  controlling the children, pets
     and visitors; attempting to anticipate his whims and assuage his frustrations; and
     suppressing her fear, sorrow and rage, which, if revealed, will lead to punishment.
     
     Taught that they can be punished for virtually anything they say or do, the victim and
     children become afraid to make choices, to do anything on their own.  For abuse victims
     and their children, as well as POW's and hostages, all aspects of life relate only to how the
     batterer/captor will react. They "walk on eggshells," constantly trying to read the captor's
     mind to anticipate his wishes and thus deflect his anger.  Abuse victims become totally
     absorbed in arranging every aspect of their lives to keep him calm.
     
     Since abusers use precisely the same techniques as terrorists, it is completely logical that
     battered women suffer the same psychological effects as hostages. Subjected to these
     tactics on a daily basis, victims also isolate themselves out of shame, believing that they
     have failed their partners and thus are failing at what society has taught them throughout
     their lives are the most important roles a woman can assume -- wife, mother and
     homemaker.  Trying to do better, but never succeeding in ending the beatings, they become
     depressed, apathetic and despairing.  Abusers constantly tell them the abuse is their fault,
     and they hear from their families as well as his, "You've made your bed, now lie in it."  Even
     the children, who dare not confront the abuser, release their tension and fear by blaming
     their mother for not pleasing him and avoiding the violence that terrifies them.
     
     The tremendous isolation in which the victim lives causes her to derive too much of her
     identity and self-esteem from the batterer, so when he rejects her with verbal degradation
     and beatings, the entire foundation of her self-esteem is demolished.  Her learned belief in
     her personal unworthiness and her blame for the violence makes her isolate herself from
     family and friends who may also blame her for not keeping the violence in check.
     
     Walled in by outsiders' attitudes, victims come to believe there is nowhere they can turn for
     support, much less assistance.  The victim is forced to take on the abuser's perspective of
     her because she has found that when she reaches out for a different viewpoint, she is too
     often rebuffed.
     
     Eventually, the mental cage the abuser has erected around the victim becomes as strong
     as the walls which confine and isolate the hostage.
     
     
     Condition Three
     
     
     The captor threatens to kill the victim and is perceived as having the capability to do
     so.
     Threats of death are a nearly invariable feature of life with an abuser.  And the almost
     universal threat of batterers who kill their victims is the chilling:  "If I can't have you, no one
     will."  Because we see this threat so often repeated in media reports about those murders,
     victims are well aware of the danger represented by such threats -- and abusers recognize
     the power they can gain by making the same threat.  These threats become real when
     looking at the statistics:
     
         From 1976 to 1987, of all deaths resulting from one partner killing another (married,
       common-law, ex-married, dating), 61% of victims were women killed by male partners,
       and 6% of male victims were killed by female partners.  (Browne & Williams, in press,
       1992; Bureau of Justice Statistics, 1989)
     
         100% of Vermont's female homicide victims in 1993 are believed by law enforcement
       authorities to have died at the hands of an intimate partner or family member.  (Martinez,
       1994)
     
     So the victim decides it is safer to stay and endure an occasional beating than to leave and
     be murdered -- an entirely reasonable choice.  The victim's focus narrows to her and her
     children's short-term safety rather than long-term security through escape.  But at this point,
     the victim is no longer her husband's or lover's partner -- she is his prisoner.
     
     
     
     Condition Four
     
     
     The threatening person is perceived as showing some degree of kindness to the
     victim being threatened.
     Kindness is the cornerstone of the Stockholm Syndrome.  Stockholm Syndrome will not
     develop unless the captor exhibits some kindness towards the victim.  If the captor/batterer
     is purely evil, the victim responds with hatred.  But if the captor/batterer shows some
     kindness, in the midst of terror the victim submerges the hatred s/he feels in response to
     the terror, and concentrates on his/her captor's good side in order to protect him/herself.
     
     In many abusive relationships, the abuser is contrite and apologetic after an abusive
     incident.  This is called the Honeymoon Stage of the Cycle of Violence.  (Walker, 1979) 
     Following a period during which the tension between the couple builds to a violent
     explosion, the abuser, filled with remorse, promises with genuine sincerity of his
     repentance.  Wanting to believe him, and convinced by his sincerity, the victim convinces
     herself that it was not really that bad, and that he can change.  So the abuser convinces
     the victim and everyone else (including himself) that he can and will stop being violent.  He
     excuses his violence by blaming stress or alcohol or drugs.  At the same time he is making
     excuses to deny full responsibility, he also offers justification to deny wrong-doing --
     primarily blaming the victim for provoking him:  "If you were a better wife, I wouldn't lose my
     temper."
     
     Often the psychological confusion and shock of the traumatic incident cause both victim and
     perpetrator to minimize, deny or suppress the details of the violence. The couple rebounds
     in warmth and intimacy. It is at this time that the victim is most thoroughly victimized
     psychologically because his manipulation of her emotions leaves her feeling responsible
     both for him and for her own victimization.
     
     It must be remembered that, like most relationships, when it began, the relationship was
     probably satisfying.  Since no one is 100% bad, or 100% good, even despite the battering,
     there are aspects of the relationship which remain rewarding, and with many batterers who
     never go beyond the stage of moderate assaults, the beating may be infrequent.
     
     The bonding between captive and captor called the Stockholm Syndrome "is no longer
     considered unusual by professionals who negotiate with hostage-takers.  In fact, they
     encourage its development, for it improves the chances of the hostages surviving, despite
     the fact that it means the officials can no longer count on the cooperation of the hostages
     in working for their own release or in later prosecuting the hostage-takers."  (Graham &
     Rawlings, 1991)
     
     As shown above, all four of the conditions which cause Stockholm Syndrome in the hostage
     are recreated by abusers within abusive relationships.  Although the Stockholm Syndrome
     is caused in both hostages and battered women by virtually identical treatment, the way
     these two groups are treated by the outside world is very different (Graham, et al., 1988):
     
         Public authorities sympathize with hostages, seeing them as having little control over
       their situation, and media coverage generates public sympathy.  In contrast, abuse
       victims are blamed for their situation:  "She deserved it."  "Why doesn't she just leave?" 
       "She stays because she likes it."
     
         Authorities are likely to negotiate for the release of hostages. Hostages are generally
       released from captivity or rescued by the State.  Battered women, however, must find
       a way to leave their captivity more or less on their own, and rarely are abusers
       imprisoned -- unlike kidnappers and hostage-takers.
         
         Negotiations for the release of hostages are not dependent on their proving that they
       are targets of physical violence nor that they did not desire or provoke it.  But unless a
       battered woman can prove she was subject to life-threatening violence, the legal and
       criminal justice systems are often unwilling to intervene.
         
         Governments attempt to capture and punish hostage-takers while abusers are rarely
       punished, even for decades of abuse, unless the woman or children are killed.
     
     During the ordeal of Flight 847, businessmen changed in a mere ten days.  However,
     research shows that a terrorist captor can achieve the "conversion" effect of the Stockholm
     Syndrome with a stranger in less than 4 days using the psychological torture tactics
     mentioned earlier.  In contrast, a batterer has months or years - sometimes decades --
     to use precisely the same tactics to terrorize a victim made much more vulnerable because
     she loves him.
     
     As one victim put it, "It's hard to find an enemy who has outposts in your head."
     
     
     
       
          
     
     
     
     
                     CLINICAL PERSPECTIVE: 
                                
                   THINKING BEYOND THE OFFICE
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     If you can, help others; if you cannot do that, at least do not harm them.
       Dalai Lama
     
     
     
     
      Thinking Beyond the Office*
     
     Working as a therapist is always a challenging undertaking. Our clients are complicated
     individuals, living complicated lives. For many reasons, some related to the therapy process
     itself and some to social and institutional prescriptions, we usually work in individual offices
     and our clients come to us. They bring their pain, confusion, and problems with living with
     them, and expect that we will be able to help them with our knowledge of human
     psychological functioning, behavior, and relationships.
     
     Because we sit face to face with an individual, or a small group of individuals, our
     perspective on our clients' lives is limited by the window our clients provide us. We see
     these lives through the client's words, posture, appearance, mood, behavior, tone of voice
     - all the things that make up a person's "presentation" at this particular moment in this
     particular place. We can expand that window by asking questions and by paying attention
     to the variations and consistencies that emerge in our interactions. To a large extent our
     skill as therapists is dependent on our ability to create a coherent, accurate picture of our
     clients from our office perspective and to present that picture to our clients in a way which
     helps them find new choices and directions.
     
     Our window is also formed by the professional training we have received.  While training
     programs vary by discipline (psychology, social worker, addiction counseling, etc.) and also
     to some extent within disciplines by theoretical orientation and training philosophy, they
     share a common emphasis on the individual or the small group (e.g. the family). This
     training and our ongoing involvement in our profession provide a framework for organizing
     our thinking about our work; we take in information about our client and arrange it in a way
     which allows us to relate this person to what we know about people in general, to define the
     problem at hand, and develop a plan for treatment. Without this framework we would have
     no way to make sense out of what we observe and no way to decide on one course of
     action. 
     
     Because we are defined as mental health professionals, our training has taught us to relate
     our particular clients to our body of professional knowledge through the use of diagnostic
     categories. These categories were developed (at least in principle) to help us identify
     patterns of behavior, emotions, and thinking which are indicative of identifiable and distinct
     problems and which can thus be linked to treatment plans which are appropriate for each
     particular problem.
     
     The general acceptance of a diagnostic framework in our profession has allowed us to
     share information about human problems and treatment in a common language. Thus,
     when one professional talks about developing a treatment approach for depression, for
     example, we know what depression looks like and which of our clients fit that category,
     which ones might be helped by this new treatment approach. We are not forced to reinvent
     the wheel each time we work with someone new, and we can decide which information
     about our new client is relevant to helping this person.
     
     However, like any cognitive framework, this mental health approach must produce order in
     all this complexity by deciding which information is significant and which questions (and thus
     which answers) are relevant. In doing so, the approach also defines what information is
     seen as not significant and therefore ignored, and which questions are not asked, which
     answers are not heard. This realm of the irrelevant and unseen, however, is usually defined
     by default (defined by what it is not), rather than deliberately and explicitly. This inevitably
     creates blind spots in our professional thinking, leading us to miss or discard information
     which really is relevant and which will affect the treatment we give our clients and thus will
     affect our clients.
     
     The training manual of which this chapter is a part is intended to help mental health and
     victim service providers work together toward the common goal of helping individuals who
     come to either one or both of us. We have been working on how to coordinate our efforts,
     acknowledging that often neither of us has everything a survivor needs. Since what we
     each have to offer is different, we use different frames of reference for organizing our
     thinking about what we observe and for deciding on a course of action. Becoming more
     aware of the roles trauma and victimization play in our clients' "mental health" can help us
     see beyond our offices, into territory which may have been defined as irrelevant within our
     professional discourse but which often holds information which leads to a much more useful
     understanding. To the extent that understanding the problem more completely leads to
     more effective solutions, we are likely to be more effective in our own treatment plans and
     to recognize both the need for and the usefulness of services we do not provide. When we
     expand our awareness beyond our offices, we can expand our own professional framework,
     and also avoid the error of thinking all of reality can be reduced to what is known, or even
     knowable, within that framework.
     
     This chapter will start with certain assumptions or guiding principles based on this
     willingness to see beyond what is professionally familiar:
         First, we work with people, not disorders. If we forget this, we will limit our understanding
       of our clients by reducing them to what can be contained within any diagnostic
       framework.
         Second, psychological, physical, and social factors can only be separated abstractly. In
       our clients' lives they form a cohesive whole. If we want to be effective we cannot forget
       these interrelationships even if we only work directly within a psychological perspective.
         Third, we benefit from exploring the territory beyond professionally accepted definitions
       of relevant knowledge. We can expand our own frame of reference and we will
       recognize when to make referrals outside our system.
     
