r I 

2003 Volume 12 (1) ISSN-105-7168 

I I 

CLINICAL QUARTERLY 

I Menlo ParWPalo Alto * Boston * Honolulu * West Haven * White River Junction 

PTSD AND TELEMENTAL HEALTH: 


UPDATES AND FUTURE DIRECTIONS 


Many veterans in need of specialized PTSD 

services live in remote geographical regions such as 

tribal reservations, or rural areas of the Pacific 

Islands, where services are not easily accessible. 

Further, veterans with PTSD often use self-isolation 

to reduce stimulation, hyperarousal, and interpersonal 

conflict and consequently may be more likely to locate 

in remote rural areas with low population density. 

Historically, difficulties with access to care in remote 

The major benefits of telemedicine 

are expanding access to care and 

bypassing travel that may be 

disruptive or too costly. 

areas have resulted in a lack of specialized PTSD 

services or limited specialized service provision with 

tremendous financial, travel or personnel burden. For 

example, the Department of Veterans Affairs medical 

center located in Oahu, Hawaii provides services to 

veterans in a large geographic area that includes the 

Hawaiian Islands, Guam, the Northern Mariana Islands, 

and American Samoa. Approximately 4.6 million 

square miles of water separate these islands, and 

approximately 123,000 veterans live in this region. 

Over one third of veterans receiving mental health 

services from the Hawaii VA are diagnosed with PTSD. 

This is a significantly higher percentage than is found in 

other VA medical centers (1). 

Inside this issue 	 PTSDand Telemental Health 

New Directions 

To meet the needs of these veterans, the VA often 

flies clinicians to remote destinations to provide 

specialized mental health services, and flies veterans 

to the Honolulu Ambulatory Care Center on the island 

of Oahu to receive specialized care. The high cost of 

air travel and human resources, increased airport 

security, and scheduling difficulties all present 

significant barriers to providing necessary care. 

Telemental health seems to be a promising solution to 

this access problem, with clear advantages for the 

veteran and the provider. 

Telemental Health: What is it? 

Telemedicine is the use of electronic 

communications and information technology to provide 

and support health care when distance separates the 

participants (2). The major benefits of telemedicine 

are expanding access to care and bypassing travel that 

may be disruptive or too costly. Telemedicine often 

refers to the provision of health services via remote 

video teleconferencing (VTC) technology. VTC 

equipment sends real-time audio and video data. This 

technology is synchronous and affords face-to-face 

interactions. In telemedicine, the specialties of 

radiology, dermatology, and pathology have used VTC 

technology to provide medical care psychological services, 

cognitive testing and general psychiatry. Despite the high 

utilization of (elemental health, this technology is 

Continuedonpage 3 

1 


8 

Women and Trauma: A Clinical Forum 10 


Treating ComplexTrauma Cases 12 

NCPTSD Clinical Quarterly Volume 12 (1) 2003 

FROM THE EDITOR ... 


Clinical innovation to help deliver the best possible mental health services to veterans suffering from PTSD, 

has long been a defining characteristic of VA behavioral health services. Another hallmark of VA PTSD clinicalrelated work has been its widespread adaptation and incorporation into community-based services for non-veteran victims of trauma. For example, many of the assessment and treatment protocols developed to help veterans (e.g., PCL and the CAPS), have (with slight modification) become widely used to help victims of communitybased trauma including most recently, victims of 9/11. This issue of the Clinical Quarterly features the efforts of 

two groups of research practitioners whose work with veterans exemplify clinical innovation and the potential for 

helping trauma victims globally. 

Leslie Morland, Christopher Frueh, Kathleen Pierce, and Sarah Miyahara have undertaken an innovative 

approach to care that could potentially change how mental health services are delivered when access to care is 

problematic. The outcome of their pilot study to evaluate the efficacy of video teleconferencing technology ((elemental 

health) as applied to PTSD services holds promise to veterans who might not otherwise receive treatment, and 

possibly to quarantined communities/survivors resulting from catastrophic bio-terrorism. VA and non-VA science1 

clinical practitioners Amy Naugle, Kathryn Bell, and Meliisa Polusny have been collaborating to prevent the sexual 

revictimization of women. Through their efforts to understand the variables associated with revictimization, they 

have been able to explain why previously held strategies of prevention are ill-founded. The clinical implications of 

their work clearly have importance to the development of improved health care services provided to women 

veterans by mental health and primary care practitioners, but also to community health care services provided to 

non-veteran women who may benefit from learning about risk-reduction strategies or receiving treatment for 

sexual revictimization. /-

Bruce H.Young, Editor-in-Chief 

NATIONAL CENTER FOR PTSD 

Executive Director 


Matthew J. Friedman, M.D., Ph.D. 


VAMC/ROC White River Junction Vermont 


05009 

Education and Clinical Laboratory Division Behavioral Science Division Women's Health Science Division 

Fred Gusman, M.S.W., Director Terence Keane, Ph.D., Director Patrica Resick, Ph.D., Director 

VAMC, Palo Alto. California 94304 VAMC, Boston, Massachusetts 02130 VAMC, Boston, Massachusetts 02130 

Pacific Islands Division Neuroscience Division Northeast Program Evaluation Center 

Fred Gusman, M.S.W., Chief of Operations John Krystal, M.D., Director Robert Rosenheck, M.D., Director 

Honolulu, Hawaii 96813 VAMC, West Haven, Connecticut 06516 VAMC, West Haven, Connecticut 06516 

Clinical Quarterly Staff 

Editor-in-Chief Bruce H. Young, L.C.S.W. 

Managing Editor Josef I. Ruzek, Ph.D. 

Executive Editor Fred D. Gusrnan, M.S.W. 

Associate Editors Eve B. Carlson, Ph.D., Ilona Pivar, Ph.D., & Robyn Walser, Ph.D. 

Assistant Editor John Aboytes, B.A. 

Design & Production Bruce H. Young 

- Please feel free to contact us at die Education Division: FTS 463-2673/2494; commercial number 650-493-5000 en. 22673/22494; or E-mail: ncptsd@bruceyoung.net 

Please address all correspondence to: Editor, National Center for PTSD Clinical Quarterly, \'A Palo Alto Health Care System, 795 Willow Rd (352E117). Menlo Park, CA 94025 
NCPTSD Clinical Quarterly 

still considered an untapped opportunity for many psychologists, 

social workers, and counselors because psychiatry has delivered 

the bulk of telemental health services (3). 

Readjustment CounselingService (RCS), in collaboration 

with Veteran's Healthcare Association (VHA) has been providing 

telemedicine primary and specialty care services to veterans 

located in rural locations whereaccessibilitytoservicesis limited. 

Although formal outcome data have not been collected at these 

sites, anecdotal reports suggest strong support by veterans, 

local providers, and remote clinicians. Sites such as the Vet 

Center at Logan, WV have been providing telemental health 

care to veterans by psychiatrists located at the closest VA 

hospital, two hours away in Huntington, WV. Additional sites 

include Cleveland, OH; Greenville, NC; and Santa Fe, NM where 

veterans are receiving routine care at local Vet Centers via VTC 

from remoteVA hospitals. Although many of the services provided 

at these sites are for combat veterans with PTSD, a few sites are 

offering telemental health specialty PTSD services beyond 

medication management. 

Surprisingly, when compared to the control inpersongroup, the remoteclinician noted thatthere 

appeared to be agreater senseof camaraderie and 

cohesion amongthe VTCgroup participants. 

While preliminary research on feasibility and reliability 

of the VTC modality for general clinical assessments and care, 

and favorable levels of patient and clinicians satisfaction (4) 

have been established, little is known about the clinical 

effectiveness and acceptibility of VTC for treatment of specific 

disorders like PTSD. Although most would agree that telemental 

health may present a more convenient and more economic 

way to provide or supplement specialty care services to remote 

veterans, research is still needed to determine the quality and 

clinical effectiveness of these services. 

