Chapter 8

The Mental Health Community

Victims of crime often suffer a broad range of psychological and social injuries that persist long after their physical wounds have healed. Intense feelings of anger, fear, isolation, low self-esteem, helplessness, and depression are common reactions.1 Victimization can shatter the most basic assumptions that allow people to function normally in their daily lives-that they are safe from harm, that the world is meaningful and just, and that they are good, decent people. This happens not only to victims of violent assaults but also to victims of crimes such as burglary and fraud.2 Survivors of prolonged, repeated trauma, such as battered women and abused children, often suffer severe mental health problems.

The emotional damage and social isolation caused by victimization can be compounded by a lack of support and even stigmatization by friends, family, and social institutions, producing a "second wound" for victims. Those closest to the victim may be traumatized by the crime. They may be so overwhelmed by their own anger, fear, and guilt that they are unable to provide much care and understanding. Some friends and family members, particularly of victims of sexual assault, distance themselves from the victim and blame them for what happened.3 To protect their own belief in a just world where people "get what they deserve," and to establish distance from the possibility of random or uncontrollable injury, many people prefer to see victims as responsible for their fate.

When victims seek help, they are sometimes met with similar insensitivity. They often feel revictimized by the criminal or juvenile justice process, which traditionally has been more concerned with the rights of the accused than with those of the victim. Justice may become a central issue for victims as they seek to reconstruct their lives and begin to heal.4 Participation in the justice process is therapeutic when it helps victims to better understand what happened, allows them an opportunity to tell their story, and validates their loss and sense of being wronged. When victims are ignored, their feelings of trauma may be intensified and prolonged.

Progress Since the President's Task Force on Victims of Crime

The President's Task Force on Victims of Crime observed in 1982 that violent crime produces psychological as well as physical injuries.5 In issuing its recommendations, the Task Force challenged the mental health community to:

Provide immediate and long-term psychological treatment programs for victims of crime and their families.

Establish training programs that will enable practitioners to treat crime victims and their families.

Study the immediate and long-term psychological effects of criminal victimization.

Work with public agencies, victim compensation boards, and private insurers to make psychological treatment readily available to crime victims and their families.

Maintain direct liaison with other victim service agencies.

In addition, the Task Force suggested that legislation be enacted to ensure that designated victim counseling is legally privileged and not subject to defense discovery or subpoena.

While the physical and financial injuries of criminal victimization were emphasized in the victims' movement, for many years crime's psychological toll was not fully recognized. In the early 1980s, landmark documents called attention to the fact that victims of violent crime often experience crime-related mental health problems. In 1980, the third edition of the American Psychiatric Association's Diagnostic and Statistical Manual included post-traumatic stress disorder as a new diagnostic category and noted that it could be caused by violent crimes such as rape and assault.6 Four years later, the American Psychological Association Task Force on Victims of Crime and Violence examined the field of psychology and its allied professions. Its final report reviewed the state of psychological knowledge on victimization, surveyed theory and approaches to helping victims, and made recommendations for the mental health community.7

Major advances have been made in our understanding of crime-related psychological trauma and the best ways to provide treatment to crime victims. Research on the scope of criminal victimization and its psychological impact has grown substantially. In 1994, the fourth edition of the Diagnostic and Statistical Manual pointed out differences between acute traumatic stress disorder-reflecting what is known in the field as the crisis reaction to victimization-and post-traumatic stress disorder.8 It further recognized the impact of the subjective perception of victims in understanding traumatic events, which opened the way for further research on the effects of culture and environment on victim responses and healing. Research has led to a growing acknowledgment of the differences between the types of trauma reactions that occur after a sudden, random, arbitrary event and the reactions that occur when one is repeatedly traumatized over time in situations such as domestic violence, child abuse, hostage taking, or war.9 Other studies have provided new understanding of stress reactions of crisis intervenors, victim assistance providers, and mental health professionals when they work with crime victims.10 Although less well-developed, the research literature on efficacy of treatments for crime-related psychological trauma also has expanded.

Prior to 1982, there was virtually no systematic training available for mental health professionals on effective treatments for crime victims. The Society of Traumatic Stress Studies developed the first interdisciplinary curriculum on responding to traumatic stress in 1989.11 This information is now included in the training curricula of some mental health and medical professionals, and postgraduate inservice training through workshops is much more available.

The passage of the Victims of Crime Act (VOCA) in 1984 had an important impact on improving mental health services for crime victims because state crime victim compensation programs were required to provide payment for mental health counseling in order to qualify for VOCA funding. Within a few years, most states amended their compensation statutes to include mental health counseling as an eligible benefit, providing considerable incentive for mental health professionals to learn how to provide effective treatment to crime victims.

The Office for Victims of Crime (OVC) has supported expanding mental health services for crime victims by funding important initiatives in education for mental health professionals and counseling for crime victims. These initiatives range from supporting assessment and counseling services for child sexual abuse victims on Native American reservations to funding crisis response teams to assist victims of major mass crimes such as the 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City. In 1995, OVC provided funding to the Pennsylvania Coalition Against Rape to develop a curriculum on collaborative approaches to victim services for mental health and victim service providers.12 In the critical area of financial support for victim counseling, OVC funded the National Association of Crime Victim Compensation Boards in 1991 to develop state-of-the-art guidelines on evaluation and payment of mental health counseling claims.

In addition, the National Institute of Justice provided substantial funding for the 1994 National Conference on Family Violence cosponsored by the American Medical Association and the American Bar Association. Important recommendations were made at the conference to improve multidisciplinary criminal justice and health care approaches to family violence, including developing mental health referral sources and a communitywide assessment process that maximizes safety for all family members.

The Importance of Understanding and Treating Crime-related Psychological Trauma

Crime-related psychological trauma is a major public health and mental health problem for our nation. Because violent crime has been shown to increase both morbidity and mortality, violence and its aftermath have become mainstream public health issues.13 Violent crime puts a large number of Americans at risk of debilitating mental health problems that can severely limit their ability to live productive, emotionally healthy lives. Victims with a history of victimization suffer more crime-related psychological trauma after experiencing a new crime than do victims without prior victimization.14 Because of the sheer number of Americans suffering from crime-related mental health problems, their treatment is one of the most pressing issues facing the mental health community today.

Crime-related psychological trauma impairs the ability and willingness of many victims to cooperate with the criminal or juvenile justice system. At every key stage of the justice process-from contemplating making a report to police to attending a parole hearing-interacting with the system is stressful for victims and often exacerbates their trauma. When victims do not report crimes to police out of fear or are too terrified to testify, it is extremely difficult for the justice system to accomplish its mission.