     Integrating Awareness of Victimization into Treatment
     
     While most of us are trained to take a psychosocial history as part of the treatment process,
     often that history is only poorly connected to the diagnosis and treatment plan. Awareness
     of a past history or the present experience of trauma, abuse, and/or intimidation should
     have an effect on the way we think about everything we do, and can often mean that the
     presentation we observe will have a very different meaning and significance than it might
     in the absence of this history. Unfortunately, all too often the significant integration of the
     person's past history into treatment decisions is identified with a specific theoretical position
     (psychoanalytic/psychodynamic). Even when this history is seen as a causal factor in the
     current "condition," the diagnosis itself and the general treatment plan are often developed
     solely on the basis of the current presentation and even before any history is taken.
     
     
     Diagnosis
     
     
     The diagnostic framework within which most mental health professionals work is codified
     in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental
     Disorders (DSM-IV). It is intended to provide a set of commonly agreed upon criteria for
     conditions which can be recognized with consistency and are clearly distinguished from one
     another. The assumption is that if we can identify a condition accurately we will be better
     able to differentially apply treatment strategies and techniques, as well as facilitate
     professional research and dialogue. The DSM's diagnostic categories and the criteria for
     inclusion in each are deliberately based only on observable signs and symptoms, and are
     intended to be theoretical, to make no assumptions about etiology, and to avoid being
     culturally specific.
     
     The usefulness of such a framework is not in question. As a profession we do need to be
     able to understand each others' references. The DSM categories provide a useful reference
     point, allowing us to define our areas of agreement as well as disagreement. Even when
     we do not use this particular conceptual framework in organizing our thinking about our
     clients, the existence of this "standard" often helps us define our own positions more clearly
     by having a clear contrasting position and allows us to communicate our position more
     clearly to colleagues.  
     
     However, this professional standard has also been subject to appropriate criticism. For
     example, the DSM and its categories and criteria are largely the product of a particular
     subgroup within the mental health field, psychiatry, and are therefore strongly affected by
     the assumptions and world view of this medical profession. While other professional groups
     have had a consultative role in the development of the most recent diagnostic system, the
     farther these groups have been from the medical experience, the less voice they have had.
     For instance, social workers have not had the influence that clinical psychologists have had,
     and voices from outside the recognized mental health professions (such as victim service
     advocates or community advocates) have only had an impact on the process indirectly, and
     only to the extent that they have been heard by and have affected the "insider" participants
     in the development process.  
     
     This has clearly limited the final product by restricting the information used in creating it to
     that which psychiatry as a whole considers relevant and with which it is comfortable, most
     notably the tendency to see human suffering in terms of diseases and disorders of the
     individual. Thus the diagnostic categories are not organized in terms of "disordered
     relationship patterns" (which might lead to categories such as "shame-based disorders" or
     "disorders related to abusive use of power") or painful individual consequences of social
     and cultural norms (such as "social class related disorders" or "bias and discrimination
     related disorders"). These would not necessarily be better diagnostic categories, but they
     would be equally legitimate ones and would lead to the inclusion of information which is
     dismissed as irrelevant within a medical perspective but which may be equally relevant to
     the life experiences of our clients.
     
     We also need to be aware that the development of these diagnostic criteria are not even
     an objective reflection of a unified medical perspective. The field is characterized by a
     multitude of theoretical perspectives which inevitably means that the final document is going
     to be a compromise, an attempt to find a framework which is inclusive and which allows for
     discourse and common definitions across these varying positions. Also, the debate over
     categories and criteria reflects the pressure of factors which are outside the realm of
     professional discourse and which are not acknowledged openly in either the categories or
     the official discussion of the development of the conceptual framework (such as the social
     and economic interests of the different professions in the mental health field, and the class
     and power differences between professionals and clients/patients). DSM-IV and all its
     predecessors are inherently social and political documents, but the effects of these forces
     cannot be recognized unless we step outside the limited perspective of the field.
     
     In addition, the attempt to provide a diagnostic system which is not limited by cultural factors
     has produced a document in which cultural variation is acknowledged only in the
     introduction to the manual. We are cautioned (in the introduction) that these factors must
     be "taken into account" (although there are no guidelines as to how to do this) and that we
     should modify our interpretations of clients' reports of symptoms based on awareness of
     varying cultural meaning systems. The bias toward minimizing the cultural limits of this
     diagnostic system is shown both in the absence of cultural variations in the diagnostic
     categories and criteria themselves, and in the inclusion of an appendix titled "Outline for
     Cultural Formulation and Glossary of Culture-Bound Syndromes" as if the rest of the
     manual were not a cultural formulation. 
     
     What are the implications of these professional realities for our work with survivors?  In
     short, be aware of the limits of our diagnostic system.  Respect the usefulness of its
     potential for organizing our understanding and informing our decisions, but do not confuse
     it with a complete picture of our clients' lives, or even psychological experience.
     
       More specifically:
     
         Do a history before you assign a diagnosis. This increases the  probability that you
       will take experiences such as trauma and abuse into account.
     
         Always be aware that the diagnosis is only a means to an end, that it helps you
       as a therapist relate your clients' problems to a body of professional knowledge.
       It is potentially useful for both you and your client, but is not adequate as or a substitute
       for an understanding of your client as an individual.
     
         Communicate this limited meaning of the diagnosis to your clients.  Allow them
       to know that the diagnosis is a useful tool, not a description of them as people. Let them
       know what it tells both of you about the similarities of their experiences to those of other
       people, and what it does not tell you about the uniqueness of their experience.
       
         Use the diagnosis as a shorthand description of a collection of signs and
       symptoms not as a description of or a label for the person. Be careful in your use
       of words, and not just in front of your client. We aren't working with depressives, or
       borderlines, or even PTSDs. If we force ourselves to refer to our clients as people with
       symptoms consistent with depression or PTSD we are more likely to stay aware of the
       full range of factors affecting their functioning and experience. 
     
         Remember that the context in which signs and symptoms occur affects their
       meaning and therefore the significance in making a diagnosis.  Confusion in the
       midst of a traumatic experience has a different significance than confusion without
       trauma. Feelings of powerlessness in the face of real social powerlessness is not
       necessarily a symptom of a depressive episode.
     
         Use the diagnosis to identify problems rather than to pathologize the client. This
       means seeing the strengths and functional aspects of their behaviors as well as the
       dysfunctional ones. If you identify your clients as dysfunctional you make it difficult for
       both yourself and them to see their strengths and resources. When we validate the
       functional aspects of their behavior and the legitimacy of their emotions and needs, we
       can also identify their problems and dysfunctional behavior in a way which empowers
       them.
     
     There are several diagnostic issues that are relevant in working with clients who have been
     abused and/or traumatized. One of these is the use of personality disorder diagnoses on
     Axis II. Therapists need to be aware that abuse can affect both the way the diagnosis is
     made and the implications of the diagnosis for treatment. A personality disorder is defined
     as "an enduring pattern of inner experience and behavior that deviates markedly from the
     expectations of the individual's culture, is pervasive and inflexible, has an onset in
     adolescence or early adulthood,  is stable over time, and leads to distress or impairment
     (DSM-IV, p.629)."  
     
     Because by definition they are characterized by persistent patterns of problematic behavior,
     it is often easy to see these disorders as inherent to the individuals themselves rather than
     looking closely at the context in which these patterns developed and are maintained. Abuse
     in childhood, especially if it is prolonged, repeated, and ignored, can lead to the
     development of patterns of reaction and behavior which are functional in the context of the
     limited options open to children but become dysfunctional in other contexts. In addition,
     these patterns become incorporated into the child's view of the world and to the developing
     sense of personal identity. The children, and later the adults, make the same error that the
     therapist can make so easily - confusing the adaptations they have made to intolerable
     situations with characteristics inherent to themselves as individuals.
     
     Once the personality disorder is equated with the person, the diagnosis can have several
     negative implications for treatment. In many ways, personality disorders represent extreme
     manifestations of human emotions and reactions. However, the needs of these clients are
     often seen as evidence of the disorder. The needs thus become symptoms to be
     eliminated, whether it be the need to be taken care of (dependent personality disorder), for
     attention (histrionic personality disorder), or for attachment (borderline personality disorder). 
     
     
     Clients often experience pressure to change as pressure to eliminate the self, and even
     when they are profoundly unhappy with their current situation, self protectiveness will set
     up strong ambivalence about therapy. Recognizing that the underlying needs are valid,
     while clearly acknowledging that the patterns developed to meet them are dysfunctional,
     allows both therapist and client to identify the client with the underlying human needs rather
     than the "enduring patterns of inner experience and behavior." In this context, naming the
     abuse the client has experienced and recognizing the effects it has had can be a powerful
     way of breaking connection between destructive adaptations and the self. This process can
     be particularly empowering to clients, since it allows them to see change as taking care of
     themselves rather than as a betrayal of self.
     
     One other way that the diagnosis of a personality disorder can have a negative impact is
     that it can lead both therapist and client to focus attention on the client's distorted reactions
     to events, and thus minimize or ignore abuse or victimization in the present. While this can
     sometimes be difficult, clients need to be encouraged to recognize abusive behavior and
     take effective action to protect themselves. Therapists need to be aware that just because
     a client has learned, for example, to complain constantly (having not been listened to in the
     past when she stated something was wrong), it does not necessarily mean that there is an
     invalid basis for the client's complaints. Therapists need to remember that these clients are
     still vulnerable to abuse and exploitation in the present, and if that is ignored it increases
     the need to act out their needs in extreme ways.
     
     Some similar concerns arise in using diagnoses related to alcohol and/or drug dependence.
     Substance abuse often starts as an attempt to self-medicate overwhelming pain. Over time,
     the person comes to believe that survival depends on using and identifying with the
     substance use: "this is just who I am; I'm not strong enough to survive without this."
     
     In an attempt to get substance abusing clients to take responsibility for their behavior in the
     present, many individuals and programs reject any discussion of past abuse (or even
     present abuse) as avoiding responsibility, denial, or excuse-making. Acknowledgment of
     their deep emotional pain by these clients is seen as self-pity. However, if the only
     alternatives given to clients are denial of the addiction or denial of their pain and the real
     effects of abuse, they essentially have only destructive options - a replay of the situation
     they've been in from the beginning.
     
     Denial and avoidance of personal responsibility are certainly characteristic features of drug
     and alcohol addiction. However, one of the difficulties with the diagnosis is that once seen
     as an addict, everything else about the client may be seen through that filter. A history of
     abuse and victimization is not less significant simply because the person developed a
     pattern of substance abuse to cope with the effects. Also, current abuse is not less
     significant because it happens to someone who is drunk or high. If anything, people who
     are substance abusing are more likely to be victimized, and the abuse and exploitation may
     be even more harmful because it confirms the person's negative experience of self and
     others.  To minimize the seriousness of victimization in these contexts is to reduce the
     person to a diagnosis, to reinforce the sense of worthlessness and powerlessness (as if it's
     OK this happened to them because they're addicts), and to give the person no constructive
     way to deal with the effects.  
     
     When the seriousness of the abuse is recognized and the reality and validity of the clients'
     pain is acknowledged, sobriety can be experienced as healing and self-care rather than as
     punishment. Assuming responsibility for one's own life and behavior can be seen as
     empowering rather than an admission that s/he has been "acting like a victim." Recovery
     can and should be seen as a profound act of resistance to the pain inflicted on the person,
     and in this way it is a refusal to assume blame for the destructive behavior of others.
     Recovery is also a willingness to assume responsibility for the harm we have done to self
     and others. Clients must be helped to do both, and the reality of the second should not be
     allowed to invalidate the first.
     
     
     
     Safety Issues in Working with Survivors
     
     
     Therapists working with survivors (and with any client, for that matter) need to be aware
     that the potential for abuse and exploitation by others is an ongoing reality for everyone.
     Survivors may be particularly vulnerable to injury in this way not because they create or
     seek abusive situations, but because their ability to recognize danger, to be self-protective,
     and to defend themselves effectively may be reduced as a result of earlier abuse.  Clients
     should be helped to understand this, and recognize their vulnerability so that it can lead to
     efforts to protect themselves more effectively (empowerment) instead of self-blame and
     hopelessness.  
     