Telemental Health and PTSD: Pilot Research PTSD 

For veterans with a history of trauma exposure, 

assessment of PTSD psychiatric or psychological symptoms 

is the first step to getting appropriate treatment. The 

accuracy of a PTSD diagnosis is important for both treatment 

implications and benefit claims. To date only one study has 

systematically evaluated the use of VTC to conduct 

assessements with veterans (5). In this study, 20 Vietnam 

veterans residing on the neighbor island of Hawaii who 

sought services at the VA Community-Based Outpatient 

Clinics in Hilo and Kona completed comprehensive PTSD 

evaluations administered via VTC from a remote clinician 

Volume 12 (1) 2003 

PTSD & TELEMENTAL HEALTH 

on the island of Oahu. The assessment protocol consisted 

of a combination of online self-report measures, a structured interview, and the Clinician Administered PTSD Scale 

(CAPS). Findings from this study suggests high satisfaction across the veterans, remote clinicians, and referring 

providers (5). Veterans were satisfied with assessments - the majority (80%) reporting moderate to high comfort 

levels. The referring providers reported to being very open 

to the VTC modality. Although the remote clinicians reported a slight preference for in-person interviews, the 

use of VTC was found to be acceptable, as remote clinicians indicated that they were able to establish rapport 

and perform an accurate diagnostic evaluation from a 

remote location. 

Data on clinical outcomes from telemental health 

applications for treatment of PTSD are significantly lacking, with no randomized clinical trials (RCTs) completed 

to date. In an early case study with veterans suffering 

from PTSD, patient satisfaction and feasibility were demonstrated in a single session of group therapy conducted 

using VTC technology (6). More recently, investigators 

found that an 8-week manualized PTSD coping skills group 

was well received by veterans, clinic staff, and the remote group clinician (7). Comparison of VTC to an inperson control group revealed no significant difference 

between the two groups on measures of satisfaction and 

information retention. Surprisingly, when compared to 

the control in-person group, the remote clinician noted 

that there appeared to be a greater sense of camaraderie and cohesion among the VTC group participants. 

Some anecdotal findings from these pilot studies indicate that remote clinicians experience more anxiety with 

the VTC group than the conventional 1:ldue to the awareness of the potential for technical difficulties. In addition, 

clinicians reported having less visual acuity with the VTC 

group, making it more difficult to observe and monitor facial expression and body language, which has the potential 

to be problematic when tracking an agitated veteran with 

PTSD. However, the clinicians reported that over time the VTC 

modality became less anxiety provoking. 

There is still a great deal we need to know about how, 

when and with what patient population we can apply this 

new technology. However, based on these early pilot studies VTC appears to be a promising technology that can afford skills training and assessment from a distance for 

veterans with PTSD. Some logistic and clinical considerations and cautions are addressed below based on our 

clinical and research experiences with implementing and 

applying this technology for the care of veterans with PTSD. 

3 
NCPTSD Clinical Quarterly 

MORLAND, FRUEH, & PIERCE 

Logistical Considerations 

UsingVTCforclinical work requires planningand preparation. 

It is important to consider logistics such as preparing the room 

and theequipment and havingtechnological back-upsupport. The 

convenienceand privacy of the room must be considered. In addition, 

a phone line should be available in the room in case the VTC 

equipment becomes disconnected. Stationary chairs are 

preferred to avoid excessive body movement. Additional aspects 

of the room to consider include the lighting and setting up the 

equipment in a manner that optimizesthe clinical setting. Proper 

lighting is important to optimize the clarity of the image and 

allow for the clinician to be sensitive to any non-verbal 

communication. When usingtheVTC, there arevisuai adjustments 

to be made to improve comfort for those involved. To increase 

symmetry, or perceived power between the participants, each 

participantshould appear about equal insize on the monitors. It 

is recommended that the visual field capture as much of the 

patient as possible, but at minimum a patient's head, shoulders, 

and arms. 

At this early stage of WC technology, disruptions and loss of 

transmission are realistic possibilities. Technical difficulties, 

e.g., hardware malfunctions, connectivity failures, poor or erratic 

audio and video quality, can occur frequently and disrupt the 

transmission and ultimately theclinical process. Should any of 

the VTC equipment fail duringa session, it is imperative to have 

a telephone available at each point and available technicai support on call for each VTC contact to help troubleshoot. At the 

remotesite where technicians may not be available, it is important to have someone who can follow technical instructions by 

phone. The phonecan be used in the interim until the problem is 

resolved. If the problem cannot be resolved, the phone will be 

the primary modality through the end of the session. Although 

this may not be ideal, it offers a modest alternative. 

Clinical Considerations 

Clinicians looking to integrate teiemedicine into their practice must receive training and practice on using the equipment in 

order to feel comfortable and not allowthe technology to distract 

from the clinical process. Clinicians report more comfort with 

WC after several repeitions of working with it. A clinician's comfort with using VTC will directly relate to the veteran's comfort 

and likely the overall success of implementing a telemedicine 

program. Although telemedicinetechnology is advancingrapidly, it 

is important to note that it may be human factors that hinder the 

successful implementation of such programs. it iscritical that clinicians arecomfortablewith the modality and not lose the traditional 

empathicwarmth of mental health care. Theremay besome resistance to using (elemental health by clinicians and veterans; some 

may fear that telemedicine might dehumanize clinical care. 

Dependingon equipment setup and transmission quality, it 

may be difficult to see the entire body of the veteran (clenched 

fists, shaking legs), orwith comparablesensitivity, assess emotion 

Volume 12 (1) 2003 

breathing rate, etc. Although this makes a WC ciinical interaction 

more chaliengingforthe clinician, there are tools that can aid in 

this process, such as the Subjective Units of Distress (SUDS), a 

scaiefrom 1-100that allowsthe patientto identify and reportto the 

clinician how he or she is feeling in the moment. During the VTC 

session, theSUDS can be used bythe remoteclinician totrack the 

veteran'semotional response to thesession, guideadjustments in 

thesession, or intervene with relaxation interventions such as deep 

breathingtechniques. Thistechniquecan behelpful incompensating 

forthe clinician'sdecreasedsensitivityand perception when using 

theVTC modality. 

Itis important to talk with the veteran prior to the first VTC 

interaction. Topics to help orient theveteran toVTCcan include a 

discussion of how the equipment works and what to do if 

equipment fails. Confidentiality and privacy concernsshould also 

beopenly discussed. in all, the risksand benefits of conducting 

thesessionviaVTCshould be weighed up front. Alternate orthe 

lack of alternate methods of assessment and treatment should 

be included in the discussion. This provides the veteran with a 

rationale for having sessions via VTC and can serve to increase 

his or her comfort, satisfaction, and cooperation. 

Finally, the need for clinical back-up servicesshouid not be understated. Some preliminary guidelines can be proposed at present. 

As a general rule, VTC sessions without an in-the-room clinician 

should not be attempted with patientswho are emotionally unstable 

or volatile, due to the distance from the remote ciinician and the 

potential fortechnical difficulties. Remotesetvicestoemotionally 

unstable or volatile patientsare only suggested when the specific 

service cannot be provided by the on-site clinician (i.e., psychiatry 

or specialty PTSD services). It is optimal when a member of the 

clinical team can beassigned tosit in on the consultations with 

patients via VTC. If the on-site provider already has rapport with 

the patient, this can help to establish safety and ease from the 

onset of the consultation. Of course, many rural sites lack the 

staff to provide this in-the-room coverage. In such cases, it is 

essential that a clinical staff member at minimum be on-site 

during any VTC consult, to act as technicai and clinical back 

up. If there is no one at the remote site to cover this function, one 

should carefully considerwhether a WCconsultation is advisable. 

