Joanne L Davis Heidi S Resnick and Rachael M Swopes

According to a national survey, approximately 18% of American women will experience an attempted or completed rape in their lifetime.1 The course of recovery following a sexual assault may vary across individuals as a function of different factors including individual, event-related variables, pre- and postassault stressors, social support, and prior learning history.2 Some people may experience few symptoms until days, weeks, or months after the assault. Some people may naturally heal from a trauma and not ever experience more than transient adverse reactions, while others may develop symptoms of psychological disorders.3 However, when someone experiences a traumatic event and resulting symptoms, she may wonder "Is this normal?" "Will I get better?" "Do I need to get some help?" or "Am I alone?" She may believe that life will never be the same again or not know what to expect in terms of recovery, or if recovery is even a possibility. The survivor may wonder if there is anyone out there who can help her through this difficult situation.

Psychoeducation provided after a traumatic event can help answer these and other questions for the survivor, as well as her friends and family. Psychoeducation also can provide information about adaptive coping strategies that can be utilized to minimize some of the naturally occurring posttraumatic distress.4 According to Phoenix, such strategies can also be used to avoid maladaptive strategies such as substance use that might lead to increased symptoms or adverse long-term consequences.4 While psychoeducation has the potential to provide benefits to survivors of sexual violence, limited research has examined the efficacy of psychoeducation alone to impact short- and long-term outcomes in terms of symptoms and function ality following sexual violence. Our chapter focuses primarily on the use of psychoeducation as a component of secondary intervention approaches in which information is delivered relatively soon after a highly stressful event (e.g., assault) has occurred. In addition, our primary focus is on effects of sexual violence occurring to adult women. It should be noted, however, that psychoeducation content describing possible reactions following a traumatic event, the theories behind development and maintenance of such reactions, and strategies for successful coping and related rationale are also integral components of traditional (e.g., tertiary interventions) treatment for post-traumatic stress disorder (PTSD) and other psychological disorders,5,6 as well as included within multiple-session early interventions that also include additional treatment strategies such as imaginal and in-vivo exposure to trauma-related cues.7,8

WHAT IS PSYCHOEDUCATION?

Psychoeducation is considered delivery of information aimed at preventing or reducing problems following exposure to a potentially traumatic event and that may be used with individuals prior to exposure to an event or as secondary intervention to prevent or reduce problems that may develop after an event has occurred.9 The content may include information about psychological or behavioral reactions that may occur, as well as coping strategies that may be helpful. As noted by Wesseley and colleagues, information may be provided in different ways, and these might include written materials, direct verbal communication, or other media such as video, audio, or web-based delivery.9 These methods may vary from purely informational, or passive, approaches to more active therapist-led interventions.10 For example, one might hand out pamphlets or brochures. The Internet is now an easily accessible way to distribute large amounts of information. Help lines and call centers may be able to provide information to someone in crisis, and widespread media outlets such as television or radio are efficient ways to disseminate information. Self-help books attempt to provide step-by-step guidance through a crisis. In addition, some counselors are trained to provide psychoeducation either as stand-alone services or as part of larger interventions. Psychoeducation provides information but may also include additional components, such as teaching cognitive behavioral tasks.10 It is important that content and delivery modes be evaluated in terms of possible efficacy and effectiveness of information delivery. Additional information will be provided later in this chapter regarding extant knowledge about efficacy of these various techniques.

IMPORTANT ELEMENTS OF PSYCHOEDUCATION

Phoenix discussed several key content areas that are often included in psychoeducation programs for trauma survivors.4 First, information may be presented on the body's natural responses to stressful situations. This information can help normalize reactions that the individual may be experiencing, as well as provide information regarding what to expect in the future. Second, information may be discussed regarding trauma history and previous attempts at coping with stressful events. Third, general information related to the traumatic event or common reactions that may follow exposure may be presented. Fourth, the survivor may be taught new skills for coping with negative reactions (e.g, relaxation exercises, deep breathing, and ways to manage stress). Of course, this type of skills training is also part of various treatment approaches (e.g., cognitive-behavioral therapy), and as previously discussed, the literature is not always clear regarding what falls under the broad umbrella of psychoeducation.

Another important element to include is information identifying which reactions to trauma may benefit from more formal help seeking. Teaching an individual when to ask for help can be invaluable, as many people do not seek help following a traumatic event.11 They may be afraid that they will be stigmatized for admitting that they were the victims of a trauma or that they need help. People may believe that they can handle it on their own, or they might believe that no treatments are available to help them with their symptoms. Educating survivors on the range of treatments available for common post-traumatic symptoms, such as PTSD, depression, or increased anxiety or substance use, might empower them to seek help. Psychoeducational materials could provide referrals to local clinicians or agencies along with specific information regarding available resources in the community. While many elements of post-trauma recovery are similar across types of traumatic events, the following provides information specific to sexual violence.