     Many survivors recognize the pattern of repeated trauma and abuse in their lives, and come
     to see themselves as having been "singled out" for bad things. This leads to a sense of
     inevitability, as if something about them makes them "magnets" for destructive people.
     Often therapists make the mistake of trying to undermine this way of thinking by arguing
     that the survivor is not special in this respect, that bad things happen to everyone.
     However, this approach may have the unintended effect of invalidating the survivor's
     accurate perception that victimization has become a pattern and minimizing the significance
     of the pain that is experienced. Survivors need to recognize and take seriously any abuse
     or threat of abuse as a first step toward changing this pattern.
     
         Don't be afraid to acknowledge a survivor's continuing vulnerability to abuse and
       victimization. What survivors need is the clear message that this vulnerability is in part
       a negative side effect of earlier efforts to protect themselves from the pain and fear of
       traumatic experiences and in part the result of the social distribution of power. They can
       thus be empowered to make changes without blaming themselves for the vulnerability
       itself. 
     
         Do a careful assessment for current abuse and exploitation, and repeat this
       throughout the therapy process. Don't assume that if abuse isn't occurring at the time
       of the initial assessment that it isn't occurring later. Don't assume that your client will
       volunteer this information, or accurately represent its seriousness.
     
         Don't accept clients' assessment of danger and/or harm at face value.  Survivors,
       especially those in currently abusive or threatening situations, often deny or minimize
       danger or injury as a way of managing their own feelings of vulnerability. When clients
       say that the situation isn't that bad, they may be reporting their assessment of the
       treatment they deserve or the degree of their emotional numbing more than reporting
       the actual danger. Ask specific questions, and point out the discrepancies between their
       reports of actual behaviors or events and their evaluations or interpretations of those
       behaviors or events.
     
         Make safety from harm by others a first goal in therapy. In order for survivors to
       deal with prior trauma they have to begin to believe they will not be overwhelmed by the
       emotions associated with that trauma. Part of this belief is based on knowing that the
       abuse belongs to the past rather than to the present.  If the survivor is being abused
       currently, or there is a real threat of abuse, without effective ways to deal with the
       current situation, the survivor may actually be overwhelmed and therapy will end up
       confirming all the fears that have held the dysfunctional patterns in place.
     
         Make referrals and help clients to make use of community resources.  As a
       therapist you cannot protect clients and you should not try. Nor should survivors
       be encouraged to think they can handle dangerous situations on their own. Know
       what is available in your community and how to help your clients gain access to
       these services. (Victim service providers are good sources for this information.)
     
         Do not encourage clients to make themselves vulnerable in situations in which
       they really have no control. Do not encourage clients to confront abusive or
       exploitative people if there really are no effective constraints on the perpetrator's
       behavior or if the clients really have no way to escape or protect themselves. Do not
       involve perpetrators in the survivors' therapy if the survivors are still vulnerable
       to attack or victimization once they leave your office or if you cannot protect the
       survivors from harm (physical, verbal, or emotional) in your office. This means
       that most couples counseling in cases of domestic violence or family counseling
       involving perpetrators and child victims should involve separate therapists for victim and
       perpetrator, and risks should not be taken with the victim's safety in the interests of a
       systems approach to family dysfunction.
     
     Self-harm or self-injury/mutilating is often an issue in the treatment of survivors. It is a
     distressing behavior, often as much or more for the therapist than for the client. Self-injury
     can take physical forms, such as cutting or hitting, or it can take internal forms, such as
     internal verbal abuse or the intrusion of painful images or memories. As self-destructive as
     these behaviors appear to be (and are), they have usually developed as a way of managing
     even more painful injuries and emotions and are therefore difficult to give up. Clients must
     be given alternative ways of meeting this need if they are to give up behaviors which have
     given them at least some protection.
     
     Physical self-injury can be the hardest for therapists to tolerate, and it is easy for them to
     communicate their panic to the clients. This can both frighten and shame the clients
     (although this is rarely the therapist's intent), and lead to efforts to hide the behavior to
     protect or please the therapist. This may make the therapist more comfortable but does
     nothing to help the clients.
     
     Internal self-injury can be just as self-destructive but is obviously even easier to hide. It is
     common in survivors and can serve the same variety of functions that physical self-injury
     does (e.g., self-punishment, either stimulation or numbing of emotions, a trigger for
     dissociation, reinforcing a sense of control and strength, etc.).
     
     Survivors are often frightened and ashamed of this behavior, seeing it as evidence that they
     are crazy or bad. Efforts to "control" it by trying to stop usually end in failure, increasing the
     fear and shame. Survivors often feel sure that if anyone knew they would be rejected, or
     worse. They usually cannot see the connection between the trauma and the self-injuring
     behavior, and so it feels like there is no reason for the behavior other than their "craziness"
     or "masochism." 
     
     Self-injuring behavior can be a serious threat to survivors' safety, even when it is not
     suicidal in intent. When it is used to manage emotions and intrusive thoughts and images,
     the behavior may escalate dangerously in times of greatly increased stress or crisis. If it
     occurs in the context of dissociative episodes, survivors may have a reduced awareness
     of their actual environment and therefore a reduced capacity for self-protective responses.
     Internal, non-physical self-injury can be equally dangerous. It leads to repeated trauma, with
     all the negative psychological effects of any trauma. Because it almost always involves a
     degree of dissociation, it reduces awareness of the external environment and increases the
     survivor's vulnerability. It may also lead to extremely risky behavior, such as driving in an
     impaired condition. Therefore the behavior should be clearly and directly approached as a
     safety issue.
     
         Do a careful assessment for self-injury, both physical and psychological. This
       assessment should include both an evaluation of the behavior and an evaluation of the
       behavior's functions. This is the first step in treatment, and it communicates to the
       survivor that the behavior is neither meaningless nor crazy.
     
         Do a careful evaluation for suicide risk as well as self-injury. This will help you
       distinguish between behavior which is self-destructive in intent and that which serves
       other purposes but in self-destructive ways.  Both are serious problems, but may require
       different interventions.
      
         In treatment, focus on finding alternative ways to meet the functions served by
       the self-injury, not just on eliminating the destructive behavior. This keeps the
       focus on positive change and allows both therapist and client to build on the survivor's
       strengths and impulses toward self-protection. Direct assaults on just the behavior
       almost always lead to failure, frustration, and shame (for both therapist and client) and
       can severely undermine the therapy.
     
         Recognize your limits. As with harm from others, the therapy relationship cannot
       provide a protective cocoon for survivors. Your role is to help them find and use the
       support systems available.
     
     
     Medication Issues in Working with Survivors
     
     
     Medication can play a useful role in the healing process for survivors since victimization and
     trauma have physical as well as psychological consequences. However, when all painful
     or uncomfortable emotions are automatically defined as symptoms of a mental disorder,
     medication may be used inappropriately in ways which actually hinder the resolution of
     traumatic events. In addition, survivors may be given the message that there is something
     wrong with them (i.e., they should be reacting differently) when emotions and behavior are
     evaluated only as symptoms.
     
     Strong, difficult emotions such as sadness, fear, and anger are human responses to painful,
     frightening events and need to be experienced, identified, and given meaning by survivors.
     However, if these emotional reactions have persisted over extended periods of time without
     the survivor having the opportunity to express and understand them, they may overwhelm
     the survivor's physical and psychological ability to respond to people and events in the
     present. The distinctions between past and present, danger and safety, abusers and
     non-abusers can become blurred.  For example, the sadness and grief that is an
     appropriate response to significant loss, if unresolved, may undermine the body's ability to
     maintain a stable mood and the survivor may become not just sad but depressed.  
     At such times medication may provide not only relief but may help the survivor sort through
     emotions more effectively and recognize the source of the original grief. Similarly, chronic
     hyperarousal may interfere with the body's ability to regulate arousal, and the survivor may
     experience anxiety and panic that is not clearly connected any more to present events.  If
     the therapist does not recognize the possibility of such physical consequences of trauma,
     clients may become unnecessarily frustrated and discouraged in therapy.
     
     On the other hand, the current emphasis in much of the mental health field, especially
     among psychiatrists, on the biochemistry of mood and anxiety disorders often leads
     therapists to focus on physical symptoms and to label disturbances in mood or emotion as
     "biochemical imbalances." This often leaves survivors believing that their reactions to
     abusive experiences and situations are caused by their biological inability to "handle stress."
     It is too easy to go from this belief to a treatment focus on changing the survivors rather
     than on helping survivors change their situations, and medication can become the logical
     way to eliminate or change the survivors' reactions. Within this framework, behavioral,
     cognitive, and emotional interventions become only additional ways to change a disordered
     client.
     
     While it is unreasonable to ignore the physiological changes that can and do result from
     victimization and trauma, there are several ways therapy can become less effective if our
     perspective on our clients becomes too heavily biological. We can easily collude with
     survivors' (and society's) self-protective denial about the reality of victimization and abuse,
     supporting their efforts to minimize the seriousness of the abuse by maximizing their sense
     of weakness and "dysfunction." We can turn the goal of effective coping into increasing the
     capacity to tolerate the effects of abuse, powerlessness, injustice, and so on by focusing
     on managing mood and emotional reactions to events.  
     
     If we see human pain primarily in terms of biology, we are also less likely to ask questions
     about why these clients might have become emotionally or physically overwhelmed. We are
     less apt to consider the answers to these questions as relevant to treatment, and thus less
     prone to direct our clients' attention to changing the problems in their lives, or to recognizing
     the problems in society as a whole. Problematic behavior patterns are also less likely to be
     understood (by both therapists and survivors) as positive attempts to manage the effects
     of abuse if the emotional reactions themselves are seen as symptoms of a biological
     disorder. The strengths and resources (both physical and psychological) of survivors are
     likely to be ignored or minimized.
     
     Thus, the biological effects of victimization need to be taken into account, and medication
     may be a useful part of treatment. However, it cannot be the focus of treatment when
     victimization and trauma are involved without masking the meaning of our clients' emotional
     responses.
     
         Evaluate the biochemical factors in your clients' experience only as part of the
       total picture, so that emotional and cognitive responses are not seen in isolation.
       For example, a family history of depressive episodes may be important because it helps
       us understand the way trauma may affect this particular survivor, but it does not make
       genetic vulnerability to depression the cause of the survivor's problems, nor should it be
       allowed to distract therapy from trauma issues or to make the survivor's pain seem less
       appropriate or "unhealthy."
     
         Medication should be considered when the survivor's depression, anxiety, or
       other emotional responses overwhelm the ability to protect themselves (from
       self-harm or injury by others), or the ability to use psychological resources to
       process the trauma and make constructive changes in the environment. It should
       not be used to avoid painful emotions in all circumstances because this would prevent
       real confrontation with the abuse and/or trauma.
     
          Know your psychiatric referral base. Make sure whenever possible that the
       psychiatrists to whom you refer survivors are familiar with victimization issues, and are
       willing to work with you as the therapist providing psychological treatment. Also, make
       sure the psychiatrists understand the importance of other service providers (such as
       victim services providers) and are willing to work with them.
     
     
     
     Evaluating Outcomes in Therapy
     
     
     The way each individual therapist evaluates the outcome of the work with a client depends
     a great deal on the therapist's theoretical framework.  However, there are some general
     principles which apply to psychotherapy work with survivors and which cross disciplines and
     theoretical perspectives.
     
     
         The evaluation of outcome always needs to look at the survivor as a whole
       person. The reduction of painful or uncomfortable emotions cannot be evaluated as
       positive if abuse or victimization is continuing or if past trauma is still being
       re-experienced internally. Under these circumstances the absence of emotional pain
       would indicate that adaptation to the trauma was still requiring responses that maintain
       your client in a victim position (such as dissociative reactions to abuse or the
       psychological numbing of depression which would interfere with taking effective action
       to end the abuse).
     