Clinical Cautions 

Given the novelty of VTC equipment, interacting with a new 

veteran through VTCwithout a referral is not recommended. There 

should be some form of screening or orientation prior to theVTC 

session. For example, at minimum the veteran should be 

screened for emotional stability (i.e., psychosis, volatility, 

suicidality, etc.) in order to determine if a VTC consult is 

appropriate, and if so, what level of safeguards should be in 

place (i.e., ciinician in the room). How the patient perceives a VTC 

interaction can be unpredictable. Clinical emergencies pose a 

challenge. Suicide threats, violence, and other harmful behaviors 

are difficult to manage through VTC. Although careful screening 
NCPTSD Clinical Quarterly 

of WC patientsshould reduce this risk, situationssuch as this are 

bound toarisefrom time to time. Again, with thesetypesof consults, 

it is important to have a clinician on-site with the patient during 

the VTCsession. The referring and remote cliniciansshould have 

direct accessto each other as necessary. In addition to providing 

emergency back- up services, having a clinician on-site in the 

room might helpveteransfeel more secure and comfortable during 

difficult times. 

At the current time, it is not recommended that traumafocused type interventions (e.g., exposure therapy) or trauma 

focused type treatments be provided utilizing WC. The possibility 

of intense emotional distress abreaction is high with this type of 

treatment,and management ofthe content and affect of asession 

would apt to be very difficult when providing remote services. 

Since the purposeof providing remote services hinges on the lack 

of adequate or specialized services in a distant site, it would be 

imprudent to open up an individual's traumatic experiences 

without havingsolid clinical backup. If that level of clinical service 

were available, it would be a better practice to allow the on-site 

clinicians to do process or trauma-focused work with the PTSD 

patients. 

Future Directions 

At this point more research is necessary to fully understand 

the various clinical, technical, and ethical issues that relate to 

applyingtelemental health to PTSD. We are at a very early stage 

in the development of protocols for assessing and treating PTSD 

through (elemental health. More rigorous comparisons between 

WC and traditional in-person interactions are necessary to appreciate the impact of WCon the processof mental health care. In 

particular, randomized controlled trials are needed to support the 

efficacy and effectiveness of VTC with veterans and other populations. Furthermore,future researchstudiesshould build upon previousfindings to maximize practical information and minimize trialand-error. Although there is a great need for more research, this 

fact should not impede or preclude current use of WCfor certain 

applications. By bridgingthe distance between clinician and patient, telemedicine has the potential to profoundly influence the 

delivery of PTSD-related services to the many remoteveterans with 

PTSD who have been previously unable to accessspecialty care. 

References 

1. Department of Veteran Affairs. (2000). Honolulu VAMROC 

Vistasystem Renort. 

2. Field, M. (1996). ed Institute of Medicine. Telemedicine- A 

guide to assessingtelecommunications in health care. 

Washington, DC: National Academy Press. 

3. 	 Mahue, M. (2001). E-Health. telehealth & telemedicine: A 

guide to startup and success. Lanham, MD: Lexington 

Books. 

Volume 12 (1) 2003 

4. 	 Frueh, B.C., Deitsch, S.E., Santos, A.B., Gold, P.B., Johnson, 

M.R., Meisler, N., Magruder, K. M. & Ballenger, J.C. 

(2000). Procedural and methodological issues in 

telepsychiatry research and program development. 

Psychiatric Services, 51,1522-1527. 

5. 	 Miyahira, S., Morland, L.A., Pierce, K. S., & Wong, M. (in 

progress). Assessing PTSD using telemediclne in the 

Pacific Islands. 

6. 	 Deitsch, S.E., Frueh, B.C., & Santos, A.B. (2000). 

Telepsychiatry for post-traumatic stress disorder. 

Journal of Telemedicine and Telecare,6.184-186. 

7. Morland, LA, Pierce, K., &Wong, M.(under review).Telehealth 

and PSTD psychoeducation groups in the Pacific 

Islands: Afeasibility study. 

Dr. Leslie A. Morland 3 a c n ca ps,cholog st at me 

NCPTSD Pat-fic Isand D.. 9.0" locate? n nono! ., ri 

C "i ca and researchicseaicn nterosi'; r\c -de deieloo no 

guidelines for provision of clinical services to trauma 

victims In rural locations using telehealth technology. 

Additional interest includes examining the relationship 

between trauma, PTSD and female reproductive health 

in the Pacific islands. 

Dr. Christopher Frueh received his doctoral degree in 

clinical psychology from the University of South Florida 

in 1992. He Is currently Associate Professor at the 

Medical University of South Carolina, and staff 

psychologist at the Ralph H. Johnson VA Medical 

Center, Charleston, South Carolina. He is presently 

principal investigatoron 5 NiH-funded research grants, 

including one to study the use of videoconferencing 

for providing treatment to veterans with PTSD. 

Dr.Kathleen S. Pierce is aclinical psychologist currently 

working for the state and in the private sector in 

to traumn survivors livino in rural iocations usin0 

telehealth technology. 

Dr. Sarah D. Miyahira is currently the Director for 

Intramural Research at the Pacific Telehealth and 

Technology: A DoDNA Joint Venture and the former 

Acting Director of the NCPTSD Pacific Islands Dlvlsion. Her professional and research interests include 

the application of innovative technologies in behavioral health and medical Interventions, PTSD assessment and treatment, ethnic minority mental health, 

and research ethics. 
NCPTSD Clinical Quarterly Volume 12 (1) 2003 

October 9 Is National Depression Screening Day 

Participating Clinicians Can Earn Continuing Education Credits 

This year's National Depression Screening Day (NDSD) - held on October 9 and 

co-sponsored by the National Center for PTSD - offers a concise, easily comprehensible questionnaire that screens patients for post-traumatic stress disorder along with 

depression, bipolar and generalized anxiety disorder. By striving to build mental 

health resiliency during stressful times, the program offers solutions to the 54 million 

Americans, and their communities, who suffer from mental health disorders. 

New this year, clinicians interested in conducting an NDSD event can receive 

three continuing education credits for completing a self-education component. Details 

can be found at www.mentalhealthscreening.org. 

NDSD can provide the gateway to treatment for veterans and others - such as 

loved ones of overseas troops, or victims of terrorist attacks - who may be suffering 

from PTSD or other mood or anxiety disorders. 

Registered sites receive an Event Planning Guide that includes tips on program 

implementation and sample publicity materials. Kits also include screening forms 

with scoring instructions and referral guidelines, diagnostic aids, clinician's guide, 

videos, posters and educational materials for diverse audiences. Sites that service 

low-income or uninsured populations can register for a discounted Public Sector Kit. 

Last year, screenings took place at roughly 6,000 sites nationwide, including 

hospitals, mental health clinics, colleges, primary care offices and in public settings. 

To download registration materials, go to www.mentalhealthscreening.orP/reg or call 

(781) 239-0071for more information. 
NCPTSD Clinical Quarterly Volume 12 (1) 2003 

NATIONAL CENTER FOR PTSD 


CLINICAL TRAINING PROGRAM 


The Education and Clinical Laboratory Division for the National Center for Post 

Traumatic Stress Disorder at the Palo Alto CA VAMC, in collaboration with the 

VA Employee Education System, offers a Clinical Training Program (CTP). The 

training program is approved for 30 Category 1 CEUs for physicians, 

psychologists, social workers, and nurses. 