PSYCHOEDUCATION SPECIFIC TO SEXUAL VIOLENCE

Whether provided as a stand-alone intervention or part of a broader treatment intervention, a number of areas of information may be helpful to discuss with survivors, and potentially family members and friends, including facts about sexual violence, common immediate and long-term effects, positive coping skills, and times of high risk for relapse.

FACTS ABOUT SEXUAL VIOLENCE

Survivors of sexual violence may often feel that they are alone in their experience because they are not aware of how many other women have had similar experiences. It may be helpful for survivors to know that, unfortunately, sexual violence is far too common in our society. In addition to forcible rapes that include physical force or threat and that may include injuries related to assault, another type of rape occurs when a woman is incapacitated due to alcohol or drug use (incapacitated rape, or IR) and incapable of consent or control of the situation or when a drug is administered without knowledge or permission of the victim (drug or alcohol facilitated rape, or DAFR).12 Kilpatrick and colleagues found that 14.6% of women in a general population sample reported a lifetime history of forcible rape while 5% reported a history of DAFR/IR.12 Kilpatrick and colleagues also studied the prevalence of these types of rape within a college sample of women and found that 6.4% reported a lifetime history of forcible rape and 6.4% reported a lifetime history of DAFR/IR.12

Sexual violence that entails unwanted sexual contact or attempted sexual assault, whether due to force or threat or incapacitation of the victim, is not the fault of the victim. Unfortunately, however, victims of sexual violence often blame themselves for the assault.13 It is important that the survivor receive the message from friends, families, and professionals that regardless of what she did or did not do during the assault, it is not her fault. People do what they need to do during an assault to survive it—sometimes this may be attempting to fight the attacker off, sometimes this may be acquiescing to the perpetrator's demands. Whatever the survivor did may have helped her live through the experience.

COMMON EFFECTS: IMMEDIATE AND LONG TERM

People respond to sexual assaults in a number of ways. Some feel acute distress, while others may feel little distress at first or may be in a state of shock or feel numb, then experience more difficulties later on, sometimes even years after the event. Still others report experiencing few difficulties at all.214 Recovery may also seem like a "one step forward, three steps back" kind of process at times, which can be very frustrating and may increase feelings of hopelessness and distress. Some individuals may be at higher risk for experiencing significant distress following a sexual assault. For example, research finds that individuals who have a previous history of trauma, which is not uncommon among victims of rape,15 may experience a cumulative impact of these events and experience more symptomatology than someone without a previous history.1617 Individuals whose lives were threatened or who perceived life threat may also be at greater risk for significant distress.18

Most individuals who report experiences of sexual violence to police, rape crisis, or other authorities appear to experience initial symptoms of PTSD,19 although not everyone will meet criteria for the disorder. PTSD includes three categories of symptoms including reexperiencing symptoms (e.g., flashbacks, nightmares, intrusive thoughts), avoidance symptoms (e.g,. not talking or thinking about the assault as well as avoiding people, places, and situations that remind them of the assault), and hyperarousal symptoms (e.g., always feeling on guard, difficulty falling or staying asleep).20

At first, these symptoms may be helpful—indeed acute responses of physiological arousal, hypervigilance, and so on, may have been what helped survivors to make it through the experience. They become problematic, however, when they keep occurring, after the danger is gone. Also, survivors may begin to be afraid of and react to things, people, and situations that are similar to the assault but were not present during the assault. For example, rape victims may grow to fear men who look like the perpetrator, then perhaps most men. When survivors fear an increasing number of people, places, or things, they are likely to experience physiological and psychological responses to these stimuli and begin to avoid them. Not only will this restrict a person's life considerably, but it will keep the survivor at a high state of arousal, which may wear her down psychologically and physically.17

Other consequences after a sexual assault may include feeling confused, angry, sad, anxious, and afraid, having panic attacks, interpersonal problems, self-destructive and impulsive behaviors, dissociative symptoms, somatic complaints, feelings of shame, despair, and hopelessness, and social withdrawal.23 Experiencing a sexual assault can also change how we think about ourselves, other people, and the world.21 This may happen particularly in the areas of powerlessness, esteem, safety, intimacy, and trust.22 In fact, these areas have been called "stuck points"25 and may be related to significant negative emotions and behaviors during wake time and may also show up in bad dreams and nightmares.

