Continuing Education Program Sexual Assault Sample
Continuing Education
How to support patients who have experienced sexual assault
Psychologists can help their patients navigate the complex contexts that survivors often face while attempting to cope with their assault
CE credits: 1
Learning objectives: After reading this article, CE candidates will be able to:
- Identify the common consequences of sexual assault for survivors.
- Discuss the role of stigma and the challenges that survivors may face around disclosing their sexual assault to friends and family.
- Describe options for treating patients post–sexual assault who have symptoms of post-traumatic stress disorder, anxiety, and depression that include community-based and culturally relevant practices.
For more information on earning CE credit for this article, go to CE Corner.
Sexual assault can be a life-rupturing event, shattering feelings of trust for survivors and triggering struggles within relationships. Because sexual assault remains stigmatized, those who have experienced it may not feel able to reach out for social support in the same way as survivors of other types of traumas.
Providers who treat people who have been sexually assaulted need to be aware of these impacts and well versed in understanding sexual violence and trauma, said Carlos Cuevas, PhD, a clinical psychologist and professor at Northeastern University in Boston. There are many barriers to seeking help for people who have been victimized, and it's important for those who do make that leap to be believed and supported.
"By the time somebody shows up to your office they have had to jump over a whole lot of hurdles to come tell you something that is one of the most difficult things to have to tell another person," Cuevas said. "I always tell my clients when they come in that I'm impressed they're showing up at a therapist's office."
A widespread problem
Quantifying sexual assault is perennially challenging because sexual violence is underreported to law enforcement. The National Crime Victimization Survey, a self-report survey that asks participants to report crimes against them that occurred in the 6 months preceding their participation in the survey, found a rate of 1.2 sexual assaults or rapes per 1,000 people in the United States over the age of 12 in 2020 (Bureau of Justice Statistics Bulletin, October 2021). A review of studies outside the United States and Canada on global sexual victimization of adolescents and adults found past-year prevalence between zero and 59.2% for women, 0.3% to 55.5% for men, and 1.5% to 18.2% for lesbian, gay, bisexual, and transgender individuals (Dworkin, E. R., et al., Psychology of Violence, Vol. 11, No. 5, 2021).
Though differing definitions and methodologies clearly return a range of prevalence numbers for sexual assault, the bottom line is that the experience is common, and clinicians are likely to treat individuals who have been assaulted even if it is not the primary reason for treatment. Research has shown that sexual victimization often has mental health consequences, particularly post-traumatic stress disorder (PTSD), depression, and anxiety. Findings have been consistent on this front going back at least four decades, according to a review led by community psychologist Rebecca Campbell, PhD, of Michigan State University: Studies dating back to the 1980s find that between 17% and 65% of women who have experienced sexual assault develop PTSD, 13% to 51% develop depression, and up to 40% experience generalized anxiety (Trauma, Violence, & Abuse, Vol. 10, No. 3, 2009). Alcohol dependence and substance misuse are also common.
Though these impacts are well-known in the psychology community, the #MeToo movement and high-profile cases such as that of financier Jeffrey Epstein have pushed sexual assault into the public spotlight in recent years. The psychology community, too, is increasingly attuned to the impacts of complex trauma, said Shavonne Moore-Lobban, PhD, a counseling psychologist who specializes in trauma and an assistant professor at The Chicago School of Professional Psychology's Washington, D.C., campus. Complex trauma can spring from experiences such as sexual assault as well as the cumulative impact of factors such as racism and other forms of violence.
"Our acceptance of sexual assault and sexual abuse as something that is traumatic has really expanded," said Moore-Lobban, who also coauthored the book The Black Woman's Guide to Overcoming Domestic Violence (New Harbinger Publications, 2022).
Research has also shown connections between identity and coping after sexual assault. Men and boys may be more reluctant to disclose sexual abuse due to stigma and beliefs around masculinity. LGBTQ+ individuals may also face unique stigma and lack social support to cope with an assault. A study by Cuevas and his colleagues found that among Latinx youth, 12- to 18-year-olds who identified as gay, lesbian, or bisexual experienced higher rates of sexual victimization compared with heterosexual teens (Journal of Interpersonal Violence, online first publication, 2022). Sexual minority teens reported less social support from significant others and family than heterosexual teens, a factor that was associated with multiple subsequent victimizations as well as higher levels of psychological distress.
Race and racism can also play important roles in the type of support people who have been assaulted receive. People of color often find themselves being disbelieved or blamed if they experience microaggressions or blatant racism, Moore-Lobban said. This can be compounded for sexual assault survivors of color, who may find that victim-blaming after sexual assault mirrors the kind of downplaying and blame-shifting that occurs when a victim draws attention to racism.
Ultimately, Cuevas said, the context around a sexual assault and the victim's social milieu really matters.
"If you have an adult woman who was sexually assaulted when she was out for a jog, and it was the first time it happened, it is potentially going to look very different from a gay or lesbian youth who was assaulted by somebody they knew and was shunned by their family because of the fact that they are gay or lesbian," Cuevas said. "Those are two cases where you're working with a survivor of sexual assault, but the context around their experiences is going to make it a very different therapeutic process."