Crisis Reactions and Short-term Trauma

Most crime victims suffer crisis reactions after serious crimes. They often experience shock and a sense of disbelief, thinking, "this can't be happening to me." Many describe high levels of physiological anxiety such as rapid heart rate and hyperventilation as well as emotional reactions such as feeling helpless, terrified, and extremely angry. These are common "flight or fight" responses that occur in dangerous situations. They may be accompanied by disorientation, confusion, shame, guilt, and grief.

Some victims survive the crime and the accompanying reactions with few lingering effects. More continue to experience the reverberations of crisis over the next few weeks or months. This is particularly true if the crime has substantially disrupted their day-to-day lives. Victims of violent crime may feel high levels of fear, anxiety, and general distress, disrupting their ability to concentrate on simple mental activities. Some become preoccupied with the crime, worry constantly about their safety and the safety of their family members, and become concerned that other people will not believe them or will think that they are responsible for what happened. Even more distressing for these victims, especially those who are harmed by members of their family, is that violent criminal acts destroy their belief that their world is safe and that the people they live, work, and go to school with can be trusted.

Acute traumatic stress disorder is one description of short-term trauma and reflects findings that indicate that for many people such symptoms subside within a month after victimization.15 It is not unusual for memories of the event to disrupt victims' thoughts and sleep. They may have recurrent nightmares, become irritable, suffer outbursts of tears, feel estranged and isolated from loved ones, or be wary of any sudden, intrusive sensation.

With the help of strong social support and pre-existing lifetime coping skills, the intensity of traumatic reactions is likely to decrease over time. But it is not unusual for reactions to continue until individuals feel that their lives have stabilized and that they have regained a sense of safety and security in their world. Crisis reactions can also reappear at later times in their lives when another event triggers their memory of the original trauma.

Long-term Psychological Trauma

For some victims of violent crime and their families, psychological trauma may last for months or years. Research demonstrating that violent crime can produce long-term psychological harm has grown enormously since the publication of the President's Task Force Report in 1982.

Many victims of and witnesses to violent, highly stressful events develop symptoms that are referred to by the American Psychiatric Association as post-traumatic stress disorder, or PTSD. For victims of crime, these events may include sexual assault, physical attack, robbery, mugging, kidnaping, child sexual assault, observing the serious injury or death of another person due to violent assault, and learning about the violent assault or death of a family member or close friend.16 Reactions to these events can be a destructive force in a person's life for a long time. They include:

Persistent re-experiencing of the event, including distressing recollections, flashbacks, and dreams, and emotional and physiological reactions to anything that triggers an association.

Persistent avoidance of things associated with the traumatic event and reduced ability to be close to other people and have loving feelings.

Persistent symptoms of increased arousal, including sleeping disorders, outbursts of anger, an inability to concentrate on simple tasks, wariness, and highly sensitive startle responses.

Significant distress or impairment in social, occupational, or other important areas of functioning.

While PTSD reactions generally have been acknowledged as common among victims throughout the world, it should be emphasized that cultural perceptions of threat and response to danger may affect how people respond to violent crime.

Research has indicated that rates of PTSD are much higher among those who have been victims of violent crime than among those who have been victims of other types of traumatic events. One such study found that the lifetime prevalence of PTSD was significantly higher among crime victims than among victims of other traumatic events. The same study found that crime victims who believed they would be killed or seriously injured during the crime were much more likely to develop PTSD than were victims whose crimes did not involve life-threatening injury.17 Rates of PTSD appear to be higher among victims who report crimes to the criminal justice system than among nonreporting victims.18 Importantly, research indicates that many crime victims with PTSD cannot recover without treatment and that some crime victims have PTSD for years after their victimization.19

Long-term crime-related psychological trauma is not limited to PTSD. Compared to people with no history of criminal victimization, victims of violent crime have significantly higher rates of major depression, suicide thoughts and attempts, alcohol and drug abuse problems, and anxiety disorders or dissociative disorders. While the complexities of psychological trauma are not completely understood, the interrelationship between symptoms of PTSD and other mental health concerns is reflected in the research surrounding Complex PTSD or the Diagnosis of Extreme Stress Not Otherwise Specified (DESNOS).20 The symptoms of PTSD are included in the description of this phenomenon but it also includes symptoms relating to dissociation, anxiety, depression, and suicide. Victims of chronic abuse and violence may be more likely to exhibit these reactions than simple PTSD.

Counseling and Mental Health Interventions

The differences between immediate crisis reaction, short-term trauma, and long-term trauma are the foundation of the major types of interventions used by mental health providers when treating victims of crime. The interventions are not mutually exclusive, and the need for crisis intervenors, victim service providers, mental health professionals, and other healers to work together is critical in many cases.

Crisis intervention refers to the immediate counseling response to victims in the aftermath of a crime or traumatic event. The goals of crisis intervention are to reassure victims of their immediate safety and security, allow them an opportunity to express their reactions, assist them in reducing their immediate emotional distress, and provide them with information and assistance on what they can expect to happen next in their lives.

Posttrauma counseling describes interventions that provide longer term support to victims to help them better understand the psychological effects they are dealing with. Posttrauma counseling also helps victims develop skills and social or spiritual support to begin to cope with the victimization. The methods and tools mental health providers use in posttrauma counseling include cognitive-behavioral techniques, peer support groups, ritual and meditation, education, and physical and mental activism.

Posttrauma therapy refers to psychological or psychiatric interventions that typically involve clinical sessions with a mental health professional. Mental health professionals are trained in trauma-related reactions and may employ a number of therapeutic interventions.

Complex trauma therapy is still in its infancy stage. With new information and research emerging on the impact of chronic victimization, multiple victimization, and victims who have coexisting mental health problems, diagnosis, treatment, and interventions have become increasingly complicated. However, research being conducted by the Department of Defense-Health Services to identify the interrelationship between individual coping capacities, ordinary stress, latent and acute trauma reactions, and effective trauma treatment plans may create opportunities in the future.

Cultural Competency in Mental Health Counseling

According to Erwin Parsons, "All ethnically focused clinical, sociological, anthropological, and experimental studies converge to one central conclusion regarding ethnic America: Ethnic identification is an irreducible entity, central to how persons organize experience, and to an understanding of the unique 'cultural prism' they use in perception and evaluation of reality. Ethnicity is thus central to how the patient or client seeks assistance (help-seeking behavior), what he or she defines as a 'problem,' what he or she understands as the causes of psychological difficulties, and the unique, subjective experience of traumatic stress symptoms. Ethnicity also shapes how the client views his or her symptoms, and the degree of hopefulness or pessimism towards recovery. Ethnic identification, additionally, determines the patient's attitudes toward his or her pain, expectations of the treatment, and what the client perceives as the best method of addressing the presenting difficulties."21

Trauma, suffering, recovery, and healing are defined differently in different cultures. Asian cultures, for example, emphasize character building and purposeful and responsible behavior, rather than gaining insight or reducing symptoms. Native cultures emphasize restoring harmony among relations with the Great Spirit and Mother Earth when someone is victimized or harmed. The individual in these cultures does not strive for independent accomplishment, selfhood, or personal fulfillment apart from being a part of a family, clan, or community.