COPING SKILLS

As noted above, psychoeducation also may involve information on coping skills. Although this may overlap with more in-depth therapeutic interventions, many coping skills do not require the assistance of a mental health professional. If survivors have not had an occasion to develop such skills in the past, however, the assistance of a mental health professional may be useful. Coping strategies generally fall into one of two categories—adaptive or maladaptive. Adaptive strategies include those that will draw on the survivor's natural strengths and help her to feel mentally and physically better. In the days and weeks following the sexual assault, self-care is very important, especially making sure that basic needs are being met, particularly for those areas comprising three primary indices of health: healthy eating, exercising, and sleeping well.

Many resources are available to help survivors cope with the experience of sexual violence. Maintaining a routine as much as possible including attending school, work, and social activities is important. While survivors may feel like isolating and withdrawing from others, it is important to utilize those social supports and activities that have helped in the past. These natural resources often include social supports that the individual typically turns to in times of stress: family, friends, community, and spiritual connections. While survivors may not wish to disclose everything about their experience to everyone, it may be important for them to let some people know that they are going through some hard times and need extra support.

If survivors do choose to disclose their experiences, they will likely come across a variety of responses. People often do not know how to respond to disclosures of sexual violence and reactions may range from support and love to anger at the perpetrator and desire for revenge to disbelief. Negative reactions to sexual violence disclosures are not uncommon.23 There are numerous reasons why people have negative reactions, and even those who are generally supportive may have a difficult time coping with and understanding this event.16 While there is little information on why others may react negatively, we do know that negative responses may be related to increased symptoms for the survivor and self-blame.16 If survivors are struggling with sexual violence and have had difficulty with others' responses, it may be helpful for them to attend a support group of sexual violence survivors.

Many survivors benefit from engaging in activities to help themselves feel mentally and physically stronger. Some activities include working out at a gym or at home, taking a martial arts class, and learning other means of self-defense. Another way for survivors to feel empowered is to identify those situations or places that are not actually dangerous, but in which they feel afraid and try to face those head-on. This is generally called exposure and involves gradually facing fears until the situation no longer produces feelings of anxiety. Exposure is a key component of many of the best treatments available for PTSD, and some people will feel more comfortable trying this technique with the assistance of a mental health professional.

Many also find healing and empowerment from giving their time, money, or attention to others who have been through similar experiences.

Generally, survivors would not do this until they have experienced significant healing and recovery from their own experiences. There are a number of ways to give back, including volunteering for agencies that target sexual violence, becoming a sexual assault advocate, working to raise awareness of the issue, and helping community efforts to fight crime in general.

Other potential coping strategies include finding ways of reducing one's overall level of physiological and psychological arousal, becoming more relaxed and calm. Yoga, meditation, or progressive muscle relaxation may be helpful in learning new strategies for achieving relaxation in this stressful time. Bookstores often sell audio versions of relaxation scripts that survivors can listen to and follow along with when feeling distressed. It is important to keep in mind, however, that while many of the strategies mentioned above may be helpful, there is limited evidence to indicate that they will lead to long-term recovery on their own. Recovery will likely take engaging in a number of these strategies, the support of others, and possibly the help of a mental health professional who specializes in treating survivors of traumatic events.

Following a highly stressful or traumatic event, people may also engage in maladaptive coping strategies, especially if they have not learned adaptive coping strategies. Maladaptive strategies include drinking alcohol, using illicit drugs or misusing licit drugs, smoking, isolating from others, over- or undereating, and over- or undersleeping. Some of these strategies may be comforting and provide short-term relief from or avoidance of distress but are unlikely to be helpful in the long term and may actually be quite harmful. In general, attempts to escape from or avoid talking about or working through the assault for extended periods of time are associated with greater, not lesser distress.24 Thus, psychoeducation can address these pitfalls and provide information about strategies to counteract such behaviors.

When to seek additional help. Knowledge can be very empowering, and understanding the facts about sexual violence and its aftermath, engaging in coping strategies that are based on empirically supported cognitive behavioral approaches, seeking help and support from friends and family, and taking care of themselves may be sufficient for some people to alleviate some distress and/or promote adaptive coping following an assault. For others, this may not be sufficient, and further help may be needed. Typically individuals choose to seek professional help when they are having a hard time doing things they used to do, including attending school, working, and engaging in social activities. While it is not unusual for these "normal" activities to be interrupted in the immediate aftermath of sexual violence, if the survivor continues to experience difficulties a few weeks following the event, she may want to talk to a mental health professional. Even if the survivor has made significant progress, there may be times when she may experience an increase in her distress level. New experiences of significant life stressors or additional traumatic events, anniversaries of the sexual assault, or encountering trauma-related stimuli may lead to increased distress.