Each year we welcome many mental health professionals from across the United 

States and from around the world. Most clinicians who enroll in the program have 

a working knowledge about treating the effects of trauma and PTSD and are 

looking to upgrade their clinical skills. The CTP offers a broad range of educational 

activities, including: 

* Lectures * Clinical consultation * Clinical observation of group treatment 

* Group discussions facilitated by staff 

Specific training topics include warzone trauma group treatment, treatment of 

women veterans, treatment of sexual assault related PTSD, relapse prevention, 

cross cultural treatment issues, assessment and treatment of families, disaster 

mental health services, cognition and PTSD, assessment of PTSD, and 

psychiatric assessment. 

Training programs are scheduled for a minimum of one week, though longer 

programs are available if the applicant can justify an extended stay. Programs 

are scheduled nine times per year, on the second or third week of the month. 

Funding for attendance is not available from the National Center. There is no fee for the 

training program itself, but participants are responsible for providing their own 

transportation, lodging, and meals. Interested applicants are encouraged to explore 

funding options through their local medical centers or VA Employee Education System. 

For more information, or to request an application, please email: 


Josef.Ruzek@med.va.gov 


or telephone FTS 700-463-2673; commercial number 650-493-5000, ext. 22673. 

NCPTSD Clinical Quarterly Volume 12 (1) 2003 

Friedman, M.D., Ph.D. 


It is with great pleasure that I announce that Patricia Resick, PhD, has accepted an appointment as Director of the 

National Center's Women's Health Sciences Division (WHSD) at the Boston VA Medical Center. She is currently 

Professor of Psychology and Director, Center for Trauma Recovery at the University of Missouri-St. Louis. 

It has taken a number of years to find someone of Dr. Resick's stature to fill this key leadership position within the 

National Center. During the interim, Marie Caulfield, PhD, and Lynda King, PhD, have done an excellent job maintaining 

the forward momentum of WHSD, initially generated by Jessica Wolfe. 

Dr. Resick has an international reputation as a clinical scientist in the field of traumatic stress. She has dedicated 

her career to furthering our understanding and developing effective therapeutic interventions to address the catastrophic psychological impact of interpersonal aggression as exemplified by rape, domestic violence, and childhood 

sexual abuse. For over 20 years her research has helped us understand the devastating consequences of sexual 

assault: how it affects one's view of oneself; how it promotes psychopathology and social maladjustment; how it may 

distort perceptions of one's environment; and how such distortions promote maladaptive thoughts, feelings, and behavior patterns. More importantly, she has taken the insights gleaned from these studies and created therapeutic 

interventions designed to correct such dysfunctional behavior. Here is where she has emerged as a world leader who 

has been a mentor for the rest of us. She has developed her own treatment approach, Cognitive Processing Therapy, 

designed it for both individual and group therapy contexts, and written a comprehensive treatment manual to guide 

clinicians. But that is only the beginning. 

During the past 14 years, Dr. Resick has put her theories and therapy manual through their paces by testing them 

in rigorous and elegant treatment outcome studies. Her scientific papers are a joy to read because they are lucid, 

conceptually-driven accounts of well-designed treatment trials that have repeatedly demonstrated the efficacy of Cognitive Processing Therapy. It is important to recognize that this is extremely difficult research to carry out. Ishould also 

emphasize that Dr. Resick's therapeutic approach represents one of only a handful of effective treatments for sexual 

assault and interpersonal violence which affect so many American women and men in the course of their lifetime. 

Dr. Resick is an excellent lecturer, mentor, and role model as a clinician scientist. The esteem that she has earned 

from an international community of scholars, researchers, and therapists is indicated by her appointment to editorial 

boards, scientific study sections, leadership positions in scientific organizations, and invitations for lectures and visiting 

professorships. Noteworthy appointments in specific professional organizations include: the Association for the Advancement of Behavior Therapy (of which she is President-elect), the International Society for Traumatic Stress Studies (of which she was recently vice president), the American Psychological Association (Divisions 9, 12, & 35),the 

American Psychiatric Association (DSM-IV PTSD Working Group), and the National Organization of Victim Assistance. She has also played prominent roles in both VAand NIMH research activities. 

Her distinction as a scientist is attested by her success in obtaining research support in an increasingly competitive 

funding environment as well as by her prolific record of published articles in peer reviewed scientific journals and 

chapters in books. 

Despite her heavy clinical, research, and teaching responsibilities, Dr. Resick has maintained a strong sense of 

social responsibility exemplified by her participation in numerous national, state and local organizations dedicated to 

assisting victims of sexual assault and interpersonal violence. Such humanistic commitment has been officially noted 

by the Missouri House of Representatives which passed a resolution congratulating and recognizing her for outstanding victim assistance on behalf of victims of crime. She has also received many other honors in recent years. 

In summarv. . Dr. Resick is one of those extraordinary ~eoole who reallv has made a difference. Her creative . .. . innovations have generated new hope among the victims of rape and interpersonal violence by providing important new 

tools to the therapists who seek to help them. She has accomplished this while maintaining a determination to improve 

the world through social action without losing her warmth, humor, or zest for life. We areextremely pleased that she 

has joined the National Center and look forward to working with her closely in years to come. 

I 

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2 

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NCPTSD Clinical Quarterly Volume 12 (1) 2003 

-

NATIONAL CENTER FOR PTSD 


EDUCATION, TRAINING, & SUPPORT SERVICES 


PTSD Assessment Library 


Available upon request are selected instruments from our library of assessment and program evaluation tools (with 


accompanying articles), together with templates describing over 100 trauma-related measures courtesy of 


Beth Stamm, Ph.D., and Sidran Press. Telephone (650) 493-5000 ext. 22477. 


PTSD Article Library 


A helpful set of key articles on aspects of PTSD is available to VA or Vet Center clinicians free of charge. 


Telephone (650) 493-5000 ext. 22673. 


PTSD Video Library 


The Menlo Park Education Team maintains a small videotape lending library exploring topics related to 


PTSD diagnosis, evaluation, and treatment. Videotapes may be borrowed free of charge. Telephone 


(650) 493-5000 ext. 22673. 

PTSD Program Liaison and Consultation 


The Menlo Park Education Team can helu VA health care urofessionals locate needed resources. Services mav 


include assistance in locating relevant articles, locating resource persons, or problem-solving. Staff are available to 


consult in the areas of PTSD Diagnosis and Treatment, Program Development and Design, Women and Trauma, 


Relapse Prevention, and with other PTSD-related concerns.~ele~hone (650) 493-5000 ext. 22977. 


National Center for PTSD Web Page 


The NC-PTSD Home Page provides a description of activities of the National Center for PTSD and other trauma 


related information. The world wide web address is: http://www.ncptsd.org 


PILOTS Database 

PILOTS, the only electronic index focused exclusively on the world's literature on PTSD and other mental 

health consequences of exposure to traumatic events, provides clinicians and researchers with the ability to 

conduct literature searches on all topics relevant to PTSD. http://www.ncptsd.org/PILOTS.htrnl 

NC-PTSD Research Quarterly 

The Research Quarterly reviews recent scientific PTSD literature. Telephone (802) 296-5132 for subscription 

information. 

Disaster Mental Health Training and Consultation 

NC-PTSD staff provide disaster mental health training, including presentations and oneltwo day trainings 

sponsored by host agencies. Consultation regarding program development and other related technical 

assistance is available. Telephone (650) 493-5000 ext. 22494 or email: ncptsd@bruceyoung.net 

Conferences and Training Events 

The Menlo Park Education Team provides consultative support for the development of training in PTSD. Services 

include assistance in finding faculty and designing program content. Telephone (650) 493-5000 ext. 22673. 
NCPTSD Clinical Quarterly Volume 12 (1) 2003 

I 1 

WOMEN AND TRAUMA: Annabel Prins, P~.D. 


A CLINICAL FORUM NC-PTSD 


Clinical considerations in working with lesbian survivors of hate crime 

Annabel Prins, Ph.D.& Claire Sandringham, M.S. 