Many cultures do not isolate physical, emotional, and spiritual factors in health and illness. Trauma affects the whole person. Cultures therefore have different "idioms of distress." Southeast Asian refugees, for example, often complain about body dysfunction such as headaches or chest pains when experiencing depression. Asians in general experience and report psychosomatic stress.

Many cultures, including American Indian, Asian, Pacific Islander, and Latino cultures, depend upon shamans for healing. The concept of shaman is at least 20,000 years old and encompasses the idea of priest and healer. Shamanistic approaches are radically different from the dominant beliefs of Western physicians and mental health practitioners. Indigenous holistic healing practices are not "alternative approaches" but the traditional approaches of the majority of the world's people. In a nation as pluralistic and multicultural as the United States, it is crucial to recognize cultural differences in addressing the needs of crime victims.

Emerging Mental Health Issues for Victims of Crime

A number of issues of importance to meeting the mental health needs of crime victims have emerged over the past decade. These issues either were not addressed by the President's Task Force or have become more salient in today's society.

Repeat Victimization, Chronic Victimization, and the Cycle of Violence

In 1982, there was little acknowledgment that many people are victimized repeatedly during their lifetime, increasing their risk for crime-related psychological trauma and complex mental health problems. Studies show that a substantial number of crime victims have been victimized more than once, and that a history of victimization is associated with risk of subsequent violent assault.22 Other research suggests that the risk of developing PTSD and substance abuse problems is higher among repeat victims of violent assault than among those who have experienced only one violent assault.23 Evidence also suggests that a history of victimization in youth increases their risk of involvement with delinquent peers and delinquent behavior.24 Moreover, the involvement of youth with delinquent peers and substance abuse appears to increase their risk of victimization.25 Another line of research has found that a history of child abuse and neglect increases risk of delinquent behavior during childhood and adolescence as well as the risk of being arrested for violent crime as an adult.26

Chronic victimization as a result of domestic violence, child abuse, or hostage taking also contributes to higher risks of mental health problems. Victims of chronic violence present particularly complex histories when they have not only been abused by loved ones or intimates but also been victims of stranger crimes. They, too, may present coexisting mental health problems, including problems developed during an individual's attempt to survive and to cope with the chronic violence.

The High Prevalence of Crime Perpetrated by Acquaintances

Since the release of the President's Task Force report in 1982, it has become increasingly clear that violent assault by a stranger is much less common than assault by people known to the victim. Child abuse victims, rape victims, physical assault victims, and homicide victims are all more likely to be attacked by someone they know well than by someone they do not.27 Being attacked by a family member, friend, or acquaintance poses particular problems for victims in the criminal and juvenile justice system and creates special issues for them in counseling.

Victimization of Children and Adolescents

The focus of the President's Task Force report was on the adult crime victim. The extent to which America's youth are disproportionately victims of violence was not fully appreciated. Violence is a major problem for children and adolescents,28 and research shows that a history of violent assault during childhood or adolescence increases risk for a host of major mental health problems such as PTSD29 and substance abuse.30 Treating violence-related mental health disorders in young victims requires special expertise, and because young people face unique problems in the criminal and juvenile justice systems, therapists should understand their special needs.

Other issues should be considered when treating the mental health needs of child victims. First, the complexity of problems child victims face often means that treatment must extend beyond brief intervention. This is particularly true if the goals of treatment are to support victims throughout the justice systems and child protective services process and to address prevention and other developmental issues. Second, crime-related psychological trauma is likely to be exacerbated at key developmental milestones in a child's life, and child victims require more treatment at those times. Third, although more research is needed on this issue, it appears that victimized girls are more likely than victimized boys to be victimized in the future, and victimized boys appear to be more likely than victimized girls to become physically aggressive. These important findings suggest the need for slightly different treatment approaches for girls and boys.

Confidentiality of Communications Between Victims and Their Counselors

A provision of the 1994 Violence Against Women Act directed the Attorney General to study and evaluate the manner in which states have taken steps to protect the confidentiality of communications between sexual assault or domestic violence victims and their counselors. The Act also required the development of model legislation that provides maximum protection within constitutional limits for the confidentiality of such communications. In 1995, the director of the Violence Against Women Office within the Department of Justice wrote about the need for such protection in a report to Congress entitled The Confidentiality of Communications Between Sexual Assault or Domestic Violence Victims and their Counselors:31

A successful prosecution depends on the cooperation of the crime victim. Yet in many cases of sexual assault and domestic violence, a woman who has been attacked frequently finds herself victimized a second time when her case goes to court. This is particularly true when the victim receives counseling from a domestic violence or rape crisis counselor who often is not a licensed psychologist or psychotherapist, and lacks the testimonial privilege afforded to other professionals such as psychotherapists or psychologists in most states.

In far too many cases, defense attorneys subpoena counseling records and call counselors as witnesses. The attorneys use the records to shift the court's focus from the crime to the victim's thoughts and comments regarding the emotionally devastating incident. Often, victims face the threat that their most intimate feelings will be disclosed in open court and become a matter of public record.

Sexual assault and domestic violence victims must be able to communicate freely with their counselors, secure in the knowledge that the private thoughts and feelings they reveal during counseling will not be publicized as a result

of reporting the crime.

According to the report, as of December 1995, 27 states and the District of Columbia had enacted statutes that protect, to differing degrees, confidential communications that arise from the relationship between sexual assault and domestic violence victims and their counselors. Some state statutes provide an absolute privilege in which disclosure is not permitted under any circumstances. Others provide a semi-absolute privilege in which disclosure is permitted only under specified circumstances that serve the public interest. Still others provide a qualified privilege in which disclosure is permitted after certain requirements are met or balancing tests are employed. State courts have reached different conclusions about the constitutionality of statutes providing absolute or semi-absolute privilege in these cases.

