Rape Crisis Centers As Service Providers

While there have been many changes to the structure, strategies, and function of RCCs over the years, their direct services have essentially stayed the same. Most RCCs provide free, short-term crisis intervention services.15 Current funding sources (e.g., state Victims of Crime Act funds) often require that three basic services are offered: (a) 24-hour crisis hotline—trained volunteers and staff provide crisis counseling, information, and referrals to a wide variety of community resources via telephone, 24 hours a day; (b) counseling (group, individual, support groups)—licensed professionals, paraprofessionals, and volunteers provide counseling services to address the sexual violence experienced by survivors; and (c) legal and medical advocacy—trained volunteers and staff accompany and assist survivors as they obtain emergency medical care, report their assault, and move through the criminal justice system.15 Even if RCCs do not receive such funds, it is likely that they offer the same services. In Campbell et al.'s11 study of 168 RCCs in 1995, all had a rape hotline and almost all (95%) offered medi cal, police, and court advocacy even though they were not receiving any assistance or funds from the Violence Against Women Act of 1994. Additionally, most all of the centers offered crisis intervention and individual short-term counseling with nearly half providing long-term counseling and counseling in group settings. Both volunteers and paid staff work together to provide these services. Volunteers frequently staff crisis hotlines and provide some advocacy, while counseling services are most frequently provided by licensed professionals.11 Of the three basic services offered, legal and medical advocacy prove to be the most challenging for center staff and volunteers.6,16,17 Advocacy will be discussed in more depth in the next section, where we take a critical look at what it entails, its effectiveness, and its impact on survivors and partnering agencies. Additionally, we will return to counseling in the final section of this chapter to discuss different techniques or strategies and their effectiveness in working with rape survivors.

In addition to providing direct services to survivors and their families, RCCs engage in community organizing and help communities become active to make larger social change and spread awareness within their communities. Many of these efforts serve two main purposes, education and action. RCCs engage in many different activities in an attempt to educate. First, they assist mainstream organizations with training. RCCs assist in training police recruits on rape, visit schools to teach sections of health education courses, and train prosecutors on questioning perpetrators and victims.6 Second, RCCs create and distribute materials on rape and related topics to the media and the community at large.6 These materials cover a variety of topics and can be created for survivors (e.g., list available resources and natural reactions to rape), for their loved ones (e.g., how to be a supporter), and for a variety of other stakeholders. Third, RCCs engage in community outreach. For example, RCC staff attend community events where they can interact with and provide community members with information and resources. Finally, many RCCs provide prevention programming. Many times, this programming is offered in schools and other institutions.6 As opposed to risk reduction programming or direct service, prevention programming can target the root cause, including gender roles and gender inequities. While older RCCs (i.e., centers established before 1979) are more likely to provide programming that focuses on the underlying causes of rape, such as gender inequities, it is found across RCCs.11

While many of these educational efforts are taken on with the end goal of action, many RCCs also take direct action. First, RCCs work to build community connections and partnerships to improve the response to rape. RCCs help to create or collaborate with sexual assault nurse examiner (SANE) programs to improve how survivors are treated and responded to when they access medical care.6,18 Additionally, RCCs frequently help organize sexual assault response teams (SARTs) that engage different community members from different backgrounds (e.g., nurses, lawyers, police officers, advocates, etc.) to create a community-wide response to rape, improve existing services, or develop new programs.6 Second, RCCs participate in or help organize social change activism and public demonstrations. Campbell et al.11 found that nearly three-quarters of the 168 RCCs surveyed participated in events like the Take Back the Night March, the Clothesline Project, or victim rallies. Finally, RCCs take action by lobbying elected politicians, thus affecting policy outcomes and creating legal reform.6,11,19,20,21,22 The steady increase in the number of RCCs in the United States and the funds supporting these centers suggests that these centers and their valuable services are not likely to fade out.6,23 The research to date has not yet examined how RCC services are responsive to the needs of women of different races, ethnicities, cultures, abilities, and other facets of social location. As this literature develops, RCCs must be ready to develop their services accordingly. Next, we will turn our attention to specific services, their effectiveness, and their impact on survivors and communities.