This book describes a number of treatment options that exist for individuals who may be struggling to cope with the sexual assault on their own and want to seek professional help. Many of these treatments have been tested by researchers. The treatments have varying levels of study and support. A number of manuals are also available for use by practitioners and some for use by survivors themselves and are identified at the end of the chapter. Most approaches will include psychoeducation as well as in-depth intervention content.

EVIDENCE FOR USE OF PSYCHOEDUCATION

A recent (2008) series of articles in volume 71, issue 4, of the journal Psychiatry raised key issues about psychoeducation, including how to define it, limitations of existing data about its efficacy, and recommended future research questions and approaches. As noted by Wesseley and colleagues, research is needed to determine which types of information might be helpful, harmful, or have no appreciable impact.9 They suggested that a potential negative consequence of psychoeducation is that symptoms might be prescribed or suggested when they otherwise might not be problematic and that psychoeducation might interfere with other naturalistic approaches to recovery such as use of existing social support networks.

Potential benefits of psychoeducation and risks of not providing information that might be helpful were also discussed,5 6 25 as was the need for theoretical underpinnings, broader conceptualization of what might be in-cluded,26 and questions of what might constitute sufficient and ecologically valid approaches.27 The need for evaluation of psychoeducation was consistently recognized, and suggested factors to be controlled for or further studied included content, context of information delivery, targeted population (e.g., all exposed or those with risk factors that might include symptoms predictive of later problems, prior history of victimization), timing relative to event, duration, and depth of focus. The suggestion by Wesseley and colleagues to tailor content in ways that are designed to foster resilience was consistently noted as an optimal approach.9

Three studies cited by Wesseley et al.9 evaluated the use of psychoeduca-tion booklets given to individuals who had experienced a variety of traumatic events that led to injury28 29 or automobile accident victims30 who sought emergency hospital treatment. These studies, as well as a fourth study that included education alone as a condition compared with debriefing and assessment only in a mixed group of violent crime victims,31 are reviewed here. Psychoeducation content in all cases appeared to include information about symptoms and possible help available. Content beyond that was difficult to determine across studies without more information. The content in the booklet used in the Scholes et al.31 study may have been most comprehensive and was briefly described as including information about cognitive behavioral strategies to prevent or reduce symptoms associated with traumatic events.

The time of delivery of content across studies ranged from an average of three weeks postevent,33 at least two weeks but within one month,31 approximately one month,32 or six to eight weeks postevent.30 Participants in two of the studies were prescreened as either having symptoms indicative of acute stress disorder and increased risk of subsequent PTSD31 or meeting symptom criterion score after an initial three-week assessment period.32

Results of two studies indicated significant reductions in symptoms of PTSD, depression, and/or other anxiety across time, with no differences as a function of psychoeducation as compared to assessment only or debriefing33 or similarly high risk control.31 Results of Ehlers et al.32 were that attending multiple sessions of cognitive behavioral therapy was associated with significant reduction in PTSD, depression, anxiety, and disability compared to assessment only or self-help booklet. They also found that the self-help booklet did not appear to be more helpful than assessment only and was associated with poorer end state functioning and lower prevalence of asking for treatment. Findings from the Turpin et al.30 study indicated reduced symptoms over time and few differences associated with psychoeducation. They reported that those in the control group were less depressed at follow-up and that there was a nonsignificant trend for higher reduction of PTSD cases in the control group as well. The authors raise the issue of potential lack of representativeness of recruited participants (approximately 10% of those who were eligible to participate). Those assigned to treatment and control groups did not differ on baseline measures of functioning; however, the extremely low recruitment rates in some studies call into question representativeness and make it difficult to evaluate utility of information that may be targeted broadly to the population seen in specific settings.

A limitation of the studies reviewed above is the lack of information about potential utility of psychoeducation delivered much sooner after an event has occurred. If information might usefully prevent or reduce symptoms of PTSD or other problems such as potential for alcohol or drug use as an avoidant coping strategy, it would be important to evaluate such strategies at earlier time points following a potentially traumatic event. As suggested by Kilpatrick, Cougle, and Resnick,27 research that evaluates specific psychoeducation content in the early aftermath of traumatic events is warranted to answer questions about the utility of specific content of information as a preventive intervention. Such data would be useful in terms of evaluating types of informational messages, if any, in the shorter-term aftermath of specific stressor events. It is also important to consider the representativeness of samples included in such studies, whether or not they are selected based on additional risk characteristics.