Federal legislation to protect the confidentiality of victim-counselor communications has not been enacted, and the United States Supreme Court has not addressed the issue of whether absolute testimonial privilege is constitutional.32

Impact of Health Care Reform on Availability of Mental Health Counseling for Crime Victims

Massive changes are occurring in health care financing and health care delivery systems. These changes include reduced direct federal and state funding for mental health services such as mental health centers, increased managed care in the private sector, proposed reductions in Medicaid reimbursement for health care services including mental health, and the formation of large health care networks that emphasize primary care and de-emphasize specialty care. These changes are generating enormous financial pressures to reduce costs, which is most often accomplished by reducing services. This trend is likely to continue.

Until comprehensive health care reform is achieved that specifically includes coverage of mental health counseling for crime victims, the availability of quality mental health services for crime victims is likely to be reduced, putting more pressure on mental health counselors to seek funding from crime victim compensation and other financial resources.

Recovered Memories

Much controversy has been generated about the extent to which memories of abuse during childhood can be repressed, sometimes for long periods, and later recovered. In a few cases, therapists have been accused of falsely implanting repressed memories, which some refer to as "false memory syndrome."33 However, other professionals object to the term, saying that there is no evidence to suggest that the syndrome exists. This controversy has resulted in attacks on the legitimacy of certain types of therapy conducted with adults who disclose that they have been physically or sexually abused as children. Some therapists whose adult clients remembered having been assaulted as children during the course of treatment have been sued by parents accused of assault.

Evidence of repressed memory exists outside the crime victims field. For example, scientific data on memory repression during World War II documented hundreds of cases of repressed memories in troops returning from battle. In many of the cases, psychologists diagnosed soldiers with what would now be classified as PTSD. The psychologists' historic reports show that many of the soldiers could not remember traumatic experiences that others in their platoon described. Once they were able to recall the traumatic experiences, their PTSD symptoms disappeared.34

Judith Herman, author of Trauma and Recovery, points out that "people subjected to prolonged, repeated trauma develop an insidious, progressive form of post-traumatic stress disorder that invades and erodes the personality . . . . Through the practice of dissociation, voluntary thought suppression, minimization, and sometimes outright denial, they learn to alter an unbearable reality." She goes further with the concept of suppression, pointing out that clinicians who work with severely traumatized patients often become suspect among their colleagues. "Regression, dissociation, and denial," she writes, "are phenomena of social as well as individual consciousness."35

A survey about child abuse was sent to 500 American Psychological Association members and practitioner-oriented divisions; 330 members (56 percent women) returned the questionnaire. Childhood abuse (sexual or nonsexual) was reported by 22 percent of the sample and 41 percent of those reported a period of "forgetting." Overall, 47 percent of the participants who had experienced "forgetting" were able to corroborate the abuse. Those who recovered their memories in therapy were just as likely as those whose memories were triggered outside of therapy to be able to corroborate their abuse.36

The courts have varied reactions to repressed memory. In three high-profile cases decided in 1997, one court found the theory of repressed memory to be validated and generally accepted by recent scientists. But in the other two cases, the courts expressed reservations given the state of scientific knowledge and controversy in the area.37

Promising Practices in Crime-Related Mental Health

Innovative programs have been developed that provide excellent mental health services to victims with crime-related psychological trauma. Crime victims involved with the criminal and juvenile justice systems face special problems, and effective mental health programs for them must do more than just provide counseling services. Most of the programs discussed in this section use a multidisciplinary approach to ensure that victims are informed about how the system works and are prepared to deal with the stress of participating in the system. These programs work closely with crime victim compensation programs and victim assistance agencies to help victims access other services, and they make a special effort to ensure that mental health professionals serve victims as advocates, helping them get the information and assistance they need.

Several programs include an educational component in which student mental health professionals receive specialized training in how to provide effective mental health treatment to crime victims. This training is important because of the shortage of mental health professionals with specific expertise in assessment and treatment of crime-related psychological trauma. By providing training to student mental health professionals and continuing education to practicing clinicians, these programs are increasing the cadre of mental health professionals who can provide competent care to crime victims.

A final attribute of these programs is that most have a research component. Research is important because it provides

new knowledge about the scope of violent crime, the nature of crime's impact on mental health, and the effectiveness of mental health interventions.

The National Crime Victims Research and Treatment Center (NCVC) at the Medical University of South Carolina in Charleston, South Carolina, provides specialized mental health services for crime victims of all ages and their families. NCVC trains mental health professionals about effective mental health treatment for crime victims and works closely with local police agencies, prosecutor's offices, rape crisis centers and battered women's shelters, the state crime victim's assistance network, and the state crime victims compensation agency. NCVC staff identify physically injured crime victims hospitalized in the medical center and provide them with information about the criminal justice system, typical psychological trauma experienced by crime victims, crisis counseling, and referrals for outpatient treatment. NCVC also conducts research on the scope and mental health impact of violent crime.

Among the comprehensive array of programs developed by Victim Services in New York City are several mental health services. Its licensed mental health center provides goal-focused individual counseling and trauma reduction and supportive group services for victims of violent crime, including domestic violence, sexual assault, incest, and robbery, as well as homicide survivors. At precincts and in courts and community offices, the agency offers crisis intervention and stress education and management services to victims shortly after the crime is committed. Counseling is also available in schools and shelters for children who witness crimes, including domestic violence, and a crisis response team has been established to respond to victims of natural and community disasters. At one of the agency's nine community offices, the counseling services are provided by social work students and other mental health professionals who work for free in exchange for the opportunity to train with victims. At all sites and in every setting where mental health services are offered, staff are available to address the practical needs of victims by, for example, helping them navigate the court system, obtain crime victim compensation, arrange for child care, or repair or replace locks.

The Harborview Sexual Assault Treatment Center in Seattle, Washington, one of the oldest treatment and research programs in the nation, has been a national leader in developing comprehensive mental health services for sexually abused children and adults. The program has improved the quality of mental health services for victims of sexual assault through training to physicians and mental health professionals.

The Rape Treatment Center (RTC) at Santa Monica-UCLA Medical Center provides comprehensive services for sexual assault victims 24 hours a day, 7 days a week. In the 1970s, RTC pioneered a model for victim care that integrated psychological interventions into the emergency medical care process. This model was disseminated throughout the United States via a training film produced by the National Institute of Mental Health. RTC also offers long-term counseling for victims and their significant others, as well as advocacy, accompaniment, information and referrals, and other support services. To enhance the treatment of victims wherever they turn for help, RTC provides professional training for medical, mental health, law enforcement, criminal justice, judiciary, and school personnel, including a course on victim issues for every new recruit at the Los Angeles Police Department Training Academy. Stuart House, RTC's facility for child victims, enhances collaboration with other victim service providers. The facility has an onsite multidisciplinary team, including police, prosecutors, and child protection personnel, who investigate abuse allegations and minimize "system" trauma to child victims. Stuart House also provides comprehensive treatment services and expert pediatric forensic examinations.