         A positive outcome in therapy should include  re-establishing survivors'
       connections to the community. This involves a sense of belonging, of being
       supported by a network in which their experience is recognized and taken seriously. It
       also involves a sense of empowerment, of being able to take effective action which has
       an impact on others. This sense of empowerment incorporates not only an ability to act
       on their own behalf, but also a sense of commitment to change in their communities,
       although this commitment can take many forms. A therapist truncates survivors' healing
       by treating it as only an internal, psychological process.
     
     Therapy in the Context of the Survivor's Life
     
     A therapist working with survivors tries to create a safe space in which survivors' voices can
     be heard, often for the first time. The therapy relationship and the actual meeting space are
     thus to some extent protected from the stresses of the "outside." However, the healing
     process itself is not and cannot be protected in this way. It occurs in the context of the
     survivor's entire life, and is affected by all the stresses and needs which are part of that life.
     Therapists must therefore recognize that since healing, rather than therapy, is the ultimate
     goal, these stresses and needs must be addressed if therapy is going to be helpful to the
     survivor.  
     
     At the same time, however, the therapist's usefulness to the survivor will be reduced if the
     therapist tries to deal directly with all these issues.  The therapist would be taking on more
     than any one person can do, and therefore inevitably leave too little time and energy for
     therapy. Also, if the therapist becomes too directly involved in other areas of the client's life,
     the therapy relationship can no longer be as protected and safe as it needs to be. The
     therapist needs to find a way to keep therapy clearly connected to the rest of the survivor's
     life, and at the same time protect therapy's unique place within that life. This necessarily
     means helping clients find and maintain other relationships in which many needs and
     stresses can be more effectively addressed.
     
     While the therapist cannot effectively assume responsibility for addressing all of a client's
     needs, the therapist must know what these needs are, how they are affecting the client's
     life, and how to help the client address them effectively. Not assuming responsibility for
     meeting these needs is not the same as ignoring them. One of the most effective links to
     effective help is the victim services provider, and therefore the active involvement of these
     provider networks can create a supportive environment for therapy.
     
     Survivors may have any number of unmet needs and stresses which negatively affect the
     quality of their lives. More specifically, these stresses can undermine the healing process,
     keep the client locked in a cycle of revictimization, block healthy growth and development,
     and limit the client's ability to nurture those who are dependent on the client (especially
     children, who become caught in the victimization process without the ability to act on their
     own behalf). Basic needs such as food  and shelter are often provided by abusers. Even
     when these are not directly linked to tolerating abuse, the lack of basic necessities, or the
     threat of losing them, is obviously going to increase the survivor's feelings of hopelessness
     and powerlessness.  
     
     Survivors, like everyone else, also need to know they have access to physical and legal
     protection from victimization. Unfortunately, the justice system does not have a good record
     on providing this protection to many of those most vulnerable to victimization. Having an
     advocate who is familiar with these social institutions and who can facilitate their effective
     use is often critical, and this advocacy is the role of the victim services provider.
     
         Be aware of, and help your clients be aware of, needs which you are not able to
       address directly. Survivors are often not good at identifying these needs, since they
       may have learned to tolerate or deny deprivation and insecurity in order to reduce pain
       and anxiety.
     
         Be aware of community resources and make your clients aware of these.  This
       does not mean you must become the link between the client and these services, but that
       both you and the client maintain an awareness of the client's connections, or lack of
       them, to community providers and resources.
     
         Do not be afraid to facilitate these connections. You do not need to step out of your
       role as therapist to believe these needs are important and to act in a way consistent with
       that belief. You can facilitate the survivor's use of community resources by addressing
       psychological barriers to reaching out to safe and supportive individuals and groups. 
       You also need to recognize that your social position (both personal and professional)
       may give you more influence and access than your client (e.g., doctors may listen to you
       more seriously because of your professional status). See yourself as part of this larger
       social network and participate in it in ways that are useful to your clients.
     
         Work with your client to find the balance between active collaboration with other
       service providers and protection of the privacy and safety of the therapy process.
       This balance will be somewhat different for each survivor.  However, it is up to you as
       a therapist to understand how therapy differs from other helping relationships and to be
       clear (with yourself and your clients) about what you as a therapist can and cannot do
       for your clients. You thus communicate that you can be relied on without setting up
       unrealistic expectations for therapy or setting up other providers as competitors.
     
     
     When thinking about community resources for clients, it is important not to restrict thinking
     to social agencies or institutions which are defined as "helpers." Other social institutions and
     groups, such as churches, unions, and neighborhood groups, can provide important
     experiences of validation, support, and empowerment. (Be aware that these groups may
     provide opposite experiences as well for many survivors.) Because survivors have often
     learned to keep their experiences and needs secret, they may have little practice in
     matching specific needs with the resources offered by others. They may even have difficulty
     differentiating among their many needs.  
     
     
     In these circumstances their own neediness and the helpfulness of others may be seen in
     very black and white terms; dependency/help-seeking jumps back and forth between zero
     and 100 per cent. Every relationship (sometimes every interaction) can become a test
     (either consciously or not) of the survivor's own right to need help and/or of the other
     person's ability to help and be trustworthy. When this occurs, survivors who do risk
     reaching out often find themselves experiencing repeated disappointment and betrayal even
     with those who are trying sincerely to help. Learning how to make more differentiated
     requests for help and to recognize the value of what a particular person has to offer can
     transform the survivor's life from a series of disappointments into a network of specific
     sources of support. Conversely, learning to recognize the limits of even the most supportive
     people can help protect the survivor more effectively from victimization in the future,
     because trust does not have to be either an all or nothing process.
     
     Understanding the difficulties that survivors often have in differentiating their needs and
     their trust is vital to therapists working with them. We are much less likely to become
     defensive in response to our clients' disappointment, anger, and frustration with therapy and
     with us as therapists if we understand how necessary it has been for them to avoid
     "mistakes" in trusting or needing others. It becomes easier to communicate that it is safe
     to rely on us as therapists without getting caught in trying to prove that we will never
     disappoint or fail them (an impossible task since they have needs we cannot meet).  
     
     Recognizing the difficulties involved in learning to trust others in less than black and white
     ways is also very important if we are going to work collaboratively with other providers and
     with the survivor's support system. While it is critical to validate the client's experiences of
     hurt, disappointment, anger, and so on in dealing with the other person, this needs to be
     done in a way which does not distort the total relationship.  Survivors may need help
     evaluating relationships in ways which take into account both positive and negative
     experiences. They need to feel empowered to take negative experiences seriously enough
     to do something about them, but they also need to know that all relationships involve
     negative experiences and that healthy relationships can deal with hurt, anger, and other
     difficult emotions. If we as therapists jump too quickly to "defend" our clients and reduce
     their experiences with others to a defensive black-and-white perspective, we may
     inadvertently reinforce the distorted view of reality which the original victimization created. 
     
     The same principles are involved in helping clients establish a support network among
     friends and family. If therapists see other people in the survivor's life only in terms of
     dysfunction or of their potential for harm, then clients are put in a position of either
     defending them (against us) or becoming isolated from them. Also, by leaving so little room
     for other people to make mistakes and be imperfect, we may make it difficult for clients to
     recognize or acknowledge their own mistakes and imperfections without overwhelming
     shame. This is not to say we should minimize or excuse abusive or destructive behavior,
     but we need to remember that human relationships should not be oversimplified. 
     
     We also need to help survivors learn how to draw the best from the friends and family on
     whom they rely. Often these supportive people are left floundering in the dark because
     clients can't explain what they need or what they are experiencing. Survivors may be afraid
     or ashamed to talk to others, or may just not know how. Therapists may recognize that
     friends and family are important but often make unjustified assumptions about the way
     support is available to individual clients. For instance, many therapists assume a survivor's
     husband "should" be her closest emotional support, when it is often a friend or sister. If a
     therapist considers involving immediate family members in therapy for survivors,
     interventions involving significant others with less socially recognized ties should also be
     considered. The other person may be provided with education and information which would
     be helpful in the relationship and therefore to the survivor.  
     
     Specific relationship problems related to the unrecognized effects of the earlier victimization
     can be addressed in ways which empower the survivor and also model effective
     communication. Other people may be able to help the clients identify and use resources
     available in their social and physical environments of which the therapist is not aware.
     Helping others who care about the client find ways to effectively provide support is often a
     great relief to both the survivor and the other people. Also, involving close friends as well
     as family in the healing process can help break down the isolation created by shame and
     can strengthen the experience of emotional closeness for both the survivor and the other
     person.
     
     However, care needs to be taken when involving other people in a survivor's therapy. The
     therapist needs to consider both the impact on the therapy relationship and on the client's
     life outside the therapy session. Safety concerns always need to be addressed (see
     previous section on safety).  Also, clients need to feel they have control in the therapy
     relationship and that others, well-intentioned or otherwise, will not supplant the survivor in
     the working relationship with the therapist.
     
         Work with the survivor carefully in planning any involvement by others.  Listen
       to your clients' descriptions of their social worlds. Set goals with which your clients are
       comfortable and be as specific as possible.
     
         Be very careful to address issues of confidentiality. Your client should feel in control
       of what is revealed and under what circumstances.
     
         Remember, others are being enlisted as your client's allies, not yours. Do not
       allow others to change the primary partnership that exists between you and your client.
     
     Another source of social support that may complement individual psychotherapy is group
     work - support groups, self-help groups, and therapy groups. Groups can do many things
     that individual therapy cannot.  They can reduce the feelings of isolation and shame that
     are so common among survivors, giving them a place to both speak and listen, to discover
     both their commonalties and uniqueness. Groups also allow survivors to experience
     themselves as both helping and being helped by the same people, thus creating an
     atmosphere of mutual empowerment. Groups can also increase a survivor's awareness of
     personal strengths and resources very effectively. In many groups there is an expectation
     that people will be more open and direct than is often the case in other social settings.
     Survivors often receive feedback from other participants which can challenge assumptions
     and attitudes that have their basis in defensive reactions to past abuse. 
     
     Not all of these types of groups function in the same way, however. While these labels are
     sometimes used differently, in general the types can be distinguished both by their structure
     and their goals. Therapy groups are led by trained therapists, who assume a different kind
     of responsibility for monitoring and directing the group process than other participants. 
     Therapists also do not participate in the group interactions in the same way other
     participants do, therefore, since they should not allow themselves to get so focused on their
     own issues and reactions that they cannot observe and respond to the whole group's
     dynamics. This often allows therapy groups to address more difficult, potentially disturbing
     issues in more safety, since interactions among members are being observed and can be
     stopped, examined, and redirected when necessary. Therapy groups also are more likely
     to have an explicit goal of facilitating change, and members expect to be challenged to
     examine and change their ways of thinking, behaving, and feeling.
     
     Support and self-help groups vary greatly in their structure and can often be defined
     generally only by the lack of a therapist leader. Support groups may or may not have a
     designated facilitator, but that person does not usually have the same responsibility for the
     group's process as a therapist would and may participate more fully as an equal group
     member. Self-help groups do not usually have a designated leader or facilitator, although
     group members may take on responsibility for specific group functions. The groups may
     have consistent participation by the same members, or may have no such expectation of
     commitment to attend regularly, functioning more as "drop in" groups that members use
     when they are in need or want. The goals of these groups are often less specific, and may
     vary greatly among members in any specific group. Often there is more emphasis on
     support rather than on promoting a specific type of change or growth. Because
     responsibility for the group's functioning lies squarely with the members, these groups can
     often be very empowering, but may also be a less protected environment for dealing with
     issues which feel overwhelming or  which make the individual feel very vulnerable.
     
     Therapists should help each client evaluate potential group participation in terms of the
     individual's needs and goals. Just like relationships with individuals, relationships with
     groups can be more or less helpful, and can even be destructive or abusive. Thus, the
     survivor has really two types of questions to consider when thinking about whether to
     participate in a group. Does the survivor have needs which could be potentially addressed
     in a group, and if so, what type of group would meet those needs best? And does this
     particular group, with these particular members, function in a way which works for the
     survivor? Because a group setting is often very frightening to survivors who are used to
     hiding their thoughts and feelings, the individual therapist can often be very helpful in both
     facilitating this connection, and in helping survivors evaluate their participation in a way
     which validates their experiences but does not reinforce their negative expectations (of
     themselves or others) which are based on past abuse rather than the actual group
     behavior.
     