MEDICAL ADVOCACY SERVICES

Providing medical advocacy for survivors remains one of the most challenging tasks for RCC staff and volunteers.6,16,17 Rape victim advocates assist survivors as they seek services following their assault. Through this work, rape victim advocates aim to prevent "the second rape," or secondary victimization—insensitive, victim-blaming treatment from system personnel that mirrors and elevates the trauma of the initial rape.2,6,24,25,26,27,28,29,30 The rape victim advocate's job is twofold—improve direct service delivery and stop secondary victimization.

While rape victim advocates can work with survivors as they navigate different social systems, their work within the medical system will be of primary focus here. Following a sexual assault, rape victims may need emergency medical care for a number of reasons. Victims may have suffered physical injuries during the assault such as cuts, bruises, or lacerations. A medical exam can help to detect and treat these injuries. Semen, blood, hair, fiber, or other forensic evidence can be collected during the exam (often termed a "rape kit") to aid in later prosecution if desired. Additionally, many women have concerns regarding sexually transmitted infections (STIs) and pregnancy. Hospital staff can provide information and preventive treatments to attend to these concerns.31

Rape victims often experience long waits in hospital emergency departments for these services, and during that wait, they are not to eat, drink, or urinate as it can destroy evidence of the assault.32,33,34 When finally seen by medical personnel, survivors often receive very brief explanations of what will occur and why.31,32,35 Frequently, evidence collection procedures are performed incorrectly, as hospital emergency department personnel do not receive adequate training, while those with training do not conduct exams frequently enough to maintain their aptitude.32,33,36

Most rape survivors seeking medical services receive a medical forensic exam and forensic evidence collection kit (70%-81%), but fewer receive comprehensive health care services.37,38 For example, less than half receive information of the risk of pregnancy (40%-49%).38,39 Additionally, between 20% and 43% of victims are able to gain access to and obtain emergency contraception to prevent pregnancy.37,38,39,40 Approximately one-third of victims receive information on the risk of STIs and HIV from the assault and between 34% and 57% actually receive medication to treat and/or prevent STIs.37,38,39,40,41

In addition to the invasive nature of the exam and gaps in service delivery, many victims report the experience as cold, impersonal, and de-tached.2,37,42 While medical personnel may find questions regarding prior sexual history, sexual response during the assault, what they were wearing prior to the assault, and their actions prior to or during the assault necessary, rape survivors find them very upsetting, and they can result in a negative impact on victims' mental health.37,42 As a result of contact with medical personnel following an assault, most rape survivors reported feeling bad about themselves (81%), guilty (74%), depressed (88%), violated (94%), nervous or anxious (91%), distrustful of others (74%), and reluctant to seek further help (80%).37,42 Rape survivors who place their trust in the medical system, only to experience a "second rape," risk the possibility of additional distress.43

Rape victim advocates can be instrumental in preventing many of these common problems and gaps in medical services for victims. Studies show that RCC victim advocates increase the likelihood victims will be able to obtain needed services and that advocates prevent secondary victimization. In terms of medical service delivery, Campbell and Bybee25 found that 82% of survivors who had the assistance of an advocate during their hospital emergency department care received an exam, 70% of those working with an advocate received information on pregnancy, 38% received emergency contraception, 67% received information on STIs, and 79% received STI-preventive antibiotic treatment. These rates are higher than what is typical in the other studies of victims' experiences in hospital emergency departments. Additionally, Campbell2 found similar results when comparing survivors who worked with an advocate to those who did not work with an advocate at two different hospitals during the same six-month period. Women who had the assistance of a rape victim advocate were significantly more likely to receive information on STIs (72% versus 36%), were more likely to receive information on HIV (47% versus 24%), were more likely to receive STI prophylaxis (86% versus 56%), and were more likely to receive emergency contraception to prevent pregnancy (33% versus 14%) than women who did not have the assistance of an advocate. Both of these studies suggest that advocates improve medical service delivery for rape survivors.

As previously mentioned, the advocate's role is not only to improve service delivery, but also to prevent secondary victimization. Wasco, Campbell, Barnes, and Ahrens44 found that survivors who worked with an advocate reported less distress after contacting the medical system, as compared to survivors who did not work with an advocate. Similarly, Campbell,2 in comparing the experiences of survivors who had the assistance of an advocate with survivors who did not have the assistance of an advocate over the same six-month period, found that hospital staff were more likely to refuse to conduct a medical exam and/or evidence collection kit when the survivor did not have the assistance of an advocate (36% versus 36%). Additionally, survivors who did not have the assistance of a medical advocate were more likely to report being treated coldly or impersonally (69% versus 36%), were more likely to be asked how they were dressed at the time of the assault (48% versus 28%), were more likely to be asked about their prior sexual history (73% versus 44%), and were more likely to be asked if they responded sexually to the assault (20% versus 3%) than survivors who did work with an advocate. Finally, survivors who did not have the assistance of an advocate were more likely to report blaming themselves (82% versus 54%), and to state that they were reluctant to seek further help (91% versus 67%). These studies, combined, suggest that RCC medical advocates not only improve service delivery but also decrease survivors' experiences of secondary victimization.