The Crime Victim Recovery Project at the University of Missouri at St. Louis works closely with police and victim assistance agencies to address crime-related psychological trauma. Through the program, crime victims are provided with state-of-the-art cognitive-behavioral treatment. Similar to NCVC and the Harborview Center, the program operates specialized training programs for mental health professionals.

In New Haven, Connecticut, the Child Study Center at the Yale University School of Medicine and the New Haven Department of Police Services have developed a collaborative program to address the psychological impact on children and families of chronic exposure to community violence. The Child Development-Community Policing program brings together mental health professionals and police officers to intervene with children who are victims, witnesses, or perpetrators of violence. The program also emphasizes cross-training by police and mental health professionals.

The National Organization for Victim Assistance (NOVA) has trained mental health providers all over the country as part of their crisis response training. NOVA's crisis response teams include trained mental health providers who work together with law enforcement, medical professionals, victim advocates, religious leaders, and others to provide assistance to communities in the aftermath of major crimes and acts of terrorism.

Victim Support Groups

Many victims who have participated in victim support groups have found that interaction is an important part of their healing process, as the voices of four support group members indicate:

I don't know what I would have done without them. . . . I was in the pits of depression for weeks . . . [and] thought seriously of suicide. They literally saved my life.

You can only pretend so long. . . . You act as if you can deal with it when you really can't. . . . They were there when I needed them. . . . They made me feel the reality of it.

It's a wonderful experience to be around those you know can truly understand how you feel because they feel the same.

It seemed as though no one could really understand what was happening to me until I became involved with the group. . . They know because they've been through it.

Support groups for all types of victims have emerged during the past 15 years. Sometimes these groups are facilitated by trained mental health professionals; other groups are led by crime victims themselves. Many victims say that participation in victim support groups was a significant factor in their healing process.

Parents of Murdered Children (POMC) and Mothers Against Drunk Driving (MADD) have hundreds of chapters throughout the country, and many of them offer victim support groups. In a survey of nearly 300 MADD members whose loved ones were killed or seriously injured in a drunk driving crash, the survivors said that support groups aided their emotional recovery by providing a setting to share their feelings, keep the memory of their loved one alive, and exchange vital information about assistance and compensation programs with others who were experiencing similar trauma.38

Victim Activism

Taking part in efforts to make their communities and nation safer and more just may also help victims recover from the emotional trauma of violent crime. Victims of crime have found many ways to become active in the aftermath of crime. On the community, state, and national levels, victims are working to change the justice system and raise public awareness about the consequences of crime and violence. For many victims who have fought to enact the thousands of victims' rights laws, the opportunity to stand up for the rights of other victims of crime has helped them overcome feelings of helplessness. By participating in Neighborhood Watch and sexual assault prevention programs, warning parents and their children about the dangers of drunk driving, or helping to educate children and incarcerated offenders about the impact of crime through participation in victim impact panels, victims feel a sense of greater control. Their actions help to ensure that what happened to them will be less likely to happen to others.

Recommendations from the Field for the Mental Health Community

Mental Health Community Recommendation from the Field #1

The mental health community should develop linkages with crime victim compensation, victim assistance programs, and criminal and juvenile justice agencies to ensure that victims have access to adequate counseling or mental health treatment at each stage of the justice process, from the time the crime occurs through incarceration, pardon, parole, and appeals. Federal and state laws should be amended to ensure that government covers mental health counseling costs for crime victims throughout the criminal justice process and beyond in cases of long-term psychological trauma.

The President's Task Force identified key stages of the criminal justice process but did not specifically address crime victim's needs for counseling at each stage of the process. An offender's parole, probation, and release can be as stressful for victims as the trial itself, and many jurisdictions have overlooked counseling services during these traumatic periods.

The Victims of Crime Act should be amended to clarify that compensation and assistance programs can be used to fund mental health counseling for crime victims at all key stages of the criminal justice process. States should ensure that victims are able to receive services or reimbursements from state compensation programs to cover counseling costs related to their participation in the criminal and juvenile justice process. Victims may need to re-enter counseling many months or even years after the crime to help them deal with the sentencing or release of an offender.

Model programs provide excellent examples of how mental health professionals can work closely with justice system and victim assistance agencies. Information about these programs should be widely disseminated with descriptions of how they are organized and staffed, the services they provide, how they are financed, and how they have addressed the practical issues of interacting with the criminal justice system and victim assistance agencies. Exchange programs should be established to encourage mental health providers to visit model programs and observe how they work.

Mental Health Community Recommendation from the Field #2

Legislation should be enacted in every state and at the federal level to ensure that designated victim counseling is legally privileged.

Crime victims are much less likely to be candid with their counselor or seek counseling at all if they know that anything they confide is discoverable by defense attorneys. Without candid discussion, good therapy for victims is difficult, if not impossible.

The 1995 Report to Congress of the Violence Against Women Office offers two model statutes that present alternative privileges in recognition of the differences in state constitutions, case law, and statutes. Governors, state legislatures, and Congress should give serious consideration to these model statutes and adopt appropriate legislation.

Mental Health Community Recommendation from the Field #3

Research on the mental health consequences of victimization and treatment of crime-related psychological disorders should be expanded.

Although a great deal is known today about the psychological impact of crime victimization, more research is needed. To provide valuable data on an important consequence of criminal victimization, the National Crime Victimization Survey should be modified to include brief measures of psychological trauma that individuals suffer in response to violent crime. This information will help victim service providers, mental health practitioners, and justice officials better understand and meet the many needs of victims caused directly by trauma.

Considerably more is known about effective mental health treatment of adults than about what works with child victims and their families. More research is needed to give therapists a solid foundation of knowledge about which techniques are most effective with child victims and witnesses. Leading child abuse experts David Finkelhor and Lucy Berliner have strongly recommended that further studies be conducted to establish clearly the efficacy of treatment for sexually abused children and to learn more about the optimal length of treatment, the problem of treatment dropouts, and other important treatment-related issues that have not been researched sufficiently.39 (For more discussion of this topic, see chapter 5.)