EVALUATION OF PSYCHOEDUCATION IMPLEMENTED FOLLOWING RAPE OR OTHER SEXUAL ASSAULT

Psychoeducation alone or as part of multiple-session treatment has been evaluated within studies of early post-sexual-assault interventions designed to reduce acute distress and prevent or reduce longer-term problems such as PTSD. Mixed findings have been observed related to psychosocial early interventions that include psychoeducation as one component among cognitive behavioral approaches delivered within one month after a sexual assault. For example, Kilpatrick and Veronen found symptom improvement among victims of rape who received four to six hours of an early cognitive behavioral skills-based intervention between six and twenty-one days postassault, but improvement was not greater than that seen in the control group.32 Foa and colleagues found that a brief multisession cognitive behavioral intervention delivered within one month postassault (including rape) was associated with reduced prevalence of PTSD post-treatment but not at a follow-up at 5.5 months postassault.33 A subsequent study found reduced symptoms of PTSD and general anxiety associated with cognitive-behavioral treatment relative to supportive counseling at three months pos-tassault but not at longer-term follow-up.34 Foa and colleagues noted that finding may be consistent with cognitive behavioral intervention affecting earlier recovery postassault.35

With regard to interventions that may be more consistent with psychoed-ucation delivered apart from additional intervention components directed by a therapist, Resnick, Acierno, and colleagues developed a psychoeduca-tional cognitive-behavioral intervention delivered in a video format titled Prevention of Post-Rape Stress.35 The video comprises two major components: 1) Medical Exam Preparation, which includes information about the medical exam, supportive messages from health care providers and rape crisis advocates, and a woman modeling positive coping (not blaming self, positive statements about care seeking) during the exam; and 2) Steps to Recovery, including description of reactions that may occur during (e.g., panic or other physiological, cognitive, or behavioral reactions) or in the days and weeks after an assault, modeling of coping strategies in the aftermath of assault that are based on cognitive-behavioral approaches including in-vivo graduated exposure, behavioral activation, identification of cues or situations that may be associated with drug or alcohol use, and promotion of activities and contexts that do not involve substance use. A learning theory model of possible later reactions to reminders of assault is presented to promote a sense of understanding of how reactions may be maintained over time and to provide a rationale for in-vivo exposure exercises and strategies to counter potential avoidance behaviors including use of drugs or alcohol.

Extant studies of the Prevention of Post-Rape Stress intervention have been conducted with samples of those consecutively seeking post-rape medical care, without screening to identify individuals at additional high risk based on initial symptom profile. It should be noted, however, that over 90% of such patients may report symptoms sufficient to meet PTSD criteria at two weeks post-rape,22 and as such they may be considered fairly high risk across the board. Preliminary data reported by Resnick and colleagues indicated that women who were shown the video were less distressed immediately following the medical exam, controlling for pre-exam self-reported distress.37 Results indicated differences between women who had experienced prior sexual violence and women who had no previous history of sexual violence. Specifically, women who had experienced previous sexual violence showed positive effects of the treatment video in that they endorsed reduced frequency of PTSD and depression symptoms at a six-week follow-up. At the six-week follow-up, women in the video condition with no history of sexual violence had a higher PTSD symptom frequency count, but this effect was no longer statistically significant by the six-month follow-up.20 A second report of findings with a larger sample of 268 participants found that among women and adolescents who reported recent preassault marijuana use, those who were in the intervention condition reported significantly lower frequency of marijuana use at each assessment point through six months postassault than preassault marijuana users who received standard care alone.36

Current research is ongoing to evaluate potential effects of the two-part Prevention of Post-Rape Stress intervention (NIDA, R01DA023099; PI Heidi Resnick and Patricia Frazier). Another study is currently evaluating the Steps to Recovery component only. While previous research examined the use of the full intervention shown prior to the sexual assault exam, a study currently under way is evaluating implementation of only the Steps to Recovery component of the video shown immediately after the sexual assault exam has been completed (OCAST HR-08-017, PI Joanne L. Davis). There are several potential advantages to such an approach, including shortening the amount of time needed to deliver the intervention by almost half and allowing for further refinement and focus on potential key psychoeducation elements. The advantageousness of this approach, of course, also hinges on demonstration that the shorter Steps to Recovery component delivered postexam is efficacious in terms of reduced distress at the medical exam time frame and/or reduced frequency of psychological reactions and targeted behaviors at later follow-up assessments.