     A special issue which comes up when looking at therapy in relation to other parts of the
     survivor's life is that of the therapist as an "expert witness" in legal proceedings involving
     the survivor. Therapists need to be very aware that the structure, goals, and rules that
     apply in psychotherapy are very different from those that apply in the legal arena. Legal
     proceedings are based on an adversarial process intended to resolve conflicts either
     between individuals or between the state and an individual. The goal is most certainly not
     healing. Therefore if therapists decide to become a witness in a legal proceeding, they need
     to recognize that their role as a healer, and even the effects that the proceedings may have
     on the survivor, become irrelevant. Therapists who make this choice must recognize that
     they have become participants in an adversarial process, and that they will be challenged
     in ways which may have little or nothing to do with their therapeutic relationship with their
     clients. The rules that govern what is relevant in a courtroom are very different that those
     that govern what is relevant in the therapy room.
     
         Don't go into any legal proceeding unprepared and uninformed. Know what it is
       you will be expected to be an expert on - your client's psychological functioning, the
       effects of abuse on behavior in general, some other specific question. You need to seek
       advice and information.
      
         Being an expert witness is not the same as being an expert therapist. An expert
       witness must also understand what it means to give legal testimony, not a topic typically
       covered in a therapist's training. You can do your clients more harm than good if you
       think that your knowledge of psychology is enough to make you a good witness. If you
       are interested in doing legal advocacy as a therapist, get specialized training.
     
         Exposing the therapy relationship in a courtroom will change the relationship.
       Sometimes these changes are predictable, sometimes they are not. Often there are at
       least temporary negative changes, and it may be difficult to restore the sense of safety
       around the therapy relationship.  Discuss this issue clearly with your clients. Make sure
       that both of you understand that you may be asked tough questions which you will be
       required to answer, that the questions will be asked in ways which serve the purposes
       of the two opposing sides, not in ways which necessarily promote a full understanding,
       and that you will often not be given an opportunity to qualify or explain your answers. 
       
     The Therapy Relationship
     
     The relationship between the therapist and the client is really the cornerstone of all good
     therapy, and the principles of all good therapy also apply to therapy with survivors.
     However, there are some special issues that may come up in working with survivors which
     affect the way those principles are applied.
     
     
     Believing Survivors
     
     
     Survivors have often been forced to keep secrets in order to survive, either because they
     or others on whom they depended were directly threatened with harm if they did not or
     because they believed that speaking out would lead to harm, rejection, or shame. Over
     time, they may have difficulty believing themselves, since there is little or no external
     validation for their perceptions or memory. For this reason, their attempts to speak about
     their experiences are often extremely difficult and they will monitor the reactions of their
     therapists carefully for signs that they are not believed.  
     
     A  therapist who works with survivors must be prepared to listen carefully and with respect
     to their accounts of their experiences. However, believing that clients are telling the truth
     about their experiences is not the same as accepting their perspective as complete or their
     interpretations of events as objective reality. We do our clients no service by accepting
     uncritically everything they say, since we would often end up reinforcing the distortions they
     have developed to protect themselves from overwhelming pain or fear. For instance,
     survivors often believe that they are somehow responsible for abuse they receive at the
     hands of trusted others such as parents. Survivors may believe that parents were abusive
     because they were trying to correct bad behavior; that the abuse was actually an indication
     of parental love. Believing this may have protected them from having to face the fact that
     they were dependent on adults who were actually dangerous.  
     
     Therapists must help survivors speak of all the pieces of their experience and find their truth
     in the total picture that emerges. Some of that picture may continue to contain uncertainty,
     since there will always be some things which cannot be known or understood completely.
     Survivors need to learn to trust themselves to know and speak their own truth, not to trust
     us to tell them the truth of things of which we have no direct knowledge. If we recognize that
     there are inconsistencies in their interpretations, or if other possible interpretations have
     been ignored, we help them find their truth by pointing this out.  
     
     This is true for obvious distortions such as believing abuse is an indication of love; it is also
     true for assuming the only alternative is that abuse indicates hate. At the same time, every
     interpretation and assumption survivors make tell us something about the reality of their
     lives and experience (e.g., why would a child need to deny any anger with an abusive
     parent?). We help our clients to listen to themselves by listening carefully and respectfully
     to everything they say and not rushing too quickly to certainty about an objective truth.
     
     
     
     Commitment to Clients
     
     
     Working with survivors, especially those who have experienced victimization in childhood
     and/or repeated victimization, may require an investment of time and energy which is
     somewhat different from that required by other clients. If we encourage survivors to face
     the full psychological and emotional reality of their victimization, we are also de-stabilizing
     the systems they have developed to manage their emotions.  They need to know we are
     there to help them through the transition period until new systems have been developed.
     Especially during crisis times, this may mean having more flexibility about meeting times,
     phone contacts, etc.  There may be an extended time in which we are the only ones with
     whom survivors feel safe to speak the truth, and therefore we will be a critical source of
     validation when they feel doubt and fear. 
     
     We also need to recognize that we cannot assume responsibility for single-handedly
     changing survivors' negative experiences. We cannot be available at all times, always able
     to meet their needs. The clearer we can be with our clients about what we can and cannot
     do, the less likely we are to leave them feeling like we have betrayed the trust we promised.
     However, it is also important that we make it clear that their needs are legitimate, even if
     we are not able to meet them all, since survivors have often been given the message that
     their needs are unreasonable (or even that any needs are unreasonable). Finding the
     balance between the flexibility they require and recognizing our own limits can be difficult
     but is important. We should discuss this issue openly, and as often as needed, with our
     clients. Also, consultation with supervisors and colleagues who have experience working
     with trauma and abuse is very important in maintaining this balance.
     
     Within many traditional approaches to psychotherapy, therapists are encouraged to
     maintain a "neutral," emotionally uninvolved stance in relation to clients. "Services" are
     provided in ways that are regulated by the therapist alone, and attempts to change these
     rules by clients are often interpreted as "manipulative." (The diagnosis of borderline
     personality disorder is often both the source of and justification for these interpretations.)
     However, this approach to therapy can have negative consequences for survivors, for
     whom lack of control has been associated with injury and violation. Survivors need to know
     that they have influence in the therapy setting and that they have an effect on the therapist
     as a human being in order to feel safe and begin to develop trust.  This does not mean that
     they need to be in complete control, only that they need to know their feelings and needs
     are being taken into account. Therapists need to be comfortable sharing control in working
     with survivors. 
     
     Showing emotions in the context of human reactions to the survivor's experience can also
     be an important source of validation for the survivor, and a highly effective way of modeling
     healthy ways of expressing emotions. When working with survivors, therapists who feel a
     strong need to control all emotional expression may end up putting more energy into
     protecting themselves than into attending to their clients, since much of this work is
     emotionally difficult. Because their trust has been so violated by others on whom they felt
     dependent in the past, survivors often assume the worst in their interactions in the present.
     For this reason, they may need more feedback about what their therapists are thinking and
     feeling than would be true for other clients. This feedback can also be an effective way to
     begin challenging distorted perceptions and beliefs.
     
     Survivors may also be labeled "manipulative" if they attempt to control the therapy in
     indirect, covert ways. It is important that therapists recognize that this indirectness has often
     been developed as the only safe way to influence their social environment. If clients have
     "hidden agendas" in their interaction patterns, it may be because staying hidden was
     essential in their efforts to survive; to meet the needs that could not be addressed safely
     in more open ways.  
     
     When therapists interpret clients' behavior as attempts to control the therapists rather than
     as the clients' attempts to meet their needs the only way they know how, the therapists are
     more likely to react defensively and to set up a struggle for power in the therapy. If the
     therapist feels that this covert process is occurring, it is much more effective to redirect the
     interaction by helping the client identify the needs that are being addressed this way, and
     then deal with these needs more openly and directly. This not only reinforces the sense of
     mutual respect and control, undermining any struggles over power, it also models new ways
     of interacting and exerting power that the client can use outside the therapy setting.
     
     The realities of social services in this country provide other challenges to a therapist's work
     with survivors. Many therapists work in settings which do not give them many options in the
     work they do with clients, severely limiting the frequency and timing of sessions, the access
     clients have to their therapists between sessions, the kinds of therapy that can be provided,
     and so on. Therapists who have to work within these restrictive conditions can help clients
     identify and validate all their needs, can support their efforts to meet some of those needs
     in other settings, and can advocate for clients within the therapists' agencies and with
     funding sources. In these circumstances, coordination of services with victim services
     providers can be especially important. 
     
     Though limited, the psychological services therapists can provide in these situations can
     be useful in and of themselves, and may help empower survivors to take their experiences
     and needs seriously and seek out additional help. However, recognition of the inadequacy
     of these services can be very difficult for therapists, who may be left feeling disempowered
     and discouraged. Just as for our clients, it is important for us to seek out support for our
     work, validation for our perceptions, and the empowerment that activism in the community
     can give us.
      
     
     
     The Effects of Personal History on the Therapy Process
     
     
     This topic is usually addressed in terms of transference and countertransference. However,
     these words have been used in very imprecise ways in the professional literature.
     Originating in psychoanalytic theory, transference referred to the client's tendency to react
     to the therapist in ways that unconsciously identify the therapist with significant others in the
     client's life. Countertransference is the same process, but involving the therapist's reactions
     to the client. The words are currently used much more generally by those who do not
     necessarily have a psychodynamic orientation to refer to the way both client's and
     therapist's personal histories affect their perceptions of and reactions to each other.
     
     Because the work with survivors is often emotionally intense and requires so much
     openness to emotional experience on the part of both client and therapist, it makes sense
     that both are likely to feel quite vulnerable. For survivors this means that defensive
     strategies that protected the survivor in the past are going to be used in the therapy and
     with the therapist. Clients try to fit their therapists into the conceptual and emotional
     frameworks they have developed over the years, giving their therapists roles that are based
     on the survivors' abusive histories. Some of these roles can be quite flattering to the
     therapists, and can provide a great deal of emotional gratification.  
     
     Therapists can be seen as rescuers, strong and decisive. They can be seen as perfect,
     nurturing parents; as kind and tolerant lovers; as powerful authority figures; as brilliant,
     intuitive seers. It is critical, for the sake of both the client and the therapist, that the therapist
     recognize these perceptions as expressions of the survivor's unmet needs, and not confuse
     these perceptions with their self-identification. Accepting these perceptions in self-gratifying
     ways is ultimately harmful to the clients, at best leaving distortions unchallenged and at
     worse setting them up for yet another betrayal by someone on whom they had a right to
     depend. However, telling survivors that they are "wrong" and that their perceptions are
     invalid (only transference) only encourages them to hide these perceptions and rarely
     changes them, pushing them underground in the therapy interactions. Helping clients use
     these perceptions and wishes to understand their past experiences is another way of
     recognizing the ongoing effects of earlier victimization, of validating their experience without
     reinforcing the problematic adaptations they have had to make.
     
     Sometimes the roles that clients impose on therapists are not so flattering. Many survivors
     have learned to protect themselves by staying on the alert for injury or betrayal. They may
     feel less vulnerable seeing the therapist as an uninvolved "professional helper" for whom
     the survivors are just another job. They may see therapists as weak and ineffective when
     they cannot make everything better quickly for their clients; as rejecting and uncaring when
     they set limits or are not immediately available; as critical and punitive when they give any
     "negative" feedback; as sexually seductive when they express caring or concern.
     
     Perhaps the most distressing role for therapists who have worked hard to establish trust
     and safety with their clients is to be seen as abusive, to be identified with the survivors'
     abusers in any way. It is very difficult for therapists not to respond to these perceptions
     defensively, feeling hurt and angry, arguing their innocence. As with the more "positive"
     distortions, therapists must be able to see these confusions for what they are, and help
     clients recognize how victimization has become incorporated into their understanding of
     themselves and others.
     