In addition, more research is needed regarding effective treatment methods for children who witness violence. A recent study found that 43 percent of male adolescents and 35 percent of female adolescents had witnessed some form of violence firsthand, and that 15 percent of youth who had witnessed violence developed PTSD, compared to 3.3 percent of surveyed youths who had not.40 In the 1997 report, Family Violence in America-Breaking the Cycle for Children Who Witness, the International Association of Chiefs of Police (IACP) points to numerous studies indicating the alarming number of children who witness violence in their homes and in the larger community. In one recent study, 40 percent of students in the 6th, 8th, and 10th grades in low-income areas of New Haven, Connecticut, reported witnessing at least one violent crime in the previous year.41 Nearly one-third of students in the 5th and 6th grades from low-income areas of Washington, D.C. reported having witnessed a shooting, while 17 percent reported having witnessed a murder.42 The IACP report also reported that more than 3 million children in the United States each year are at risk of witnessing domestic violence in their homes.43

Mental Health Community Recommendation from the Field #4

Initial and continuing education programs for mental health professionals should include education on the crisis, short-, and long-term trauma issues arising from victimization and appropriate mental health treatment for crime victims and their families, including counseling options available to them. Training also should include information regarding the cultural diversity of victims, stressing the importance of responding with sensitivity to ethnic and cultural differences.

Addressing educational needs was one of the key recommendations of the 1982 Task Force for mental health professionals. Although some progress has occurred in the past 15 years, there is still a need for education in two critical areas: (1) academic curricula to educate student mental health professionals in psychology, social work, psychiatry, nursing, and counseling in appropriate mental health treatment for crime victims and their families, and (2) inservice continuing education for practicing mental health professionals about effective treatment for crime victims.

Counseling and other kinds of physical, emotional, and spiritual support interventions should be available to meet the specific needs of individual victims. Victims should be given options for counseling, including support groups, traditional healing, supportive or trauma counseling, and mental health therapy, depending on their needs and desires. Mental health professionals should also be identified who have proficiencies in dealing with the special issues of repeat victimization, chronic victimization, and coexisting mental health problems. Mental health professionals need to be encouraged to make their services available to victim service providers in emergencies as well as during standard office hours.

Training programs should include information that will help practitioners work more effectively with culturally and ethnically diverse populations. Research studies, treatment programs, and professional education on the impact of crime on victims should address the various ways cultures respond to trauma, including mental health intervention and counseling, healing and purification rituals, shamanistic and holistic practices, and indigenous and transcultural approaches.

Mental health providers should be aware that techniques other than traditional Western methods are being utilized in the counseling of crime victims. One such technique is Morita Therapy, an Eastern psychotherapy that has been used in the United States for the past 30 years to assist crime victims. The Victim Services Unit of the Waco, Texas, Police Department trains its crisis intervention teams in Morita methods, and domestic violence counselors and shelter staff in Georgia, sexual assault therapists in Florida, and child abuse workers in Texas are using Morita to better understand and respond to victim trauma.

Mental Health Community Recommendation from the Field #5

Interventions and counseling services should be developed for victims with multiple mental health problems. Special attention should be given to individuals suffering from repeat or chronic victimization and individuals with limited access to financial, social service, and health care resources.

New knowledge about repeat victimization, chronic victimization, and the cycle of violence has several implications for providing appropriate mental health counseling for crime victims. One implication is that mental health professionals should include crime prevention and substance abuse prevention in their work with victims to decrease the risk that new victimization or substance abuse problems will occur. A second implication is that mental health professionals should not assume that the crime they are treating is the only one the victim has experienced. To be sure that a victim is being treated appropriately, mental health providers must construct a careful crime victimization history. A third implication is that providing effective mental health counseling to victims may well be an effective way to reduce the risk of future victimization, substance abuse, delinquency, and violent behavior.

Victims with multiple mental health problems pose particular challenges for the criminal justice, juvenile justice, mental health care, and health care communities. Because these victims often have few resources and are difficult to treat, they tend to fall between the cracks. Brief mental health treatment can help them with their short-term crime-related problems, but these victims require comprehensive interventions to help them achieve long-term recovery. More programs should be established that offer coordinated, intensive, multiagency services that include case management as well as

mental health treatment.

Mental Health Community Recommendation from the Field #6

Greater emphasis should be placed on mental health treatment for child victims and witnesses, including preventive interventions that focus on reducing the risk of subsequent mental health problems, antisocial and violent behavior, substance abuse, and revictimization.

Victimization increases children's risk of a host of mental health problems including anxiety disorders, major depression, antisocial behavior, substance abuse, and violent behavior. It also increases their risk of revictimization. Mental health professionals who work in schools or with children should be trained about the impact of victimization and effective treatment approaches.

Treating the mental health needs of child victims requires mental health professionals taking their unique situation into consideration. Child victimization cases often involve protective services in addition to the criminal or juvenile justice system. Counselors must understand these systems well and be able to interact with them in the child's best interests.

Mental Health Community Recommendation from the Field #7

Insurance companies and managed health care companies should provide coverage for targeted mental health treatment for crime victims.

Insurance companies and managed health care companies need to understand the benefits of specialized mental health treatment for crime victims and should provide special coverage for such treatment. Cognitive behavioral procedures and other therapies have been successful in treating victims with crime-related psychological trauma. These treatment methods should be recognized by service providers in the mental health, victim assistance, crime victim compensation, and criminal justice communities.

Mental Health Community Recommendation from the Field #8

Mental health providers should recognize the healing benefits that participation in support groups can provide for many crime victims and provide referrals to these programs when appropriate.

In reconstructing their lives in the aftermath of victimization, many victims join support groups composed of individuals who have experienced a similar trauma. Support groups provide a mutually supportive atmosphere for victims to discuss their feelings. By talking with others, victims work to overcome their feelings of low self-esteem, isolation, powerlessness, fear, and anger. They also demonstrate to each other that they are neither abnormal nor guilty for the crime.

There are many outstanding victim support and activism programs across the nation, including those offered by such respected organizations as Parents of Murdered Children, Mothers Against Drunk Driving, and the Stephanie Roper Committee. Domestic violence shelters, rape crisis programs, and child abuse treatment programs also offer support groups, as do Parents Anonymous and Parents United, who offer support for families who want to break the cycle of abuse.

Mental Health Community Recommendation from the Field #9

Mental health providers should help victims of crime become involved in community service programs when this type of work can assist in the victim's healing process.

For many victims of crime, community activism plays a major role in facilitating their healing. Studies have shown that community involvement by victims not only provides important opportunities to educate school children as well as criminal justice and allied professionals, but also helps many victims to heal. It should be noted, however, that activism is not useful for every victim. Opportunities for community service include working in schools to help decrease victimization, assisting other victims by supporting self-help groups, advocating for reforms in public policy, and speaking on victim impact panels to educate others about crime's impact on individual lives.