Despite potential limitations in terms of longer-term effects (six months postassault) with regard to PTSD and depression symptoms, and limited extant research in general, whether psychoeducation delivered at early points or in specific contexts such as postassault medical care is beneficial in terms of prevention, early reduction of symptoms, or as a means of increasing knowledge about and accessing more in-depth services if needed, remain questions of interest with broader implications. Sexual assault victims who seek immediate postassault medical care are a high-risk group in terms of PTSD and other potential problems such as substance abuse. The medical exam is conceptualized as a potential stressful experience, and there may be benefit to providing information about adaptive coping skills, understanding of potential reactions, and supportive information. The focus at the medical exam is on compassionate and professional care as well as gathering forensic evidence in cases in which a criminal case is being investigated. Thus, complementary information about psychological reactions and ways to achieve a successful recovery may be feasible to incorporate if accepted by medical personnel and patients alike. If such content is helpful for some women in the medical exam context and in the initial weeks postassault (particularly women who may be most vulnerable in the aftermath of assault), the benefits of including it may outweigh the risks. The data from one study indicate that there may also be longer-term positive effects in terms of some behavioral outcomes.38

In addition, based on the extant literature, it would be expected that inclusion of additional, more in-depth content and multiple delivery or access opportunities would enhance efficacy and perhaps be associated with longer-term effects. It is possible that early psychoeducation may be beneficial as part of a more stepped approach in which booster content and integration with subsequent additional sessions or content is delivered. Such an approach was used by Zatzick et al., who implemented a motivational interviewing treatment targeting alcohol abuse at a hospital trauma unit for accident or assault victims who were positive for alcohol use and who were randomly assigned to treatment.43 Booster sessions and case management were conducted over the course of follow-up, and empirically supported treatment for PTSD was offered for those who met criteria at three months postinjury. Those assigned to treatment were less symptomatic on measures of PTSD and less likely to meet criteria for alcohol abuse than those receiving standard care at long-term follow-up. Additional research is needed to evaluate whether psychoeducation is beneficial, optimal timing of delivery, coordination with other treatment components, and specific populations and contexts in which it might be helpful or potentially harmful. Future research might usefully explore whether psychoeducation at an early post-treatment time point would enhance efficacy of components delivered subsequently.

HOW DOES IT WORK?

This section is somewhat limited, given the few studies that find support for early, brief psychoeducation designed to promote recovery and to prevent or reduce PTSD symptoms or other problems that may occur following sexual assault. Theoretically, the research reviewed in the preceding section (with regard to psychoeducation integrated within multiple-session cognitive-behavioral therapy or as a more stand-alone approach) is conceptualized within behavioral and cognitive frameworks, and the psychoeducation content reflects an emphasis on nonavoidance of realistically safe cues, and other positive coping strategies such as engaging social support, maintaining positive activities, and not using drugs or alcohol to cope with distress. As such, the content included may be consistent with recommendations for promoting resilience, rather than symptom prescription, by fostering adaptive coping. The findings reported by Resnick et al.20 indicated a significant moderating effect of prior history of rape on reported psychological distress outcomes. It was hypothesized that women with a prior history of assault, who were also at risk of more severe problems following a new assault, might have more of a range in terms of functioning such that the intervention could be helpful. It was also suggested that they might better understand the content of the intervention, and it may have been more salient given their prior history of assault and/or subsequent reactions including PTSD. Further examination of prior assault history or other factors that may relate to positive or negative effects of psychoeducation are critical to explore in additional research and have implications for future use of such interventions as broad based or restricted to groups that are high risk or most likely to benefit.

Given the potential for negative experiences or negative perceptions related to medical or legal service interactions by some sexual assault victims,37 content promoting a supportive response on the part of health care and other service providers as well as content addressing blame attributions may positively impact the experience of women or adolescents at the time of the medical exam and/or help to promote cognitive interpretations about the incident that would be consistent with adaptive perspectives of perceived blame and/or control. Other possible factors include potential reduction of acute distress that may then affect strength of conditioned cues or avoidance behaviors.7

As noted by Resnick et al.,38 there is empirical support for use of brief intervention strategies for substance abuse targeting both drug and alcohol abuse.38,39, 40,41 Such brief interventions include individualized assessment and targeted feedback or strategies. The psychoeducation intervention reported in Resnick et al. was broad based, and thus content was not tailored based on individual history or attitudes regarding problem use or behavior change.38 Information was presented that "some" women or girls may use more alcohol or drugs after an assault. Specific brief content was included that was designed to promote identification of situations that may be high risk for use of drugs or alcohol and engagement in activities in which drug use was not a component. In addition, discussion of avoidance of painful emotions via use of drugs or alcohol was included with disadvantages noted (potential for prolonged recovery period and risk for safety). It is possible that content directly related to potential disadvantages of drug use and strategies for coping or activities that do not involve drug use was helpful. In addition, content related to acceptance of emotional reactions such as sadness as painful but not dangerous may also decrease avoidance.