To date, large-scale epidemiological studies on the prevalence of trauma have not included hate crime 

as a specific traumatic event category (1). Similarly, studies on the psychological impact of trauma have generally excluded information on the sexual orientation of its participants (2). These are unfortunate omissions for 

two reasons. First, because hate crimes appear to be particularly traumatizing and second, because the "minority stress" associated with being gay, lesbian, or bisexual may significantly exacerbate responses to traumatic events (3,4). In this column, we will explore the prevalence and nature of traumatic experiences among 

lesbians with a specific focus on victimization experiences. We will then examine the psychological impact of 

bias-related events (i.e., hate crimes). We conclude by considering aspects of the recovery environment among 

lesbian women and exploring both positive and negative factors associated with recovery from a hate crime. 

Research in this area has encountered significant methodological problems in clearly defining lesbian 

status and the nature of victimization experiences. However, the evidence seems to suggest that lesbians, 

when compared with heterosexual women, report more experiences with physical and sexual abuse in childhood or adolescence. Tjaden et al., (1999) found that 59.5% of lesbians and 35.7% of heterosexual women 

reported a history of physical abuse (5). Sexual abuse prior to age 18 was reported by 16.5% of lesbians and 

8.7%of heterosexual women. It is not unreasonable to believe that these experiences may be related to genderrole nonconformity or to the coming out process (6). For example, in a sample of young adults, Pilkington and 

D'augelli (1995) found that 18% had been physically assaulted by a family member with clear and explicit references to their sexual orientation (7). 

Lesbians are also more likely than heterosexual women to have experienced physical and sexual assault as adults (5). For example, Tjaden et al., (1999) found that 25.3% of lesbians and 10.3% of heterosexual 

women reported a sexual assault after the age of 18. Herek and his colleagues report that 16.6% of lesbians in 

their sample had experienced a physical or sexual assault that was clearly motivated by hatred related to sexual 

orientation (3). Most of these assaults were identified as hate crimes based on verbal statements made by the 

perpetrator. A good example of this is provided by a lesbian whose love letters were found by a Sergeant in the 

Army: 

'The sergeant ....called me into his office and told me to explain the letters. When I refused,, he grabbed 

me by the collar and threw me up against the wall and told me he wasn't going to have any dykes in his company. 

He took me outside and said get in the jeep. Took me to the top of a [mountain]. Got out, pushed me against the 

side of the jeep and said he was going to show me what a real man could do. Said he was sick of all these 

lesbians. He said what Ineeded was a real man to bring me out of this gay shit". (8) 

Lesbians who have experienced a hate crime related to their sexual orientation are more likely than 

lesbians who have experienced a similar but non-biased related crime to report more severe (but not different) 

symptoms of distress, including PTSD symptoms (3). Lesbian survivors of hate crime also appear to have 

longer lasting psychological distress (approximately 5 years) than lesbians of non-biased crimes (approximately2 

years). Several hypotheses can be generated as to why these crimes may be particularly traumatizing. First, 

hate crimes are more often committed by multiple perpetrators and are more likely to involve physical injuries that 

require medical care or hospitalization. Second, the experience of a hate crime may have a profound effect on selfidentity and the coming out process. For example, hate-related victimization experiences may delay the coming out process due to fear of further violence. Herek and his colleagues found that hate crime survivors 

reported more vulnerability and fear of future crimes and less belief in the benevolence of others than lesbian 

and gay men of similar but non-biased crimes (3). Third, acceptance of the cultural myth that sexual abuse causes 

lesbianism may result in the survivor questioning her same-sex attractions and being open about her sexuality (6). 
NcPTSD Clinical Quarterly 	 Volume 12 (1 ) 2003 

WOMEN AND TRAUMA 

Certainly, hate crimes related to sexual orientation are less likely than other crimes to be reported to law 

enforcement authorities (9). The most obvious reason for non-disclosure and non-reporting is fear of secondary 

victimization (i.e., further mistreatment by others, including the police) and/or concern about the negative consequences of one's sexual orientation being publicly revealed (9). Despite significant changes in the past 10 years, 

most adults in the US still hold negative attitudes and beliefs about homosexuals. Herek (1994) found that higher 

levels of sexual prejudice were evident among individuals who were older, less educated, living in the US South or 

Midwest, and rural residents. Furthermore, sexual prejudice is positively correlated with authoritarianism, political 

conservatism, and fundamentalist religious beliefs (10). These may be important contextual features in the decision to disclose experiences of hate crimes to the police and/or health care providers. 

As suggested here, there are many considerations to be taken into account when evaluating the optimum 

recovery environment for lesbian survivors of hate crime. One important aspect involves careful assessment of 

sexual identity and extent of previous disclosure regarding sexuality/sexual orientation. Furthermore, in specific 

settings, disclosure of homosexual behaviors can lead to harassment, job loss and the risk of further hate crime 

victimization. One veteran's experience is captured in a recent study by Herek and his associates (9). 'We were 

in a foreign country and we were in the military. When inthe military you don't go to the police and say, 'Oh, they 

harassedusbecause wearegay". 

Closely related to this aspect of the recovery environment is the extent of social support available to the 

survivor. This is particularly significant for lesbians recovering from a hate crime, partly due to the self-doubt and 

questioning often generated by an attack related to their sexual orientation. 

Finally, there are various considerations to be made about those involved in the recovery environment of 

the survivor, especially those directly involved in the treatment process. One obvious factor concerns the gender, 

and possibly even sexual orientation, of the treatment provider. Furthermore, given societal trends related to 

sexual prejudice and the commonly held myths about sexuality and the nature of hate crimes, it is essential for 

treatment providers to evaluate their own biases and continually assess the impact of these biases on the recovery environment of the survivor. 

References 

1. 	 Breslau, N., Kessle, R.C., Chilcoat, H.D., Schultz, L.R., Davis, G.C., Andreski, M.A. (1998). Trauma and 

Posttrauamtic Stress Disorder in the community. Archives of General Psychiatry, 55, 626-632. 

2. 	 Kessler, R.C. (2000). Posttraumatic stress disorder: The burden to the individual and society. Journal of Clinical 

psychiatry, a,4-14. 

3. 	 Herek, G.M., Gillis, J.R., & Cogan, J.C. (1999). Psychological sequelae of hate crime victimization among lesbian, 

gay, and bisexual adults. Journal of Consulting and Clinical Psychology, 67,945-951. 

4. 	 DiPlacido, J. (1998). Minority stress among lesbians, gay men and bisexuals: A consequence of heterosexism, 

homophobia, and stigmatization. In G.M. Herek (Ed.),Stigma and sexual orientation: Understanding prejudice 

aaainst lesbians, aav men, and bisexuals (pp.138-159). Thousand Oaks, CA: Sage Publications. 

5. Tjaden, P., Thoeness, N., &Allison, C.J. (1999). Comparing violence over the life span in samples of same-sex and 

opposite-sex cohabitants. Violence and Victims, 14,413-425. 

6. Balsam, K.F. (2003). Traumatic victimization in the lives of lesbian and bisexual women: Acontextual approach. In 

T.L. Huges, C. Smith, and A. Dan (Eds.), Mental Health Issuesfor Sexual Minority Women: Redefinina Women's 

Mental Health (pp. 1-14). New York: Harrington Park Press. 

7. 	 Pilkington, N.W., & D'Augelli, A.R. (1995). Victimization of lesbian, gay, and bisexual youth in community settings. 

Journal of Communitv Psychology, 23, 33-56. 

8. 	 Herek, G.M., Cogan, J.C., & Gillis, J. R. (2002). Victim experiences in hate crimes based on sexual orientation. 

Journal of Social Issues, 58,319-339. 

9. 	 Berrel, K.T. (1992). Antigay violence and victimization in the United States: An Overview. In G.Herek and K. Berrill 

(Eds.), Hate Crimes (pp. 19-45). Thousand Oaks, CA: Sage. 