The Mothers Against Drunk Driving Victim Impact Panel Program, for example, was designed to encourage victims of drunk driving crashes to tell offenders about the devastating physical and emotional injuries their actions have inflicted. A formal research evaluation of this program funded by the National Institute of Mental Health (NIMH) showed that participation has reduced victims' psychological trauma and improved their well-being. Further research is needed to determine which aspects of the program are most beneficial to healing: giving victims the ability to share their stories with others, giving victims the opportunity to share their stories with an audience they feel needs to hear it, or both.

Mental Health Community Recommendation from the Field #10

Mental health professionals should assist in identifying secondary victims of crime and ensure that they receive appropriate counseling and mental health services.

Many people dramatically affected by crime are overlooked. Sometimes referred to as "secondary victims of crime," they include individuals in the background of traumatic events such as police officers and firefighters and classmates of children who have been kidnaped or murdered.

A recent example of secondary victims were the more than 12,000 rescue workers and volunteers who responded to the bombing of the Alfred P. Murrah Federal Building in Oklahoma City, 85 of whom were injured and one of whom died. Two-thirds reported handling bodies or body parts; one-third felt that they were in much or extreme danger; and one-half spent 10 days working in the carnage, the majority of that time directly at the bomb site. The mental health community estimated that as many as 20 percent of the rescuers would eventually need mental health care. Indeed, one police officer who responded to the bombing committed suicide on the first anniversary of the tragedy.

Moreover, much of the Oklahoma City community suffered as secondary victims. An estimated 387,000 people knew someone who was killed or injured, and 190,000 people attended funerals. A survey projected that 60,000 people were at risk for developing mental health problems and 15,000 more were at high risk.

Public education is lacking about the impact of crime on secondary victims. As a result, many secondary victims do not seek assistance for their serious psychological problems. The mental health community should help to provide crucial education about the needs of secondary crime victims and establish programs to help them heal.

Mental Health Community Recommendation from the Field #11

Mental health professionals should work with multidisciplinary teams of other trained crisis interveners, including victim service providers, law enforcement officers, emergency medical responders, and clergy, to respond to violent incidents and help communities prepare crisis response protocols.

Mental health professionals have unique skills and training that enable them to play a leadership role in helping to prepare communities to respond to incidents of mass violence. They should use this training to help schools and other institutions and businesses to prepare action plans for responding to victims in the aftermath of a major criminal incident. The importance of establishing a crisis response capability is highlighted in several other sections of this report.


Reciprocal referral systems should be established among victim service providers, crisis intervenors, counselors, mental health professionals, and justice practitioners.

Victims often find it useful to have access to different types of assistance in their efforts to reconstruct their lives. Supportive counseling may be helpful, but victims may also need therapeutic intervention. Victim service providers should work with mental health professionals to identify professionals who are trained, available, and willing to provide therapy to victims. Mental health professionals may find that some victims respond to therapy but would also benefit from support groups or additional crisis intervention at critical points in the criminal justice process. Mental health professionals should work with victim service providers and others to identify what programs and services are available to meet the needs of victims. Communities and the justice system should establish referral systems with protocols and procedures and keep them updated on a continuing basis.

Mental Health Community Recommendation from the Field #13

Community mental health centers should participate in communitywide networks of victim services and crisis response planning, protocols, and services.

Many community mental health centers are designed to primarily assist clients with chronic mental health and substance abuse problems. However, many centers also maintain crisis hotlines and may be a natural point of contact for crisis response efforts in times of emergencies. Community mental health centers can also be a valuable source of referral information for victims with trauma issues and coexisting mental health problems.


1 Davis, R.C. and L.N. Friedman, "The Emotional Aftermath of Crime and Violence," in, Trauma and its Wake: the Study and Treatment of Post-traumatic Stress Disorder ed. C.R. Figley, New York: Brunner/Mazel, 1985:90-112.

2 Lurigio, A.J. and P.A. Resick, "Healing the Psychological Wounds of Criminal Victimization: Predicting Postcrime Distress and Recovery," in Victims of Crime: Problems, Policies, and Programs, eds, A. Lurigio, W. Skogan, Vol. 25, 1990:50-67; Riggs, D.S. and Kilpatrick, D.G., "Families and Friends: Indirect Victimization by Crime," in A.J. Lurigio, W.G. Skogan, and R.C. Davis, eds., Victims of Crime: Problems, Policies, and Programs, Newbury Park, CA: Sage, 1990:120-138.

3 Davis, R., B. Taylor, and S. Bench, The Impact of Sexual and Non-Sexual Assault on Secondary Victims, New York: Victim Services, 1994.

4 Ochberg, F., M., ed., Post-Trauma Therapy and Victims of Violence, New York: Brunner/Mazel, 1988.

5 President's Task Force on Victims of Crime, Final Report, Washington, D.C.: U.S. Government Printing Office, December 1982.

6 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Washington, DC: American Psychiatric Association, 3rd ed.,1980.

7 American Psychological Association, Final Report of the APA Task Force on the Victims of Crime and Violence, American Psychological Association, November, 1994.

8 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Washington, DC: American Psychiatric Association, 4th ed., 1994.

9 Herman, J. L., Trauma and Recovery, 1992.

10 Figley, Trauma and its Wake, 1985.

11 The Society for Traumatic Stress Studies, Initial Report of the Presidential Task Force on Curriculum, Education and Training, Washington, D.C.:1989.

12 Pennsylvania Coalition Against Rape, Victim Empowerment: Bridging the Systems - Mental Health and Victim Services, Washington, D.C.: Office for Victims of Crime, U.S. Department of Justice, 1996.

13 Mercy, J.A., M.L. Rosenberg, K.E. Powell, C.V. Broome, and W.L. Roper, "Public Health Policy for Preventing Violence," Health Affairs, Vol.12 No.4, 1993:7-29; Rosenberg, M.L., and J.A. Mercy, eds., "Assaultive Violence," Violence in America, Vol. 2, 1991:12-50.

14 National Victim Assistance Academy, National Victim Assistance Academy Text, Alexandria, VA, 1997:Chapter 10, 9.

15 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders,4th ed.

16 Id.

17 Resnick, H.S., D.G. Kilpatrick, B.S. Dansky, B.E. Saunders, and C.L. Best, "Prevalence of Civilian Trauma and PTSD in a Representative National Sample of Women," Journal of Clinical & Consulting Psychology, Vol.61, 1993:6.

18 Kilpatrick, D.G. and H.S. Resnick, The Importance of Being Epidemiological: Implications for Study of Rape-related PTSD Etiology, Paper presented at the 25th annual meeting of the Association for the Advancement of Behavior Therapy, New York: November 1991; Freedy, J.R., H.S. Resnick, D.G. Kilpatrick, B.S. Dansky, and R.P. Tidwell, "The Psychological Adjustment of Recent Crime Victims in the Criminal Justice System," Journal of Interpersonal Violence, Vol.9 No.4, 1994:450-468.