     It is important to note that awareness of transference processes should not be used to
     deflect and explain away all negative feedback we get from clients. If clients have
     complaints, we need to listen carefully and respectfully. We do make mistakes, and when
     we do we need to acknowledge them and apologize. This is not only ethical behavior on our
     parts as therapists, it is also an important way of helping our clients learn how to trust their
     ability to recognize injury in the present. Often when clients have complaints about us or our
     behavior, there is both a real problem in the present and a transferential interpretation of
     that. We need to help our clients sort these out and find effective solutions.
     
     Just as clients have experiences and needs which affect the way they react to the therapist
     and the interactions in therapy, therapists bring their experience to their interactions with
     clients. Therapists need to be constantly aware of the potential for our own experience to
     affect our interpretations and emotional reactions. Do frustration and "setbacks" in therapy
     trigger feelings of hopelessness or doubts about our competence, leading us to seek
     reassurance from our clients that things are going well in therapy? Are we so uncomfortable
     with being seen in sexual ways by our clients that we cannot address our clients' sexual
     feelings or thoughts?  Are we afraid of being taken advantage of, and therefore react
     defensively to our clients' expressions of neediness or disappointment? Do we need our
     clients to like us so much that we discourage expressions of anger with us or avoid
     confrontations when they are needed? These are just some of the ways that our own issues
     can be brought into our work, interfering with therapy. A relationship with a supervisor
     and/or colleagues whom we trust with personal information is important in examining these
     reactions in an ongoing way.
     
     Working with survivors can have special significance for therapists who are also survivors.
     They may identify strongly with their clients, and care deeply about their clients' healing and
     recovery. This common experience can be helpful in many ways for both therapist and
     client. It can facilitate both understanding and empathy on the part of therapists.    
     
     If the therapists have experienced their own healing, it can powerfully reinforce feelings of
     hopefulness which are communicated to clients both directly and indirectly, and which can
     support the therapists through the difficult periods in therapy. However, it is really important
     that therapists be able to distinguish their own experiences and those of their clients. If a
     therapist's identification with the client means the therapist's own sense of safety can be
     undermined by the client's victimization or difficulty making changes in abusive
     relationships, then a therapist is likely to feel anxious and insecure and communicate this
     doubt and fear to the client. If a therapist's own anger at her/his abuser is allowed to be
     directed at the client's abuser, the client's anger may remain hidden or get distorted, or the
     client may fall back on a defensive protectiveness of the abuser.
     
     It can also be distressing for a therapist, who is also a survivor, to be perceived as abusive
     by a client that the client's transference cannot be addressed. Therapists who are survivors
     need to know their own limits in terms of how much stimulation of their own pain and fear
     they can tolerate without becoming defensive in ways which make therapy impossible. They
     need to be willing to balance their desire to help other survivors with respect for their own
     needs.
     
     
     
     Social Roles and Expectations
     
     
     Social roles, the culturally defined sets of behaviors associated with particular positions in
     society, affect the way all of us interact with one another. We often use these social
     definitions to guide our own behavior and expectations of others without conscious
     awareness we are doing so.  We may sometimes actively reject aspects of these
     definitions, expanding our perceptions of others beyond the restrictions of their assigned
     roles.  Usually we are doing both. Whichever attitude we assume at a particular time, we
     cannot escape the influence of our culture since we must deal with it whether we resist or
     accept its prescriptions for ourselves and others.
     
     The ever present reality of social roles is an important consideration in all therapy, since the
     basis of therapy is the interaction between two individuals who exist within particular cultural
     contexts. Usually discussions of this issue encourage therapists to be aware of the cultural
     and social position of clients, and how these factors affect the clients' behavior, thinking,
     and emotional reactions. While this is certainly important, it is just as important for
     therapists to be aware of their own social and cultural context, and the way these affect
     their behavior, thinking, and emotional reactions.  
     
     Often those who participate in the status and privilege of culturally dominant positions (who
     are white, middle or upper class, male, or heterosexual) are unaware of the extent to which
     their own roles are just as culturally determined as those of groups who stand out as
     different from the culturally dominant norms.    
     
     Both "normal" and "different" are culturally determined and both need to be examined by
     anyone who wants a comprehensive understanding of another person's experience. It is
     important to remember that even identification with a particular group is at least in part a
     question of social assumptions and norms (for example, an individual whose genetic
     heritage is one-tenth African and nine-tenths European would still be identified as African
     American by most people in our society; another person who is one-tenth Irish and
     nine-tenths German would be unlikely to be defined as Irish American). Also, social roles
     are usually talked about in terms of group differences; they actually define similarities as
     well.
     
     In the arena of social roles we are rarely if ever dealing with "different but equal." Social
     groups are arranged in complex patterns of relative social status. Status is an expression
     of a particular socially defined group's perceived social value and power in relation to other
     socially defined groups. Social value and power are expressed in a wide variety of ways:
     the group's share in the distribution of limited resources; the incorporation of a group's
     interests into social policy; the visibility of a group's perspective in the media and the arts;
     and so on.    
     
     The behavior of individuals is often judged in relation to the status of the group with which
     they are identified. For example, becoming a medical doctor will have different significance
     to others if the individual is female or African American rather than a white male; it may be
     perceived as an exceptional accomplishment, as a threat, as an aberration. Similarly,
     becoming an auto mechanic would be seen differently if the person is the son of an upper
     class white family rather than of a working class family; it may be perceived as a shame,
     as an act of rebellion, as a failure. Power, the ability to influence and direct the social
     environment in which we live, often derives from the shared power of the groups with which
     we are identified. Without the collective power of the group's recognized authority and
     influence, we become isolated and vulnerable.
     
     These forces clearly affect the therapy process as well, as both therapists and clients view
     each other through the social lenses of roles and status. While this social context cannot
     be escaped, it can be made visible, and challenged when necessary. Awareness of the way
     social position has shaped the experiences of both the therapist and the client is important
     if both are going to fully understand the client's experience. Unrecognized differences
     between therapist and client in the way events are interpreted can lead to misunderstanding
     and the inability to build a working relationship.
     
     For survivors in therapy this can mean the reinforcement of emotional isolation, shame, and
     negative images of the self. It can be experienced as a re-enactment of the invisibility and
     silence that have been so destructive in the past. When therapists are unaware of or deny
     the effects of their own social power and privilege relative to their clients, the therapists
     actually make it difficult to cooperatively construct a therapy environment in which clients
     can experience their own power and value. At worst this lack of awareness can lead to an
     abuse of power (either intentional or not) which further victimizes survivors and confirms
     rather than changes their experiences and beliefs.
     
     There are many different types of social roles which are relevant to therapeutic work with
     survivors (as well as with other clients). Gender roles are clearly of central importance,
     since these have such significant implications for both personal experience and for social
     power. Gender roles are particularly important in the dynamics of domestic violence
     (including all kinds of abuse which occur in the context of personal relationships) since
     gender is an organizing concept in the structure of the family and intimate relationships of
     all types. Thus, the experience of victimization will be different for men and women, and will
     also be affected by the gender of the perpetrator. Male against female abuse is so common
     and familiar, and so supported by social norms which make "normal femininity" almost
     equivalent to the role of a victim, that the victimization of women becomes invisible and
     hard to recognize.
     
     Cultural and ethnic differences also affect the way abuse is experienced, and therefore the
     effects it will have on the individual. There is great variation in the norms governing what
     behavior is socially acceptable, how violations of acceptable behavior should be handled
     within the group, and when and how such violations should be revealed to "outsiders."
     Abuse will also be experienced very differently when it occurs within a group (when the
     survivor sees the perpetrator as a member of the same cultural community) and when the
     perpetrator is perceived as an "outsider." When group ties form the basis for a strong
     identification with the perpetrator, the confusion, sense of betrayal, and difficulty with anger
     and assigning responsibility can be reinforced (as when abuse occurs within a family).
     When the abuse occurs across socially defined groups differing in status and power, these
     social differences can increase the sense of threat, powerlessness, and inadequacy that
     are created by the victimization. Therapists need to be aware of these larger social issues
     and help their clients become aware of them as well if the survivors are to become
     effectively empowered to identify and challenge all aspects of the abuse.
     
         Start with yourself; increase your own awareness of how your background and
       social position affect your thinking and behavior. Do not make the mistake of
       thinking only your clients' lives require examination, and use every confusion and
       miscommunication that occurs in therapy to increase your awareness of the
       unconscious assumptions you carry. This will make it easier for you to recognize the
       influence of culture on your clients, and not mislabel these differences between you as
       evidence of pathology.
     
         It is your responsibility to be informed about social differences. If you are going
       to be working with someone who comes from a different social background, learn all you
       can about the experiences you do not share. If there is a social gap between you, it will
       require both of you to work to build a bridge; don't make your client do all the work.
       Remember, survivors have already had to do too much adapting to a social world in
       which their experiences are invisible or discounted.
     
         Understand that social structure is complicated and that each individual has
       connections to many groups. Inner-city Jewish experience is not the same as
       suburban Jewish experience, but individuals from both settings will have things in
       common not shared by their inner-city and suburban neighbors from other ethnic
       groups. Class, gender, geographical location, education - these and other factors will
       affect experience within a cultural group, just as cultural background will affect the
       meaning of gender, class, and so on.
     
         Remember you cannot completely rise above or eliminate the effects of social
       status and power in the therapy relationship. For instance, a male therapist cannot
       erase his social status and power, and the meaning this would have for a female client,
       no matter how much he would like to have equality. By acknowledging this social reality,
       however, he can validate the client's perceptions and create a climate in which the client
       can be empowered to challenge these social roles. In this environment, they can
       together find mutual respect and power based on their ability to create common ground.
     
         Know your limits when dealing with social differences between yourself and your
       client. Especially for clients who are survivors, differences between you such as gender
       can be powerful triggers for emotions associated with abuse. If these reactions are too
       strong and cannot be balanced out early in therapy by other factors which foster a sense
       of safety, they can overwhelm the best efforts to establish a working relationship. This
       is when a referral to a different therapist is appropriate. It does not mean that you have
       failed as a therapist, only that you cannot be all things to all people.
     
     Some clients with whom we work are particularly vulnerable at least in part because of their
     identification with social groups which have little or no status and power within this society.
     Awareness of these areas of vulnerability is important in working with survivors who have
     already been injured by abuse of power.  
     
         Previous history of involvement with the mental health system. Individuals who
       have been labeled as mentally ill often have difficulty being heard and believed when
       reporting abuse or victimization. Once their credibility has been questioned, their
       descriptions of their experience are often explained as symptoms of their illness. Also,
       these individuals are often perceived as socially marginal and without powerful
       advocates or defenders, and therefore may be seen by perpetrators as safe targets for
       victimization. Thus, current or previous mental health problems may increase a person's
       chances of being abused and reduce their ability to deal effectively with abuse when it
       has occurred. While the cognitive and emotional disturbances that characterize mental
       illness certainly distort perceptions and experience (for instance, in psychotic
       conditions), we cannot automatically assume that accounts of abuse are unfounded. It
       is our responsibility to listen carefully to our clients, perhaps even more so when their
       ability to comprehend their environment is compromised in some way.
     
         Substance abuse and dependence. Many of the same concerns apply to individuals
       who are struggling or have struggled with addiction. Their credibility is often in question,
       and they are also often marginalized. For these reasons they may be easy targets for
       abuse and less able to defend themselves. In addition, social attitudes toward
       substance abuse are still quite punitive, and these survivors are often seen as
       responsible for abuse that occurs when they are intoxicated. They are often perceived
       as undeserving of sympathy, or less seriously affected by abuse than more "innocent"
       victims. Conversely, perpetrators (particularly male) often are "excused" for their
       behavior because they were "under the influence."
     