10. Herek, G. (2000). The psychology of social prejudice. Current Directions in Psvchological Science, 9, 19-22. 
NCPTSD Clinical Quarterly Volume 12 (1) 2003 

CLINICAL CONSIDERATIONS FOR 


TREATING SEXUALLY REVICTIMIZED WOMEN 


Amy E. Naugle, Ph.D., Kathryn M. Bell, M.A., & Melissa A. Polusny, Ph.D. 

The phenomenon of sexual revictimization among women 

who seek psychological services presents a unique and complex 

set of issuesfor clinicians. In this article, we provide an overview 

of the research on sexual revictimization and its related 

psychological consequences, as well as offer assessment and 

treatment suggestions for therapists working with sexually 

revictimized women. 

Overview of Sexual Revlctimlzatlon 

Definition and Prevalence 

Sexual revictimization generally refers to the relationship 

between experiences of childhood sexual abuse (CSA) and subsequent sexual victimization as an adolescentor adult. Research 

across a variety of samples and studies consistently has demonstrated that women with a CSA history are at significantly greater 

risk for experiencing sexual assault or other unwanted sexual 

experiences later in life (1-3). For example, Wyatt, Guthrie, and 

Notgrass (4) found that 56% of female CSA survivors reported 

adult sexual assault compared to 21% 

of nonabused subjects. In a study 

Symptom Checklist (TSC; 9)than women who reported only one 

type of victimization experience (lo), indicatingthe presence of 

more trauma-related symptoms. Moreover, Follette et al. (8) 

offer evidence forthe cumulative impact of multiple victimization 

experiences. Women who identified multiple types of 

victimization experiences reported increasing levels of posttrauma symptoms. Accordingto Cloitre, Scarvalone, and Difede 

(II), revictimized women are also more likely to attempt suicide 

and experience problems in areas such as intimacy and trust 

than either women who had never been sexually victimized or 

women who had been sexually assaulted only. 

Risk Factorsfor Sexual Revictimization 

Although the relationship between CSAand revictimization 

has been demonstrated by a number of empirical investigations, 

no theory accountingfor mechanisms mediatingthis association 

has been definitively supported. That beingsaid, a number of 

situational variables and both victim and perpetrator 

characteristics have been identified as potential riskfactors. One 

women who had experienced CSA drinking excessively, or some complex combination of sexual 

almost 5 times more frequently than these and other problems. victimization 

examining the relationship between CSA Revictimized women do not generally present for 

and revictimization among a sample of treatment with an articulated goal of dealing specifi1.887 female Navy recruits, the data cally with revictimization issues. 

suggested a significant relationship 


between CSA and adult sexual assault Rather, they present because they are depressed, 
 (5). After controlling for childhood anxious, having problems in relationships, 
 physical abuse, rape was reported among 

potential risk 

factor is the 

nature of the 

relationship 

between the 

victim and the 

perpetrator. For 

example, the 

majority of 

among -women with no CSA history. In 

one study investigating risk factors for sexual assault, Koss and 

Dinero (6) found that 66% of the women who reported rape or 

attempted rape also had prior childhood sexual experiences. Only 

the variables indicating past traumatic experiences improved 

predictions over base ratesfor identifying rape victims. Furthermore, resultsfromastudy onfemaleveterans(7) indicated that 

more than half of women who were physically orsexually abused 

or raped during childhood also reported abusive experiences 

duringadulthood, both duringand outside of militaryservice. 

The Impact of Sexual Revictimization 

Sexual assault has been associated with a number of 

physical, psychological, and interpersonal difficulties. These 

difficulties include anxiety, PTSD, depression, anger,self-injurious 

behavior,substance abuse, somatization, sexual dysfunction, and 

distrust of others (3). The severity of these problems becomes 

even greateramong women who have had multiple victimization 

experiences(8). Revictimized women scored higheron theTrauma 

experiences 

occur in situations where the victim and perpetrator know one 

another (12,13). In fact, some data suggest that women who 

are unsuccessful at resisting unwantedsexual advances are more 

likely to be involved in a steady dating relationship with the 

offender (14).Research has also suggested that higher levels of 

consensual sexual activity may lead to increased risk of sexual 

victimization (4,15- 17). Amongfemale Navy recruits, Merrill et 

al. (5) found that women with a CSA history reported having a 

higher number of sexual partners than women without a history 

of CSA. This is important information for clinicians. Often one 

therapeutic goal is to empower sexually victimized women to 

utilize skills to prevent future assaults. Given that sexual 

victimization generally is perpetrated by a man the woman knows, 

the nature of the skills to be utilized are qualitatively different 

than what is needed in stranger rapesituations. Simply instructing 

women to locktheirdoors and avoid walkingalone at nightare not 

sufficient for preventing the type of unwanted sexual experiences 

that typically occur. Therefore, incorporating intewentionsthatfocuson 

12 
NCPTSD Clinical Quarterly 

teaching women skills to thwart stranger attacks or to protect 

themselves once an attack has ensued may be helpful, these 

strategies are not sufficiently comprehensive. 

Some researchers have found that the use of alcohol or other 

drugs by both males and females in dating situations is also 

associated with increased risk for sexual assault (6,18,19). It 

has been argued that the use of alcohol or drugs reduces male 

inhibition againstforced sexual activity and impairsa woman's 

ability to resist an attackonce it occurs. In addition, alcohol use 

may impair a woman's ability to identify additional risk factors 

earlier on in social interactions that may lead to unwanted sexual 

activity. Alcohol use bywomen may contributeto misinterpretations 

of men's intentions as well ascontribute to psychoiogical barriers 

such as concern of embarrassment or fear of rejection that make 

it difficult to resist sexual advances (20). Some sexually victimized 

women may drink or use drugs in order to reduce distressing 

PTSD symptoms (21). Furthermore, alcohol intoxication that 

functions to decrease or dampen anxiety and discomfort may 

also reduce other internal experiences that otherwise serve as 

cues that something is amiss. Therefore, while substance use 

problems may or may not be the primary focus of treatment, it is 

crucial forclinicians to assess both the nature and function of a 

client's substance use. 

Researchers have investigated whether trauma related 

symptomatology might increase women's risk for being 

revictimized. In a 10-week prospective study of 323 college 

women, Sandberg, Matorin, and Lynn (22) found that PTSD 

symptoms moderated the effects of previous victimization on 

subsequentsexualassault. Revictimization was more likely among 

women who reported high levels of PTSD symptoms. Research 

has also investigated the role of other psychological phenomena 

that may be related to the presenceof PTSDsymptoms,such as 

alexithymia. Cloitre (23) hassuggested thatvictimized women 

who are more alexithymic, or have difficulties identifying and 

labeling feelingstates, possibly asa result of chronic hyperarousal 

symptoms, may be at increased risk for revictimization. Within 

the context of acquaintance rape, an alextyhimic woman's 

difficulties identifyingand labeling her feelings may contributeto 

sexual miscommunication as well as her "no" being minimized or 

disregarded by her partner. 

In addition to the risk factors described above, there has 

been an emerginginterest in identifying potential risk recognition 

and behavioral skills deficitsthat may be associated with increased 

risk forsexual victimization. Given the high rate of sexual assault 

among previously victimized individuals, researchers have 

attempted to explain why these individuals are at substantially 

greater risk. One possible explanation for why individuals with a 

CSA history are at greater risk for revictimization is that previously 

victimized women may havedifficulty assessing whether a social 

or interpersonaisituation is risky (24,25). In addition tothe riskrecognition hypothesis, Naugle (26)suggested that a prior victimization experience could result in an impoverished repertoire. 