While medical advocates improve survivors' interactions with medical system personnel, their work cannot be done alone. It is crucial that RCC advocates create and continue to develop partnerships with medical care providers. SANEs are specifically trained to attend to the medical and psychological needs of rape survivors. SANE programs were designed to avoid the problems of traditional emergency medical care by having specially trained nurses who provide twenty-four-hour-a-day, immediate-response care to sexual assault survivors in both hospital and nonhospital settings.43 Many SANE programs work with their local RCC so that RCC medical advocates can be present during the exam to provide support to the survi-vor.33,34,45,46,47,48,49 Additionally, SANEs frequently are called upon to provide factual witness testimony or expert testimony.50,51 When a SANE provides testimony, they act as a witness, not as an advocate. For this reason, having both a SANE and RCC medical advocate working together to attend to the needs of a rape survivor resolves any role conflict.43

COUNSELING SERVICES

RCCs frequently provide counseling services to help survivors, and sometimes supporters of survivors, address the sexual violence they have ex-perienced.6,15,32 RCCs are perhaps the most visible and accessible source for rape survivors' mental health services, as they frequently provide both individual and group counseling free of charge and do not require health insurance.6,32,52 While little is known about the types of counseling/therapy offered by RCCs, recent literature notes the prevalence of both cognitive-behavioral therapy (CBT) and a feminist and/or empowerment theoretical orientation.32

The ways in which sexual assault affects women's well-being is diverse— quite simply, there is no "one way" victims react to such a devastating crime. While psychological symptoms vary during recovery, many victims experience guilt, shame, fear, embarrassment, tension, crying spells, anxiety, an exaggerated startle response, depression, anger (both generalized and directed toward men), discomfort in social situations, rapid mood swings, and/or impaired memory and concentration.52 Years later, survivors are more likely to have a serious psychiatric diagnosis such as major depression, drug abuse and dependence, generalized anxiety, post-traumatic stress disorder, and obsessive-compulsive disorder.53,54,55 All of these responses may prompt a survivor to seek out counseling services. They may also seek such services as they begin to disclose their experience to others and as they attempt to build new and foster old relationships.

Having identified survivors' needs for counseling services, we can now turn to frequently used approaches. As mentioned, little is known about RCC counseling practices. However, CBT and feminist therapy emerge as the most commonly used approaches. CBT involves systematic exposure to traumatic memories and cognitive reinterpretation of the events.56 It can include systematic desensitization, flooding, prolonged exposure treatment, and stress inoculation training. CBT works on the assumption that remembering and visualizing feared situations can help to gradually reduce anxiety.57 CBT techniques demonstrate effectiveness in reducing fear-related symptoms; however, other factors critical to rape recovery, such as reducing self-blame and increasing social support, are not focused upon in CBT, and their effectiveness in attending to these issues is not known.58,59,60,61

Feminist therapeutic approaches, alternatively, focus on longer-term symptoms like guilt, shame, and self-blame. They employ shared goal setting, the identification of rape as a social issue as opposed to a personal problem, and focus on gender inequities.15,62,63,64,65 Because feminist therapy places a focus on self-blame, guilt, and shame, group therapy is often preferred.13 This setting can break down feelings of isolation, help to develop supportive relationships, and promote sharing of experiences. This, of course, may not be ideal for all survivors, as preexisting psychological problems may interfere with their ability to participate in a group.66 In comparing those in feminist therapy to those in traditional counseling, Hutchinson and McDaniel67 found that those in feminist therapy showed larger improvements in regard to feelings of guilt and self-blame. Morgan68 found similar results among a group of female survivors of childhood sexual abuse as compared to a control group. CBT and feminist therapy do not need to be used in isolation. Rather, it is common for practitioners to combine different models and techniques to attend to immediate and long-term effects of rape.