As suggested by Ruzek28 and emphasized by Feldner and colleagues,7 research that includes development and clarification of theoretical rationale underlying proposed intervention and careful measurement of potential effects is needed. Thus, research should move beyond assessment of symptoms over time. As they noted, measurement strategies should include evaluation of change in variables that are proposed as critical or important and that are targeted by intervention content. Examples may include knowledge change based on content delivered, changes in physiological arousal, use of social support, as well as changes in beliefs and/or changes in behaviors that are specifically addressed and that may mediate observed differences in functioning or quality of life. Measures of positive functioning as well as distress would also be consistent with evaluation of psychoeducation content designed to promote resilience.

SOURCES AND TOOLS

The information above may be helpful for the survivor to understand in order to move forward and continue on their road to recovery. Often, simply "knowing" this information is not enough—many people need to talk about what they are going through, read about the issue, or talk to others who have gone through similar experiences. Luckily, there are many resources that survivors can access for information on sexual assault and recovering from sexual assault. Survivors may want to speak to a mental health practitioner. A psychologist, psychotherapist, or counselor is someone with training in helping people with many different types of problems and issues. An important consideration for sexual assault survivors who may be interested in seeking help from a mental health practitioner is whether or not to find someone who has specialized training in issues of trauma and victimization. While many mental health practitioners have skills and knowledge that can be helpful, not all are familiar with the specific struggles facing survivors of sexual assault. Survivors may request the name and contact information for trauma specialists in their area from their primary care physicians, spiritual leader, the local mental health association, or state licensing boards for psychologists, social workers, and counselors. There are also databases established by professional organizations that list professionals and their stated areas of expertise by location (e.g., the American Psychological Association: www.apa.org; the Association for Behavioral and Cognitive Therapies: www.abct.org).

Many communities also have rape crisis centers that can provide a wealth of information and resources and may also provide counseling services. One service often provided is an advocate to accompany the survivor to the initial forensic exam and subsequent court appearances (if appropriate) and to provide important information about sexual assault. Many communities also have specially trained nurses to conduct the postassault forensic medical exams, sexual assault nurse examiners, who may also be a source to receive psychoeducation about sexual assault. Unfortunately, little information is currently available to determine the efficacy of information provided in this way. The few studies that have compared services as usual with services as usual plus a psychoeducational video-based intervention suggest that there may be an advantage to including the video intervention.

Medical personnel who conduct post-rape medical exams or mental health practitioners who see sexual assault survivors soon after the assault or at later points in time may consider providing handouts or pamphlets during the initial visit. They may also consider showing the brief video developed by Dr. Resnick, Dr. Acierno, and colleagues as a means of providing information and as a starting point for discussing other assault-related issues that the survivors may be struggling with. It is recommended that the efficacy of this video be evaluated by programs that use it and that they understand that research to evaluate its efficacy is ongoing. Current studies are under way to evaluate whether findings from the prior studies are replicated. In general the use of video to deliver psychoeducation content may have benefits over self-help booklet content since it does allow modeling of behaviors by individuals who might be relatable. It is possible that learning may be enhanced with the added component of being able to visualize implementation of skills. There is some support for use of video modeling as an efficacious tool to increase patient self-care behaviors as well as to educate and/or reduce anxiety or distress related to medical procedures.42 As part of a Substance Abuse and Mental Health Services and Administration grant project (PI, Benjamin Saunders), the video has been made available for training and education purposes, as it is still undergoing evaluation. Additional potential use of the video is for training with medical professionals and rape crisis advocates. Thus, this information might be helpful for such professionals or volunteer advocates to get a better understanding of possible psychological reactions postassault, behavioral conceptualizations of reactions, and behavioral strategies that may promote adaptive coping and reduce distress and problematic coping strategies. The video is available for programs or researchers to view at www.musc.edu/saprevention. The site also includes a collateral brochure and instruction manual for the video, which are available for download.