         Dependence on others for protection. Those groups of people who are dependent
       on others for basic physical and social needs are also more vulnerable to victimization
       and less able to seek help on their own. These vulnerable groups include both the
       young and the old, for whom social stereotypes also involve diminished credibility.
       Financial dependence often restricts the ability to stop abuse by those on whom the
       survivor is dependent (as in much domestic violence). It also restricts a survivor's
       access to basics needed for healing: safety (such as a safe place to live), legal
       protection, medical services, and certainly mental health services. Others who are
       vulnerable at least in part because of their dependence on others are those with
       physical and mental conditions which limit their ability to function independently. When
       the social and physical environment presents obstacles to even day to day living for
       these individuals, victimization and abuse can be overwhelming.
     
         Socially powerless and stigmatized groups. In order to address issues of
       victimization, someone else has to be willing to listen and care. There is little of this
       interest and caring on the part of those with power for some groups of people; abuse
       and hardship may be seen as normal and even acceptable for these less powerful
       groups. This is especially true for the poor and near poor. Also, in order for someone
       to speak out about abuse, it has to be safe to be seen and heard. For stigmatized
       groups this is often not the case. Their safety in this society may depend on being
       invisible, and seeking help may involve being identified and further victimized by those
       who should be providing help. This is often the reality of day to day life for lesbians and
       gay men, for whom harassment and abuse are often socially tolerated or even
       encouraged.
     
     Often vulnerability to abuse is confused with responsibility for abuse. It is important as
     therapists to be clear that it is not the nature of the victim that defines abuse, but the nature
     of the perpetrator's behavior.  We do not determine whether a behavior is abusive based
     on how hard or easy it was for the perpetrator to commit. Being less protected, or less able
     to defend oneself, is not the same as inviting abuse. This is a distinction that is important
     to help survivors make. 
     
     Sometimes therapists have difficulty addressing issues of vulnerability with their clients
     because the therapists do not want to imply any victim blaming. While vulnerability is never
     a cause of abuse, vulnerability to abuse is still a serious issue and needs to be addressed.
     Feeling better able to protect themselves is an important goal for most survivors, and
     recognizing areas of vulnerability is one step toward that goal.  
     
     In some cases there is little that survivors can do to eliminate a particular area of
     vulnerability. In this case, empowerment can mean developing the resources the survivors
     do have, finding other sources of strength both within themselves and within their
     communities. Acknowledging limitations and vulnerabilities should not be the same as
     helplessness or resignation to continuing victimization.
     
     In other cases there are things survivors can do to reduce their vulnerability to abuse.
     Survivors can become more aware of their right to say no. They can address problems
     related to alcohol abuse. They can leave abusive relationships. These personal changes
     are often difficult, in part because past abuse reduces survivors' self-confidence. However,
     making a commitment to change can be an important way for survivors to reclaim their
     power, and limit the continuing effects of the abuse.      
     Systemic Obstacles to Effective Therapy with Survivors
     
     
     Many of the factors which affect the work we do as therapists operate within a much
     broader framework than the therapy relationship, or even the sum total of the relationships
     in our clients' lives. Social and economic forces shape what resources are available, who
     will have access to these resources, and under what conditions. Currently there is little
     consensus in our society about the appropriate social response to the needs of survivors,
     and even about the nature and extent of the problem of victimization. Much progress has
     been made increasing awareness of the extent of violence and abuse and of the
     consequences of abuse for both the individual victim and the society as a whole. However,
     a predictable but still frightening backlash has developed in response to this progress.
     
     
     
     The Backlash
     
     
     In its broadest form, the voices of the backlash object to the focus on victimization. They
     argue that identifying the frequency of abuse and addressing its long term effects
     encourage the development of a nation of "victims" who are paralyzed by self-pity and ready
     to blame others for their current difficulties. To the extent that the problems of abuse and
     violence are addressed at all within the backlash, they are seen as relatively minor,
     abnormal events or as the behavior of an isolated criminal element rather than as a part of
     the fabric of American life. Victims are encouraged to "leave the past behind them" and not
     expect any "special treatment" because of the abuse. Often the focus is shifted away from
     the survivors' experiences and on to the effects on other people when survivors speak out.
     For example, the disruption of family ties becomes more significant than the abuse that
     occurred within that family, or the price the survivor has to pay to maintain those ties. 
     
     The message of the backlash has a powerful effect on both survivors and the therapists
     who work with them. It leaves survivors doubting their emotions and perceptions,
     sometimes even the reality of their experiences.  The backlash defines survivors as the
     problem, reinforcing the messages of their victimization. It fosters a minimizing of the effects
     of abuse, making it difficult for survivors to effectively address them. And it encourages
     survivors to automatically put their own needs second to those of others, including the
     needs of others to be shielded from the truth.
     
     The voices of the backlash have become powerful and organized, often making survivors
     feel even more unsafe and afraid to speak out or seek help. Survivors are afraid they will
     not be believed, that they will be perceived as bad. These powerful voices also lead
     survivors to be afraid of the very people who offer help. Therapists and others who provide
     services to victims and survivors are publicly blamed for creating the problem, rather than
     simply exposing it. The messenger is attacked because the message is unacceptable.
     
     The effects of the backlash are seen clearly in the "memory debate," in which the validity
     of survivors' memories of abuse is questioned, especially if the memories emerge after a
     period of being unaware. (See "Honoring the Truth: A Response to the Backlash" in Bass
     & Davis, The Courage to Heal, 3rd ed., for an excellent review of this issue.) Survivors are
     accused of manufacturing these memories for attention or other secondary gains, and their
     therapists are accused of encouraging this to keep clients dependent and to increase their
     profits. (It is interesting that the validity of the memory of those accused of abuse is not
     subject to the same scrutiny even though they clearly have a much more obvious
     self-serving motive for distorting their memories of events.) 
     
     The debate has often oversimplified the understanding we do have of memory and the way
     it works, especially in cases of trauma. (This oversimplification is apparent in the frequently
     quoted work of Elizabeth Loftus, and is critiqued by those who have the most extensive
     understanding of the effects of trauma on memory, such as Judith Herman, John Briere,
     Christine Courtois, Bessel Van Der Kolk and David Calof). Therapists must have an
     understanding of these issues if they are going to work with survivors, because survivors'
     experiences and memories are often fragmented and confused. There have been therapists
     who have interpreted their clients' symptoms and feelings as proof of abuse, substituting
     the therapists' beliefs and expectations for the clients' experience. To recognize that a
     client's feelings and behavior are consistent with a history of abuse (and to explore these
     reactions with the client) is an appropriate use of our professional knowledge. To pronounce
     that we as therapists know what happened, especially when our clients do not, is
     inappropriate.
     
     Therapists are often the target of the backlash's anger and fear. Groups such as the False
     Memory Syndrome Foundation actively support family members accused of abuse in
     lawsuits against survivors' therapists. They publicly target therapists who specialize in work
     with trauma-related issues, and have developed an extensive media campaign to promote
     their views. In this climate it is easy for therapists to feel vulnerable and under attack, and
     to react defensively. We can feel afraid to trust our clinical judgment, or to intervene in ways
     that we know would be helpful to our clients. Or we may become so angry that we reduce
     the whole issue to a black and white, us versus them siege. The best protection against
     either of these defensive reactions is a strong connection to other service providers who
     are committed to self-examination and professional growth but are  also willing to challenge
     the attacks from the backlash directly and publicly.
     
     
     
     The Lack of Services and Resources 
     
     
     Although the number and types of services available to survivors has increased dramatically
     since these issues began to get more public attention, resources are still very far from
     adequate. As economic pressures have increased in society as a whole, and the social
     climate has changed, the resources that have been available have decreased or come
     under attack. The general economic decline also leads to decreases in the numbers of
     survivors who are able to afford services. Unfortunately, mental health services in general,
     and services for survivors in particular, are often seen as social "luxury items" which can
     be cut out without too much effect when money gets tight. In this climate, the services
     themselves become undervalued, and the providers are seen as less deserving of
     compensation. Therapists and service providers are caught in the middle, feeling
     overwhelmed by the needs they are trying to meet and receiving less and less in the way
     of financial and social support. 
     
     Unfortunately, providers who meet different but equally important needs of survivors are
     often in competition with each other for limited economic resources. This can lead an
     agency or group of providers to see others as threats to both its ability to provide services
     and to its ability to sustain itself and its employees. When agencies or groups become
     self-protective in this way and begin to protect their turf, services become fragmented and
     survivors suffer as well as providers. When  resources are limited it becomes even more
     important to develop cooperative relationships among different providers. This allows for
     more efficiency in providing services, and less waste of resources, effectively strengthening
     each member. Gaps in services can also be more easily identified and addressed.
     Cooperation allows providers to present a stronger, more united challenge to those who
     question the value of this work, or who would like to maintain their denial of the need for it.
     
       
     Caring for Ourselves and Each Other
     
     
     Psychotherapy with survivors of abuse and trauma is difficult work, for both the therapist
     and the client. Not only is the work of therapy draining, but the constant exposure to the
     pain and fear that result from trauma can be traumatizing itself. Therapists need to know
     that the energy, motivation, creativity, caring, even hopefulness they need are not
     self-sustaining. We must be nurtured in our lives outside the office, because our clients
     cannot and should not be expected to keep us going.  Therapists' perceptions, beliefs, and
     interactions become cynical and distorted, or just drained of emotional vitality, when their
     lives become dominated by the reality of violence and abuse of power. The experience of
     pain needs to be balanced by the equally powerful realities of joy, intimacy, love, fun, hope,
     accomplishment.
     
     It is easy for therapists who are committed to their work to become overwhelmed by the
     immense need they see. The reactions we have to our inability to meet all those needs vary
     among therapists, and from one time to another for each therapist. We feel frustration,
     self-doubt, helplessness, fear that the whole world is being overwhelmed with violence and
     pain. We may find ourselves shutting down emotionally to protect ourselves from these
     painful feelings, and thus become detached both from our clients and from our families and
     friends. We may find ourselves having difficulty responding fully to the real hurts and needs
     of family, friends, and ourselves when they seem so "minor" compared to the horror of our
     clients' lives. We may feel angry with clients for frustrating our need to feel effective,
     competent, in control - our need to feel we can change things. We may try to resolve our
     own histories of trauma through our clients, and thus not experience our own healing. We
     may become overwhelmed by despair when our best efforts cannot stem the tide of
     violence and abuse.
     
     These reactions can be countered most effectively in the context of strong connections to
     our communities. Professional communities can provide a sense of shared experience, as
     well as an understanding of our frustrations and accomplishments. With others we can feel
     visible ourselves, and the realities of our clients' lives can also be visible and taken
     seriously. We are less likely to feel that change depends on us as individuals. And we can
     also work for change at the societal level, feeling less restricted to our individual worlds.
     These communities can provide a powerful antidote to the poisonous message of abuse
     - the message that no one hears you or sees you, no one cares. However, we may need
     to look for these communities and put some energy into staying connected to them. 
     Unfortunately  professional groups are as susceptible to the denial of painful truths as
     society as a whole. Groups which consist of coalitions across disciplines may be more likely
     to overcome the nearsightedness and restricted experiences which hamper some
     professional groups.
     
     Relationships with supervisors or consultation groups can be a good way of addressing the
     links between our personal histories and our professional work. These relationships require
     trust and mutual respect in order to feel safe and supportive rather than shaming and
     judgmental. The reality of work within many organizations and agencies is that good
     supervision and other support for staff is either undervalued or unavailable. We may need
     to seek it outside the work setting.
     
     Our personal communities of family and friends are also critical. Within these we feel valued
     and valuable. We can experience the hopefulness of growth. We can reconnect with the
     reasons why healing is important and worth the effort. We need to treat our personal lives
     as valuable and worthy of protection, not just as something we do when we're not working. 
     Our personal lives should not always be expected to step aside for our work (for meetings,
     phone calls, appointments, and so on). This requires a balancing act, since our work and
     our personal lives are not often nicely coordinated. Colleagues who are also friends can
     help us with frequent reevaluations of this balance. It isn't just enough to have family and
     friends; we have to live fully among them. 
     