While the specific techniques and orientations employed by RCCs are not always explicitly identified, they seem to be working. Wasco and col-leagues15 aimed to evaluate RCC services in Illinois. Seventy-six recipients of RCC sexual assault counseling services completed a survey before and after counseling. Survey results indicated an increase in well-being and coping and lower levels of post-traumatic stress symptoms from the precounseling survey to the postcounseling survey. Additionally, Howard et al.,64 in comparing post-traumatic stress disorder symptoms before and after counseling among victims receiving rape crisis counseling services, found reductions in distress levels and self-blame over time and an increase in social support, sense of control, and self-efficacy. These studies are promising and indicate that RCC counseling services are working. However, additional research further exploring the techniques and methods employed is necessary.

LOOKING FORWARD

The changes in RCCs over the years may initially suggest that they aren't working, that something is amiss. However, this is not the case. RCCs' continuous change and adaptation illustrates their ability to evolve with the times and to maintain their role in supporting and serving survivors of sexual assault and their communities. When RCCs emerged, they aimed to provide direct services to survivors of sexual assault. Through the decades, they have continued to place survivors and their needs at the center of direct service, and they are making a difference. Historically, the number of RCCs and the funds supporting these centers have typically increased over time, but more recent data suggest that many agencies still identify funding as the single most important challenge, and some RCCs are experiencing financial cutbacks.6,23,69 It is likely that we will see additional change. RCCs may undergo another wave of transformation in their organizational structure, or we may see changes in funding sources or financial dependence. RCCs will take these changes in stride, as they always have, and will continue with their commitment to survivors of sexual assault, to their communities, and to making change.

CASE STUDY

Lisa just got to the hospital. She's not exactly sure of what she just experienced, but she knows it didn't feel right. She decided to come to the hospital just to get checked out, to make sure that everything is okay, and maybe to get a better understanding of what happened. After checking in at the emergency department, Lisa is taken to private room in the back of the emergency room. As she waits for the nurse, a woman with a bag walks into the room.

The woman explains to Lisa that she is an advocate from the local RCC. She tells Lisa that she is there to provide her with information and resources, to answer any questions she has, and to support her through the process. She then asks Lisa if she would like her to stay. Lisa says yes. The advocate pulls up a chair next to Lisa and asks her if she needs anything, perhaps a warm blanket. Lisa nods, and the advocate leaves the room, shortly returning with the blanket. The advocate then asks Lisa if she wants to talk while they both wait for the nurse to come in. Lisa agrees, and the advocate takes out an envelope that has pamphlets from different organizations in their community that provide services to survivors of sexual assault. The envelope also contains a pamphlet on victims' rights and crime victim compensation. There are handouts that Lisa can give to close family and friends to help them understand how they can support her and what she might be feeling. Lisa tells the advocate that she's not exactly sure what happened to her and she might not need all of that. The advocate tells her that either way, she can take it with her just in case she needs it; these services are always available and she can choose to use them in the future, or not.

The nurse comes into the room and gives Lisa an overview of the medical forensic exam, explaining step-by-step what she will do and why. As she finishes explaining the exam, the advocate interjects and tells Lisa that she can do all of the exam, parts of the exam, or not do it at all if she's not comfortable with part of it, and that she has the right to say no to any of it. Lisa feels okay with this. She's hesitant about the exam, but decides to go ahead with it because she knows she can stop at any time.

The nurse then asks if Lisa would like to talk to the police and file a report of what happened. Lisa turns to the advocate. The advocate tells Lisa that there is no mandatory reporting in her state, that it is absolutely her decision if she talks to the police. The advocate further explains that this would be the first step in the legal process. Filing a police report does not mean that Lisa has to pursue prosecution, but it makes it a lot easier if she decides to later. Still, it is Lisa's decision. Lisa decides that she does not want to file a report, and the advocate tells her that's fine. She tells Lisa that if she changes her mind later, the RCC can provide an advocate to go with her to the police station.

The exam then begins. The nurse does a good job of explaining to Lisa each thing she is doing before she does it. If she forgets, the advocate reminds her and asks her to explain it to Lisa. There are some parts of the exam that Lisa doesn't like, but decides that it is okay to do them. Other parts of the exam are too much and Lisa decides she does not want them done. The advocate tells her that's fine, and the nurse respects her decision. After the exam, the advocate gives Lisa some new clothes to wear home because Lisa decided to let the nurse collect her clothes as evidence. The advocate asks Lisa if she has any final questions. Lisa says no. After Lisa is discharged, the advocate walks out with her, and Lisa returns home.