Complex contexts
Psychologists may have to help their patients navigate many complex issues, including unsupportive reactions from friends and family; situations in which the perpetrator remains in the person's life; decisions about how and whether to disclose a past assault to new people; and national conversations about assault and abuse that take place on social media, exposing survivors to ugly thoughts and opinions [See Assault and social media].
Because of the stigma surrounding sexual assault and limited access to mental health services—the latter having only worsened since the coronavirus pandemic—survivors of assault often do not come forward until they've been victimized multiple times, Cuevas said. "It's important to help the client dictate where they want to start and where they want to go, but also be aware that as you are entering that process with them, there are going to be other things that are going to come up," he said.
Often, sexual assault survivors face struggles in relationships, particularly around issues of victim-blaming or denial that an assault even occurred.
When abuse occurs within families, it's not unusual for family members to support an abuser rather than the person who was abused, which can put the individual who experienced the abuse in a position of having to choose between attending family gatherings and avoiding their abuser. Part of therapy might be working through the feelings of anger and betrayal this can cause. "You're having to take yourself away from things that matter to you, and it's unfair," said Tyffani Dent, PhD, an Ohio-based clinical psychologist who provides mental health consultations, trainings, and assessments through Monford Dent Consulting & Psychological Services, LLC.
Survivors of sexual trauma are also likely to encounter mixed responses when they tell others about their experiences, said Sarah Ullman, PhD, a social psychologist and professor at the University of Illinois Chicago, and author of Talking About Sexual Assault: Society's Response to Survivors (APA, 2010), which she is updating for a likely 2023 release. Ullman's recent research has looked at the kind of responses that survivors face when they talk about their assaults. While there is a deep history of quantitative work on these questions, Ullman explained that the qualitative work is still in the exploratory stages. So far, the data suggest that survivors often receive mixed reactions in their informal support networks. For example, a qualitative study queried a diverse set of 45 survivors and their key support people, and found that friends, family, and significant others were often well-intentioned in supporting survivors, but they often struggled personally with how to do so (O'Callaghan, E., et al., Traumatology, advance online publication, 2022). Family and significant others were particularly likely to issue ultimatums to the survivor about getting formal help and to get frustrated if the survivor did not, while friends were less likely to get frustrated, perhaps because their relationships were less interdependent.
Ullman has also found that survivors delay telling others because they fear being blamed for the assault and because they don't want to burden others (Journal of Family Violence, Vol. 35, No. 8, 2020). Some worry that if they tell family members, they might react violently against the offender. "I didn't want to put my brothers in a position where they would hurt this guy or kill him," one survivor said, which kept her from telling her brothers about the assault to avoid a potential reaction.
Male survivors also face a slew of rape myths that make disclosure difficult, said Louis Rivera, PhD, a clinical psychologist at the Corporal Michael J. Crescenz Veterans Affairs Medical Center and a military sexual trauma (MST) coordinator. "Stigma is huge," Rivera said. "That goes back to male rape myths that men do not get raped, and if men get raped, then they must be gay."
The decision to disclose is a sensitive one, because the accumulated evidence shows that negative reactions are associated with worse outcomes, such as an increase in PTSD symptoms (Ullman, S. E., & Peter-Hagene, L. C., Journal of Interpersonal Violence, Vol. 31, No. 6, 2016). In quantitative studies, positive reactions are correlated with outcomes like post-traumatic growth, Ullman said, but positive reactions aren't protective against symptoms of anxiety and depression (Dworkin, E. R., et al., Clinical Psychology Review, Vol. 72, 2019). "Unfortunately, at least in the quantitative work, it seems to show the negative responses carry the day for mental health," Ullman said. However, she added, qualitative research shows that patients do report that positive reactions were helpful, even if they didn't necessarily reduce mental health symptoms.
"That's an important thing, because recovery is not just about symptoms," Ullman said. "You can have a lot of growth and still have a lot of trauma and distress."
Safety and control
Sexual assault often takes away a person's sense of control over themselves and their safety, so centering survivors' agency is important. For example, it's important to use a person's own language to describe their experience, said Dent. Some people prefer the term "survivor," while others might describe themselves as victims. "However they define themselves in that moment, I think we need to honor that," Dent said.
It's also important, Dent said, to find out what healing and accountability for the assault would look like to that individual.
"When we push automatically toward reporting it to law enforcement and seeking justice, with some communities that is not the route they want to go, and we have to accept that," Dent said.
For male survivors, therapy also involves a careful consideration of language. Men tend to report more externalizing symptoms and may describe anger or irritability rather than using words such as "depression," Rivera said. Working with male victims also involves challenging rape myths and working through gender-role socialization that tells men to push pain down and repress emotion. Rivera's research has found that male military veterans with restrictive emotionality have greater symptoms of PTSD, insomnia, and depression than men who don't restrict their emotions (Psychological Trauma: Theory, Research, Practice, and Policy, Vol. 14, No. 3, 2022). Rivera often incorporates an exploration of this masculine socialization in his work, combining, for example, evidence-based PTSD treatments such as cognitive processing therapy (CPT) with relearning new ways of thinking about masculinity. For example, a patient doing CPT might get "stuck" on the notion that because he was assaulted, he is weak or no longer a man.