         Remember you're not alone. You are part of an important process that extends over
       time, and encompasses many people. What you do is important because it is part of this
       process. You can't do it alone, so don't expect yourself to try. But don't undervalue the
       contribution you do make.  Without you the process of change would be weaker and
       slower.
          Bass, E. and Davis, L., The Courage to Heal: A Guide for Women Survivors of Child Sexual Abuse
     (3rd edition), Harper & Row, 1994.
     
     Blumenfeld, W. J. (Ed.), Homophobia: How We All Pay the Price, Beacon Press, 1992.
     
     Bolton, F., Morris, L., and MacEachron, A.,  Males at Risk: The Other Side of Child Sexual Abuse,
     Sage Publications, 1989.
     
     Briere, J., Therapy for Adults Molested as Children: Beyond Survival, Springer, 1989.
     
     Briere, J., Child Abuse Trauma: Theory and Treatment of the Lasting Effects, Sage, 1992.
     
     Brown, L. S. and Ballou, M. (Eds.), Personality and Psychopathology: Feminist Reappraisals,
     Guilford, 1992.
                   
     Calof, D., "Facing the truth about false memory,"  The Family  Therapy Networker, 17(5),
     September/October, 1993.
     
     Courtois, C.,  Healing the Incest Wound: Adult Survivors in Therapy, W. W. Norton, 1988.
     
     Chrisler, J. C. and Howard, D. (Eds.),  New Directions in Feminist Psychology,   Springer, 1992.
     
     Herman, J. L.,  Trauma and Recovery, Basic Books, 1992.
     
     Herman, Judith L. and Harvey M R., "The false memory debate: Social science or Social
     Backlash?,"  The Harvard Mental Health Letter, 9(10), April, 1993.
     
     Lew, M.,  Victims No Longer: Men Recovering from Incest, Harper & Row, 1988.
     
     Lobel, K.,  Naming the Violence: Speaking Out About Lesbian Battering, The Seal Press, 1986.
     
     Mirkin, M. P. (Ed.),  Women In Context: Toward a Feminist Reconstruction of Psychotherapy,
     Guilford Press, 1994.      
     
     Pearlman, L. A. and Saakvitne, K. W.,  Trauma and the Therapist: Countertransference and
     Vicarious Traumatization in Psychotherapy with Incest Survivors, W. W. Norton, 
       1995.
     
     written for this manual by Mary Margaret Hart, Licensed Psychologist
     
          
     
     
     
     
     
     
     
     
     
     
     
     
                                 RESOURCES
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     Refusal to learn is more deeply a refusal to do.
       Abraham Maslow 
     
     
     
     Outline for Interagency Agreement
     
     In order to facilitate the active interagency coordination of services for victims it is
     suggested that interagency agreements be developed between the service providers to
     these individuals.  It is recommended that the agreement be reviewed by each center's
     legal personnel.
     
     Interagency Agreement Format:
     
     Introduction
     
         to provide a statement of parties participating in the agreement
         to provide a statement of purpose for the agreement
         to provide a time duration of the agreement
     
     General Responsibilities
              
       - to provide a general purpose statement for each party of the agreement
         to provide a listing and definitions of all terms, phrases, words and their derivations
       as it pertains to the agreement
     
     Specific Responsibilities
     
         to provide an explanation of the specific responsibilities and commitments made by
       the parties of the agreement (i.e., addressing areas of confidentiality, notice and
       enforcement)
            Example:  Under the terms of this agreement PARTY X will be prepared:
         to maintain the individual's confidentiality
     
     Enforcement
     
         to provide the specific explanation of guidelines for adherence to the agreement
       which includes any personnel disciplinary action by each party of the agreement
     
     Duration
     
         to provide guidelines (e.g., time specifications, notice) for the duration, review and
       cancellation of the agreement
     
     Signature
         to provide the necessary signatures by designated parties                       Interagency Agreement Example
                                
 Agreement of Cooperation Between the Party A (Victim Services
         Center) and Party B (Mental Health Provider) 
     
     
     Introduction
     This agreement between PARTY A  and PARTY B will provide a referral procedure primarily to
     provide support to individuals who become victims of sexual assault while residing or participating
     in program at PARTY B.  This agreement will be in effect for one year or until such time as a new
     agreement may be warranted.
     
     General Responsibilities
     PARTY A  is a non-profit corporation chartered to provide support to victims of crime including but
     not limited to victims of rape, incest, child abuse and indecent assault.  PARTY A is available to
     provide services twenty-four (24) hours a day to meet the needs of victims.  PARTY B is a
     residential, private licensed center offering X service for persons with mental retardation.
     
     Definitions
     For the purpose of this agreement, the following terms, phrases, words and their derivations shall
     have meaning as follows:
              A.   Referral procedure:  the process used to contact PARTY A
              B.   Support:  support offered by PARTY A which can include counseling and court preparation
            and any other services necessary to assist the victim
              C.   Victim:  an individual who was injured as a result of a sexual crime
              D.   Sexual assault: this includes crimes against the person such as rape, incest, child
            abuse/molestation, indecent assault, sexual harassment
              E.   Individual habilitation plan:  a component of the life management plan as described in
            Chapter 4210 that is developed for a person on the basis of assessment data which
            specifies program interventions to attain a specific goal or objective
     
     Specific Responsibilities
     Under the terms of this agreement PARTY A will be prepared:
              A.   to maintain the victim's confidentiality
              B.   to treat the victim with dignity and respect
              C.   to respond twenty-four hours a day to the needs of the victim while participating with
            PARTY B
              D.   to advocate with and for the victim
              E.   to meet the victim at the hospital
              F.   to provide police and court accompaniment and court orientation
              G.   to provide crisis intervention, counseling and follow-up, information and referrals on terms
            requested by the victim
              H.   to obtain all necessary written releases from the victim before the case discussion with
            designated persons and/or agencies
     
     Under the terms of this agreement PARTY B will be prepared:
              A.   to maintain the victim's confidentiality
              B.   to treat the victim with dignity and respect
              C.   to be non-judgmental
              D.   to provide as part of the individual's orientation to PARTY B program information about
            PARTY A's services
              E.   to provide the victim with written notification of available services from PARTY A and an
            explanation of her/his rights
              F.   to provide a private area for the victim to make any confidential contacts with PARTY A
            (i.e., telephone and/or counseling contacts)
     
     Under the terms of this agreement PARTY B will be prepared:
              A.   to provide any assistance per the victim's request in contacting PARTY A (e.g., availability
            of TDD; qualified sign language interpreter; other)
              B.   to provide for ambulance transport in case of medical emergency
     
     Enforcement
     If for any reason this agreement is not adhered to by the designated parties, each party will follow
     the terms of this agreement and their respective personnel policies regarding warranted disciplinary
     action.
     
     Duration
     This agreement shall be effective immediately and shall remain in effect until terminated upon thirty
     (30) days written notice by one or all parties involved.  It shall be reviewed at least annually and may
     be amended at any time by the mutual agreement of the participating parties.  Amendments must
     be written and approved by each party and attached to the agreement.
     
     Signatures
     
     PARTY A
     PARTY B
     
     
     
     
     
     
     ___________________________________
     Signature of Executive Director
     ___________________________________
     Signature of Director
     
     
     
     
     
     
     ____________________________________
     Type/print name above
     ___________________________________
     Type/print name above
     
     
     
     
     
     
     
     ____________________________
     Date
     _____________________________
     Date
     
     
     
     
     
          
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     Heide, K. M., Why Kids Kill Parents: Child Abuse and Adolescent Homicide, Sage Publications,
     Inc., 1994.
     
     Lurigio, A. J., Skogan, W. G. &  Davis, R. C., Victims of Crime: Problems, Policies and
     Programs, Sage Publications, Inc., 1990.
     
     National Victim Center, "America Speaks Out: Citizens' Attitudes About Violence and
     Victimization,"  NVC, 1991.
     
     National Victim Center, "Opportunities for Action: Mental Health Needs of Victims," NVC, 1989.
     
     Neiderbach, S., Invisible Wounds: Crime Victims Speak, Haworth Press, 1986.
     
     Straus, M. B., Violence in the Lives of Adolescents, W. W. Norton & Company, 1994.
     
     Virginians Alligned Against Sexual Assault, Sexual Assault Crisis Centers in the United States,
     VAASA, 1995.
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
                                Resources
     
     
     Many of these organizations have brochures or fact sheets which could be used as handouts
     for victims of trauma or crime. Many also sponsor conferences to expand skills and knowledge
     of the topics included in this manual.
     
     American Psychiatric Association, 1400 K Street, N.W., Washington, D.C. 20005,
     (202) 682-6000
     
     American Psychological Association, 750 First St. N.E., Washington, D.C. 20002-4242, 
     (202) 336-5500
     
     Center for Women Policy Studies, 2000 P Street, N.W., Washington, D.C. 20036, 
     (202) 872-1770
     
     Clearinghouse on Abuse and Neglect of the Elderly, College Resources, University of Delaware,
     Newark, DE 19716, (302) 831-3525
     
     Clearinghouse on Family Violence Information, P.O. Box 1182, Washington, D.C. 20013, 
     (703) 385-7565
     
     Crime Victims Research And Treatment Center, Medical University of South Carolina, 
     171 Ashley Avenue, Charleston, SC 29425, (803) 792-2945
     
     Families of Murder Victims, Inc., 1300 Chestnut Street, Seventh Floor, Philadelphia, PA 19107,
     (215) 875-6475
     
     Human Rights Resource Center, 615 B Street, San Rafael, CA 94901, (415) 453-0404
     
     International Association of Trauma Counselors, Inc., 1033 La Posada Dr., #220, Austin, TX
     78752-3880, (512) 454-3036
     
     MADD, 511 E. John Carpenter Frwy, # 700, Irving, TX 75062-8187, (214) 744-6233  
     
     National Aging Resource Center on Elder Abuse, c/o AWPA, 810 First Street, N.E., Washington,
     D.C. 20002-4267
     
     National Association of Social Workers, 750 First St. N.E., #700, Washington, D.C. 20002-4241,
     (800) 638-8799
     
     
     National Coalition Against Sexual Assault, 912 N. Second St., Harrisburg, PA 17102, 
     (717) 232-7460 
     
     National Coalition Against Domestic Violence, PO Box 18749, Denver, CO 80218-0749, 
     (303) 839-1852
     
     National Council on Child Abuse and Family Violence, 1155 Connecticut Ave. N.W., # 300,
     Washington, D.C.20036, (800) 222-2000
      
     National Indian Justice Center, The McNear Building, #7, Suite 28, Petaluma, CA 94952, 
     (707) 762-8113.
     
     National Institute Against Prejudice and Violence, 31 South Green Street, Baltimore, MD 21201,
     (410) 328-5170
     
     National Institute of Mental Health, Department of Health and Human Services, Park Lawn
     Building, Room 10C-24, 5600 Fishers Lane, Rockville, MD 20857, (301) 443-3728
     
     National Mental Health Association, 1021 Prince Street, Alexandria, VA 22314-2971,
      (703) 684-7722
     
     National Organization of Victim Assistance, 1757 Park Rd. N.W., Washington, D.C. 20010,
      (202) 232-6682
     
     National Resource Center on Domestic Violence, 6400 Flank Dr., # 1300, Harrisburg, PA 17112,
     (717) 545-6400
     
     National Victim Center, 2111 Wilson Blvd., Suite 300, Arlington, VA 22201, (703) 276-2880
     
     Office for Victims of Crime, 633 Indiana Ave. N.W., Washington, D.C. 20531 (202)  272-6500
     
     Spiritual Dimension in Victims Services, P.O. Box 6736, Denver, CO 80206, (303) 740-8171
     
     Southern Poverty Law Center, P.O. Box 548, Montgomery, AL 36101, (205) 264-0286
     
     Three Feathers Associates, 1808 Newton Drive, P.O. Box 5508, Norman, OK 73070,
      (405) 360-2919