A number of websites exist that provide information and psychoeduca-tional resources related to experiencing traumatic events including sexual assault. It is important to note that all websites are not created equal and may not be reviewed for accuracy or based on scientifically derived information. The National Crime Victims Research and Treatment Center [NCVC] in Charleston, South Carolina, has been an important leader in research and clinical developments in the area of traumatic experiences broadly. The website of the NCVC includes a number of resources for clinicians and the public, including a four-page handout describing common reactions to experiencing a sexual assault [Victim Reaction to Sexual Assault; http://aca-demicdepartments.musc.edu/ncvc/resources_prof/reports_prof.htm]. The International Society for Traumatic Stress Studies [www.istss.org] also has a number of resources available for practitioners and the lay public.

Numerous support groups exist for survivors of sexual assault. These may be conducted through or in affiliation with rape crisis centers. There also may be support groups run by independent practitioners or survivors themselves. While the nature of support groups varies from group to group, they generally consist of a group of same-gendered individuals who have all experienced some form of sexual assault. Many survivors take comfort in knowing that they are not alone and in the support they receive from some group members. Others may not be comfortable sharing their story within a group context or hearing other people's stories.

A number of self-help books or books about rape and sexual assault may also be of help for some survivors. Again, the quality of these is likely to vary considerably. It may be helpful to get some recommendations from a mental health practitioner for specific books. A number of treatment options exist for individuals who may be struggling to cope with the sexual assault on their own and want to seek professional help. Many of these treatments have been tested by researchers. The treatments have varying levels of study and support. A number of manuals are also available for use by practitioners and some for use by survivors themselves (e.g. Treating Post-Trauma Nightmares: A Cognitive Behavioral Approach [Davis, 2009]; Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences Therapist Guide (Treatments That Work) [Foa, Hembree, & Rothbaum, 2007]; Reclaiming Your Life from a Traumatic Experience: A Prolonged Exposure Treatment Program Workbook (Treatments That Work) [Rothbaum, Foa, & Hembree]; Cognitive Processing Therapy for Rape Victims: A Treatment Manual [Resick & Schnike, 1993]; Cognitive-Behavioral Therapy for PTSD: A Case

Formulation Approach [Zayfert & Becker, 2008]). Most approaches will include psychoeducation as well as in-depth intervention content.

CASE EXAMPLE

Evyn was brought to the emergency room by her sister after disclosing that she had been raped the previous evening in a parking garage at the airport. A sexual assault advocate met them in the waiting room. The advocate provided Evyn basic information about the process and purpose of the forensic exam as they waited for the sexual assault nurse examiner [SANE] to arrive. Evyn was visibly distressed and nervous but appeared to relax a bit as she was able to ask questions of the advocate. Evyn's sister asked about her options for legal action; Evyn turned away during this discussion and stated she did not want to talk about whether she planned to report the assault or not. The advocate provided a brochure to Evyn's sister that outlined the different legal options and procedures that Evyn would need to consider. The SANE nurse arrived and reiterated the information about the exam provided by the advocate. Following the exam, the SANE nurse showed a video to Evyn, her sister, and the advocate that described some common symptoms that some rape victims experience and various ways of coping with those symptoms. A month following the assault, Evyn was struggling with returning to work. In particular, she had trouble parking in the parking garage next to her office building, instead parking several blocks away and subsequently being frequently late for meetings. She discussed her distress about getting in trouble at work for being late with her sister. Evyn remembered part of the video describing how a woman had taught herself to not sleep with all the lights on in the house. She and her sister described how they might do something similar to help Evyn face her fear of the parking garage. They decided on a plan, which included calling the rape crisis center to talk to a counselor about their ideas.

AUTHOR NOTES

Research and manuscript preparation supported by:

1. National Institute on Drug Abuse grant no. R01 DA11158, titled "Prevention of Post Rape Psychopathology and Drug Abuse" (Heidi Resnick, PI);

2. National Institute on Drug Abuse grant no R01DA023099, titled "Prevention of Postrape Drug Abuse: Replication Study" (Heidi Resnick, PI);

3. Substance Abuse and Mental Health Services Administration, Grant No. 1-UD1-SM56070, titled "Service Systems Models Intervention Development and Evaluation Center" (Benjamin Saunders, PI);

4. Oklahoma Center for the Advancement of Science and Technology, Grant No. HR-08-017, titled "Mitigating the Effects of Sexual Assault" (Joanne Davis, PI);

5. We wish to acknowledge the contributions of Dr. Monica Fitzgerald to the development of the www.musc.edu/saprevention website and downloadable brochure materials.

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Letting Go, Moving On

Letting Go, Moving On

Learning About Letting Go, Moving On Can Have Amazing Benefits For Your Life And Success! Don't be held back by the past - face your guilt and fears and move on! Letting go is merely arriving at a decision, no more allowing something from the past tense to influence your life today or to cut down your inner sense of peace and welfare.

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