"We really have to pay particular attention to that," Rivera said. "We have to use our cognitive tools and flexibility to help our male survivors really get into the weeds about not just their stuck points, but about where these beliefs even came from."
Exploring ways for individuals to gain back a sense of power and control over their own bodies and lives can also be helpful, Moore-Lobban said. Regaining that sense might look like CPT, trauma-focused cognitive behavioral therapy, or eye movement desensitization and reprocessing, to name a few therapeutic strategies that have been shown to reduce symptoms of PTSD. It might involve helping a patient explore advocacy work or reset the mind-body connection. Trauma-informed yoga, which requires specific training to lead, is one emerging way to rebuild a sense of comfort in the body, Moore-Lobban and Dent said. A report on such "somatic interventions" with girls in the juvenile justice system (who have a disproportionately high rate of experiencing sexual assault both within and outside the system) found improved self-regulation, improved self-esteem, and decreases in perceived stress (Epstein, R. & González, T., Somatic Interventions for Girls in Juvenile Justice: Implications for Policy and Practice, Georgetown Law Center on Poverty and Inequality Initiative on Gender Justice & Opportunity, April 2017).
There are also many culturally specific healing practices that center movement, said Dent. For example, Dent is the senior director of learning and program strengthening at Black Women's Blueprint, a survivor's organization based in New York, which incorporates drumming, dance, and other artistic expression in its work.
"One of the things about sexual assault is that it's a violation of not just your body but of your spirit, so some of these practices are incorporating both of those pieces, allowing you to be okay with trust, allowing you to be comfortable in your own body," Dent said. "I'm finding those to be really exciting to see."
Assault and social media
Hashtags such as #NotOkay, #MeToo, #BelieveSurvivors, #UsToo, and #WhyIDidn'tReport have become places for people who have experienced sexual assault to share, connect, and try to spark change. But what are the mental health consequences of participating in these online social media movements? No one really knows, said Katherine Bogen, a doctoral student in the clinical psychology training program at the University of Nebraska–Lincoln.
Bogen's work focuses on why people choose to disclose their assault experiences online and what kind of reactions they receive when they do. What's clear so far is that women are at least twice as likely to disclose assault online compared with men, according to a commentary by Bogen and colleagues (Women & Therapy, Vol. 44, 2021). The hashtags can provide solidarity and consciousness raising, Bogen said, but disclosing online is also potentially risky: People who choose to do so may face mixed responses, including nasty trolling, or might find that support is elusive. "One of the risks is disclosing, essentially, into the void, and hearing silence," Bogen said.
Hashtags are also vulnerable to hijacking and infighting, which could create new stressors for survivors. For example, Bogen said, the hashtag #UsToo was originally created by women of color to spotlight their experiences but later morphed into a place for male athletes, most of whom were White, to discuss sexual abuse experiences in sports—also an important issue but not representative of the hashtag's original intent (Journal of Interpersonal Violence, Vol. 37, No. 9–10, 2020).
"The infighting becomes so distracting that the folks with intersectional marginalized identifies—those who are most likely to turn to the internet because they lack access to formal support—get pushed out of the movement that they're fighting to create," Bogen said.
Longitudinal research is needed to link the decision to disclose sexual assault online, the responses that people receive, their exposure to other people's stories, and subsequent mental health symptoms, Bogen said. In the meantime, she said, mental health professionals who work with survivors should keep up an awareness of circulating hashtags and be prepared to discuss online disclosure. It's worth talking through a patient's hopes for what they want to get out of talking about their experience online, Bogen said.
"These disclosure waves are so new and people are really optimistic and idealistic about what they'll be able to garner," she said. "Sometimes it really works and is beautiful, and sometimes they are greeted with radio silence, and that can be really harmful and upsetting."
Further reading
Post-traumatic growth in women with histories of addiction and victimization residing in a sober living home
Edwards, K. M., et al., Journal of Interpersonal Violence, 2022
Sexual assault survivors' experiences with mental health professionals: A qualitative study
Starzynski, L. L., et al., Women & Therapy, 2017
Trauma symptoms and deliberate self-harm among sexual violence survivors: Examining state emotion regulation and reactivity as dual mechanisms
Brockdorf, A. N., et al., Psychology of Violence, advance online publication, 2022
Minority stress and sexual partner violence victimization and perpetration among LGBQ+ college students: The moderating roles of hazardous drinking and social support
Edwards, K. M., et al., Psychology of Violence, 2021
Dear sister: Letters from survivors of sexual violence
Factora-Borchers, L. (Ed.), A.K. Press, 2014
Contact APA
Key points
- Sexual violence is a common experience. Survivors may be reluctant to disclose, even to mental health professionals.
- Post-traumatic stress disorder, depression, and anxiety are common consequences of sexual assault and abuse.
- Survivors may face challenges with how to reduce or eliminate contact with their abuser or may struggle with stigma and denial from their support networks.
- Social media campaigns around sexual assault can offer solidarity but may also bring their own risks.
Source: https://www.apa.org/monitor/2022/09/sexual-assault-patients
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