Several months later, Lisa has put the experience behind her. While it is still very much a part of her, she doesn't think about it quite as much and feels as though she has moved on. She never found a need to go to counseling or use any of the other services the advocate told her about. She recently started a new job. She's looking forward to the change. Some of her old coworkers were there the night it happened. Even though they didn't say anything to her about what happened that night, she knew that they knew and was sure that they talked about it sometimes.

The first few weeks at her new job are great. She is meeting new people and learning a lot. It's challenging, but in a good way. One afternoon, her coworkers invite her to happy hour. She declines, saying she has plans already, and says that she'd love to go next time. Lisa is surprised by her own response. She doesn't have plans. She's not quite sure why she responded the way she did. When she gets home that night, she is still thinking about what happened. She realizes she's worried about getting close to coworkers again and felt like she had to do this to keep herself safe. Lisa didn't like feeling this way and wasn't sure if it was normal. She continued to think about this over the next few days and finally decided to call the RCC. She remembered the advocate telling her that people use their services even if they aren't exactly sure what happened to them and that she should contact them even if she's not sure what she needs. Lisa calls the RCC and sets up an appointment with a counselor there. She is nervous but decides it can't hurt to go.

At the first session, Lisa is a bit uncomfortable talking about what happened. She still feels it was her fault, that she should have done something differently, and that perhaps she was making a big deal about nothing. She feels as though there is something wrong with her, that she's not normal now. The counselor listens to her and together, they work through many of these things over the next couple of weeks. After several sessions, the counselor asks Lisa what she would think about attending a support group. She tells Lisa that she is not alone in how she is feeling and thinks she may benefit from hearing other people's stories. It might help her to understand that she is having a perfectly normal response for what she experienced. Lisa decides to give it a try.

Lisa is nervous for the first session and a bit uncomfortable. She doesn't know if the other women will have similar stories. She worries that what she experienced isn't "real" enough. Through the group sessions, she learns that she is not alone. While she is saddened to hear that other women had to go through this too, it helps her to understand that she is not the problem, that she is not broken. Lisa starts to understand that she did not choose what happened to her and it is not her fault. Going to group therapy has helped Lisa understand that the process of healing will take time, but now she is going with others instead of alone.

WHAT CAN YOU DO?

• Locate your local RCC. Your local RCC operates to serve survivors, supporters, and their communities. They are only effective if people are aware of and access their services. RAINN, the Rape, Abuse, and Incest National Network, is a great place to start. RAINN is the nation's largest anti-sexual violence organization. You can visit their website, www .rainn.org, to find your local RCC. Additionally, you can call their national sexual assault hotline at 1-800-656-H0PE. You will be directly connected to the RCC closest to you.

• Call your local RCC's hotline. The hotline is there for you. Staff and volunteers cover the hotline twenty-four hours a day to provide crisis intervention and information. Many people that call the hotline aren't quite sure how to label their experience. That's okay. If it didn't feel right, it probably wasn't. Hotlines are for supporters too.

• Schedule a counseling appointment. Recovery takes time, and healing is possible. RCC counselors are there to support you as you begin this process.

• Attend a support group. You are not alone. Support groups provide a safe space for people with similar experiences to come together, talk, process, and support one another. Many RCCs provide support groups for survivors, loved ones of survivors, and other supporters. Contact your local RCC to find out if and when they host support groups.

• Participate in community events. RCCs began as grassroots organizations and still thrive on community involvement and activism. Many RCCs hold multiple community events throughout the year—Take Back the Night marches, Clothesline Projects, 5K races—contact your local RCC

to find out what events are coming up and how you can get involved. It's okay if you're not ready to lead the march; simply showing up is more than enough. In coming together, we can make change.

• Volunteer. RCCs still depend on the commitment and passion of dedicated individuals to provide services and make change. They are always looking for volunteers to provide advocacy services for survivors, to work the crisis hotline, to help out at community events, to provide education and outreach services, and to staff their resource libraries. Contact your local RCC to find out how you can help. Working with sexual assault survivors is both rewarding and challenging. Volunteering with your local RCC may be an empowering experience, but it should not be used in place of therapy or counseling. Taking care of yourself is most important. If you choose to volunteer, collaborate with others at your RCC to develop self-care techniques and ways to support one another.

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