That is, even if a woman could adequately identify danger or 

risk, she may still lack the requisite skillsfor effectively dealing 

with thesituation. Preliminary research providessomesupportfor 

this hypothesis. Usinga set of videotaped scenarios depicting 

Volume 12 (1) 2003 

TREATING REVICTIMIZED WOMEN 

interpersonal situations that might be related to sexual assault 

risk, Naugle(26)found that women with a priorvictimization history rated the vignettes as depicting more risk than did women 

who had not been sexually victimized. However, even though 

they rated the scenarios as being riskier, previously victimized 

women were more likely to acquiesce to the offers of the males in 

thevignettesthan were non-victimized women. 

Both the risk-recognition problemsandskillsdeficitsare not 

unrelated to the risk factors outlined above. Indeed, thesedeficits 

may be the result of chronic hyperarousai or emotional numbing 

that results from prior sexual abuse experiences (23). Such 

autonomic challenges may make it difficult for women to 

distinguish physiological changes that would normally signal a 

person to avoid or respond effectively to dangerous situations. 

Furthermore, alcohol intoxication and drug use are other factors 

that may impairjudgment and interfere with useof effective skills. 

It is important to recognize that research on risk factor sfor 

revictimization is correlational in nature. That is, we cannot say 

whether these particular skills deficits or psychological factors 

are causes of revictimization or whether they are consequences 

or outcomes of revictimization. Regardlessof the direction of the 

relationship between riskvariablesand revictimization, clinicians 

are challenged to address these issues, among others, when 

workingwith individualswho have been revictimized. 

Clinical Implications 

In working with revictimized women, the overarching goals 

for the clinician are twofold. First, intervention strategies should 

be aimed at reducing psychoiogical distress and improvingquality 

of life. Revictimized women do not generally present for treatment with an articulated goal of dealing specifically with 

revictimization issues. Rather, they present because they are 

depressed, anxious, having problems in relationships, drinking 

excessively, or some complex combination of these and other 

problems. Therefore, thisfirst goal of treatment involvesdecreasingthe distress that may have resultedfrom beingsexually victimized. Asecond goal is to specifically address riskfactorsforfuture 

revictimization and introduceskills to minimize risk. 

Orienting the Client tolreatment 

Working with sexually revictimized women inevitably will 

involve dealingspecifically with the sexual traumas at some point 

in treatment. This exposure-based therapeutic work will require 

individuals to recall distressing events associated with the 

trauma(s). Given the emotionally distressing nature of this treatment component, sexually victimized clients may be reluctant to 

begin and followthrough with treatment. In addition, childhood 

sexual abuse experienced by many women who present for treatment may have involved trusted adults who failed to provide 

protection and nurturance. These early experiences may result in 

clients being avoidant of close relationships, including the 

therapeutic relationship. Therefore, it is essential for the 

therapist to workearly on in treatment toestablish and maintain 

good rapport and trust with the client. Sexually revictimized 

clients may find it difficult to progress through certain components of therapy that are emotionally and physically draining. 

13 
NCPTSD Clinical Quarterly 

NAUGLE, BELL, & POLUSNY 

The therapist may need togently guide the clientthrough treatment without forcingtheclientto complete stepsprematurely. In 

order to maximize the likelihood that the client will successfully 

complete treatment, the therapist should make every attempt to 

set the client up for success when assigning new tasks for the 

client to complete. For instance, when learning new interpersonal skills, it may be useful to have the client practice these 

skills in settings where the client is likely to succeed before encouragingthe client to use the skills in more challengingsituations. Itmay also be helpful to discuss with theclient the potential for setbacks when trying new skills outside of therapy. By 

preparingthe client for possible relapses, the client may be less 

likely to discontinue therapy when asetback has occurred. Furthermore, it may be important for the therapist to periodically 

address behaviors that may be interfering with treatment 

progress. For example, a client may be hesitant to complete 

homeworkassignments that evoke negative emotions. The use 

of behavioral chain analyses may help the client understand how 

this avoidance of negative emotions hasfunctioned as a coping 

strategy in the past and howthe avoidant behavior may be preventing her from successfully meeting new goals. 

Assessment Issues 

Individualswho have been sexually revictimized may be at a higher 

risk for developing a number of Axis idisorders, including major 

depression, substance abuse/dependence, and post-traumatic 

stress disorder. Therefore, it is imperative that clinicians conduct 

a thorough assessment of the client's problems before proceeding 

with treatment. Acombination of self-report measures (e.g., Beck 

Depression Inventory, 27; Brief Symptom Inventory, 28) and 

structured interviews (e.g., Structured Clinical Interview for 

Diagnostic and Statistical Manual-IV [SCID-IVI, 29; Clinician 

Administered Interview for PTSD [CAPS], 30), as well as informal 

clinical interviews, can be used to assess the client's current 

symptomatology and overall level of functioning. Specific 

attentionshould be given to PTSD,depressive(includingsuicidal 

and self-injurious behaviors), dissociative, and substance abuse 

symptoms. An extensive clinical history should be conducted to 

gather detailed information on the client's traumatic experiences 

(includingnatural and man-made disasters) and the impact these 

experiences had on the client's life. In addition, the therapist 

should assessthe client's current livingsituation and relationship 

statusto determine the client's potential for sexual revictimization. 

Self-reported measuressuch as the Revised Conflict TacticsScale 

(31) may be useful in assessing the client's current and past 

physical victimization history. Sincevictimsof sexual assault may 

have an extensive medical history and are at a higher risk for 

somatization, the clinician should also conduct a thorough 

assessment of the client's physical health history. Additional 

information should be gathered regarding the client's coping 

strategies, history of interpersonal problems, and current level of 

social support. When developing a treatment strategy, the 

clinician should consider how the client's symptoms may be 

interacting with each other. For example, many sexually 

revictimized clients may use substances to help regulate and 

dampen their emotions. By teachingthe client more appropriate 

Volume 12 (1) 2003 

ways to effectively regulate affect, the client may be less likely to 

rely on substances to cope with negative emotions. Given the 

transient natureof many of thesymptomsexperienced bysexually 

revict~mizedclients, it is recommended that the therapist reassess 

the client's symptomatology and risk for revictimization 

periodically throughout treatment. 

...the first goal of treatment involves 

decreasing the distress that may have 

resulted from being sexually victimized. 

A second goal is to specifically address 

risk factors for future revictimization and 

introduce skills to minimize risk. 

In addition, assessment strategies that identify specific 

discrimination and skills deficits may allow us to develop 

intervention and prevention strategies to teach women to better 

identify environmental cues that indicate potential danger. 

Moreover, identification of specific repertoire deficits may aid 

in intervention components designed to establish orstrengthen 

the behavioral repertoires of survivors so that they can more 

effectively deal with high risksituations, while still establishing 

social behaviorthat allowsfor the pursuit of supportive intimate 

relationships. 

Intervention Strategies 

A number of empirically supported cognitive-behavioral 

interventionsexist for treatingspecific psychological problems 

that may be associated with a revictimization history. For example, cognitive therapy (32) and behavioral activation (33) 

have been demonstrated to be effective for reducing levels of 

depression. Anxiety management techniques are useful for 

addressing symptoms of anxiety and panic (34), and so on. 

However, it may be constructive toconsider implementingtreatment strategies designed to address the unique problems and 

concerns of revictimized women specifically. Cloitre (23) has 

proposed one treatment model for revictimized women that 

combines prolonged exposure techniques with additional affect 

regulation and interpersonal skills. 

TheSkillsTrainingin Affect and Interpersonal Regulation/ 

Prolonged Exposure (STAIR/PE; 23) treatment model was 

created to address the PTSD, interpersonal, and affect regulatory 

problemsoften experienced by sexually revictimized clients. The 

model contains two modules, which can be used separately or 

coniointlvduringtreatment. . , - Cloitrerecommends that theraoists 

consider using both components when the client is experiencing 

both significant skills-related deficits and PTSDsymptoms. The 

STAIR component typically involves eight sessions that focus 

on teaching clients to successfully identify and label various 

feelings, tolerate aveeive events and cope with negative affect, 

and effectively managechallenginginterpersonalrelationships 

through the use of self-control and assertiveness skills. 
NCPTSD Clinical Quarterly 

Cognitive-behavioral techniques are often used to encourage 

clients to monitor and rate their feelings, recognize and confront 

irrational thinking, and practice appropriate strategies for 

addressing difficult interpersonal situations. In addition, positive 

imagery and self-statements are often utilized to aid clients in 

regulating their emotions. 

Thesecond component included in Cloitre's treatment model 

involves the use of prolonged exposure to treat PTSD symptoms 

often experienced by sexually revictimized clients. Based on Foa's 

exposure treatment for rape victims (35), Cloitre's model 

recommendsthatthe client be gradually exposed to the traumatic 

memories both in and out of session while continuing to be 

encouraged to usecopingskills acquired in theSTAIR component. 

However, PTSD symptoms of sexually revictimized clients have 

also been effectively treated through the use of techniques such 

as Cognitive Processing Therapy (36) and Eye Movement 

Desensitization and Reprocessing (EMDR; 37). 

In addition to addressing psychological distress experienced 

by women who have been sexually revictimized, itisalso essential 

that treatment focus on strengthening behavioral skills necessary 

to prevent future occurrences of unwanted sexuai experiences. 

Given that revictimized women may have difficulty Identifying 

and responding to interpersonal and environmental risk, it may 

be important to teach clients howto recognize high-risksituations. 

Furthermore, teaching specific skills for dealing with high-risk 

encounters may also be essential. For example, assertion and 

communication in interpersonal situations and around sexuai 

negotiation may be particular areas to target in treatment. 

Teaching women to identify and express their own needs and 

preferences as well as how to be assertive in response to their 

partners' demands may help reduce incidence of sexual 

victimization. Revictimized women may benefit from therapy that 

resembles assertiveness training yet recognizes the complexity 

of the interpersonal relationships in which victimization occurs. 

Women may benefit from therapy focused on building relationship 

skills, strengthening personal values, and developing a sense of 

self worth that is lessdirectly influenced by the presence of others 

or by one's accomplishments and failures. 

While the assessment and intervention strategies described 

above are relevant to treating most sexually victimized and 

revictimized women, there may be unique issues involved in workingwith femaleveteransand military personnel. Women whoare 

currently enlisted in the military may face riskfactorsforvictimization that arespecifically related to their military involvement. For 

example, the disproportionate ratio of males to females in some 

branches of the military may contribute to a sexualized environment for women. Women in the military may have to withstand 

both more overt as well as more subtle forms of sexual coercion 

than otherwomen. Such issues may make it difficult for enlisted 

women to come forward when they encounter unwanted sexual 

experiences, especially when perpetrated by their male peers. 

Reports of sexual assault may not be taken seriously and making 

such claims may result in continued harassment by the assailant 

as well as by other male military personnel. Therapy may be the 

only safearena forfemale military personnel to talkabout their 

experiences. However, these women may not initially trust the 

Volume 12 (1)2003 

TREATING REVICTIMIZED WOMEN 

privacy and safety of the therapeutic environment and may be 

reticent to disclose information even to a therapist. Additional 

reassurance and time may be required to do thedemandingtherapeutic workdescribed above. 

Conclusion 

Working with sexually revictimized women necessarily involvestheclinician communicatingwith theclient about graphic 

details of rape and other traumatic experiences. This aspect of 

treatment may be personally distressingfor many clinicians, and 

may result in changesin their own worldview. Additionally, McCann 

and Pearlman (38) havesuggested that clinicians doing trauma 

work may experience "vicarious traumatization", or traumatic stress 

reactionsthat occur after hearing accounts of victimization during 

therapy. Clinicians may find themselves experiencing intrusive 

recollections of details of their clients' trauma histories revealed 

duringexposure work, avoiding situations that are perceived as 

dangerous, as well as experiencingstrongemotionssuch as sadness, anger, and disgust (36). Moreover, these reactions may 

influence clinicians' in-session behavior in ways that make treatment ineffective oreven harmful. For example, clinicians who are 

distressed by hearingabout details of clients'victimization history 

may avoid processingthese details in therapy. Focusingon skill 

deficits that may increase a client's riskfor revictimization without 

also validating how prior victimization may have interfered with 

the development of effective skills may be perceived as blaming 

andjudgmental. The therapeutic relationship is an important tool 

that allows clinicians to model and reinforce a more effective 

behavioral repertoire for successful living and prevention of furthervictimization. Given this, it is important that clinicians utilize 

appropriate supervision and consultation, as well as personal 

therapy if indicated, to remain effective and empathic in their 

work with revictimized women. 

References 

1.Breitenbecher,K. H. (2001). Sexual revictimization amongwomen: 

A review of the literature focusing on empirical investigations. 

Aggression and Violent Behavior& 415-432. 

2. Messman,T. L., & Long, P.J. (1996). Child sexual abuse and its 

relationship to revictimization in adult women: A review. 

Psvcholom Review, 16,397-420. 

3. Polusny, M. A., & Follette, V. M. (1995). Long term correlates of 

child sexual abuse: Theory and review of theempirical literature. 

Applied and Preventive Psvchology, 4,143-166. 

4. Wyatt, G. E., Guthrie, D., & Notgrass, C. M. (1992). Differential 

effects of women's child sexuai abuse and subsequent sexual 

revictimization. Journal of Consultingand Clinical Psvchology, 

60. 167-173. 

5. Merrill, L. L., Newell, C. E., Thomsen, C. J., Gold, S. R., Milner, J. S., 

Koss, M. P., & Rosswork, S. G. (1999). Childhood abuse and 

sexuai revictimization in afemaie Navy recruit sample. 

of Traumatic Stress, 12,211-225. 

6. Koss,M.P., &Dinero, T. E (1989). Discriminant analysis of risk factorsfor 

~xuaivictim'kationamonganationalsampleofmliegewomen, 

of Consulting and Clinical Psvcholof^y, 57,242-250. 

7. Coyle, B. S., Wolan, D. L., &Van Horn, A. S. (1996). The prevalence of 

phys'miandsexualabuselnwomenveteransseeMngcareataveterans 

affairs medical center. Miiitaw Medicine, 5%493, 
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8. 	 Follette, V. M., Polusny, M. M., Bechtle, A. E., & Naugle,A. E. (1996). 

Cumulative trauma effects: The impact of child sexual abuse, 

adult sexual assault, and spouse abuse. Journal of Traumatic 

m,9,1525. 

9. 	 Briere, J.,& Runtz, M. (1989).TheTrauma Symptom Checklist (TSG 

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Guilford Press, 

Amy E. Naugle, PhD, is Assistant 

Professor in the Department of Psychology 

atWesternMichiganUniversity. Dr. Naugle's 

research and clinical interests focus on the 

psychological, behavioral, and inteipeisonal 

outcomesassociatedwitha history of sexual 

traui'na. 

KathrynBellis a doctoral student in clinical 

psychology at Western Michigan University. 

Her primary research and clinical interestsare 

centered on understanding and treating adult 

sexual and physicalvictimization. 

Melissa A. Polusny, PhD, is staff 

psychologist at the Minneapolis Veterans 

Affairs Medical Center, and Assistant 

Professor in Psychiatry at the University of 

Minnesota.Dr. Polusny's research and clinical 

interests include acceptance theory, long term 

correlates of sexual trauma including 

revictimization, disaster mental health issues, 

and die impact of trauma exposureand emotion regulation on health outcomes.