19 Kilpatrick, D.G., and R.K. Otto, "Constitutionally Guaranteed Participation in Criminal Proceedings for Victims: Potential Effects on Psychological Functioning," Wayne State Law Review, Vol.34 No.1, 1987:7-28; Resnick, "Prevalence of Civilian Trauma and PTSD in a Representative National Sample of Women."

20 Herman, Trauma and Recovery.

21 Parsons, E., "Ethnicity and Traumatic Stress: the Intersecting Point in Psychotherapy," in, Trauma and its Wake: the Study and Treatment of Post-traumatic Stress Disorder, C. Figley, ed., 314-37.

22 D.G. Kilpatrick, et al., Rape, Other Violence Against Women, and Posttraumatic Stress Disorder: Critical Issues in Assessing the Adversity-Stress-Psychopathology Relationship, in Adversity, Stress, & Psychopathology, B.P. Dohrenwend, American Psychiatric Press, forthcoming; Resnick, Prevalence of Civilian Trauma and PTSD in a Representative National Sample of Women, Kilpatrick, D.G., C.N. Edmunds, and A.K. Seymour, Rape in America: A Report to the Nation, National Victim Center & Medical University of South Carolina, 1992; Reiss, A.J., and J.A. Roth, "Understanding and Preventing Violence," National Academy Press, 1993; Wyatt, G.E et. al., "Differential Effects of Women's Child Sexual Abuse and Subsequent Revictimization," Journal of Consulting and Clinical Psychology, Vol. 60, 1992:167-173.

23 Breslau, N., et. al., Epidemiologic Findings on PTSD and Comorbid Disorders in the General Population, forthcoming; Kilpatrick, D.G., et. al., Violent Assault and Alcohol Dependence Among Women:Results of a Longitudinal Study, Research Society on Alcoholism, June 1994:433, Abstract No. 80.

24 Ageton, S.S., Sexual Assault Among Adolescents, Lexington Books, 1983; Dembo, R., "A Structural Model Examining the Relationship Between Physical Child Abuse, Sexual Victimization, and Marijuana/Hashish Use in Delinquent Youth: A Longitudinal Study," Violence and Victims, Vol. 7, 1992:41-62 ; Straus, M.A., "Family Violence and Non-family Crime and Violence," in Crime and the Family, eds., A.J. Lincoln and M.A. Straus, Thomas:1984; Widom, C.S., "The Cycle of Violence," Science, Vol. 244, 1989:160-166; Widom, C.S., The Cycle of Violence, Research in Brief, Washington, D.C.: U.S. Department of Justice, National Institute of Justice, 1992, NCJ 136607.

25 Ageton, Sexual Assault Among Adolescents; Kilpatrick, Violent Assault and Alcohol Dependence Among Women: Results of a Longitudinal Study; Cottler, L.B. et. al., "Posttraumatic Stress Disorder Among Substance Users From the General Public," Journal of Consulting and Clinical Psychology, Vol.56, 1992:843-850.

26 Widom, The Cycle of Violence; Widom, C.S, Family Violence Across the Life Cycle, Paper presented at the proceedings of the American Medical Association's National Conference on Family Violence, Health and

Justice, 1994.

27 Finklehor, D., and J. Dziuba-Leatherman, "Victimization of Children," American Psychologist, Vol.49, No. 3, 1994:173-183 (child abuse victims); Siegel, J.M., et. al., "The Prevalence of Child Sexual Assault: The Los Angeles Epidemiologic Catchment Area Project," American Journal of Epidemiology, Vol. 126 No. 6, 1987:1141-1153 (child abuse victims); Kilpatrick, Rape in America: A Report to the Nation, (rape victims); Koss, M.P. et. al., "The Scope of Rape: Incidence and Prevalence of Sexual Aggression and Victimization in a National Sample of Higher Education Students," Journal of Consulting and Clinical Psychology, Vol. 55, 1987 162-170, (rape victims); Kellerman, A.L. and J.A. Mercy, "Men Women and Murder: Gender Specific Differences in Rates of Fatal Violence and Victimization," Journal of Trauma, Vol. 33, 1992:1-5, (homicide victims); Amick-McMullan, A., "Homicide as a Risk Factor for PTSD Among Surviving Family Members," Behavior Modification, Vol.15 No.4, 1991:545-559 (homicide victims).

28 Finklehor, Victimization of Children; Kilpatrick, Rape in America: A Report to the Nation; Bastian, L.D. and B.M. Taylor, School Crime: A National Crime Victimization Survey Report, Washington, D.C.: U.S. Department of Justice, 1991, NCJ-131645; Finkelhor, D. et. al., "Sexual Abuse in a National Survey of Adult Men and Women: Prevalence, Characteristics, and Risk Factors," Child Abuse Neglect, Vol.14, 1990:19-28; Gelles, R.J. and M.A. Straus, "Is Violence Toward Children Increasing?: A Comparison of 1975 and 1985 National Survey Rates," Journal of Interpersonal Violence,Vol. 9 No.4, 1994:450-468; McCurdy, K. and D. Daro, Current Trends in Child Abuse Reporting and Fatalities: The Results of the 1992 Annual Fifty State Survey, National Committee for Prevention of Child Abuse, 1993; Saunders, B.E. et. al., "Child Sexual Assault as a Risk Factor for Mental Disorders Among Women: A Community Survey," Journal of Interpersonal Violence, Vol.7, 1992:189-204; Burnam, M.A., et. al., "Sexual Assault and Mental Disorders in a Community Population," Journal of Consulting and Clinical Psychology, Vol. 6, 1988:843-850; Whitaker C.J. and L.D. Bastian, Teenage Victims: A National Crime Survey Report, Washington, D.C.: U.S. Department of Justice, 1991.

29 Browne, A., and D. Finkelhor, "Impact of Child Sexual Abuse: A Review of the Research," Psychological Bulletin, Vol. 99, 1986:66-77; Burnam, Sexual Assault and Mental Disorders in a Community Population; Saunders, et. al., Child Sexual Assault as a Risk Factor for Mental Disorders Among Women: A Community Survey; Jaffe, P.G., et. al., Children of Battered Women, Sage Publishing, 1990; Lanktree, C.B., et. al., "Incidence and Impact of Sexual Abuse in a Child Outpatient Sample: The Role of Direct Inquiry," Child Abuse and Neglect, Vol.15, 1991:447-453.

30 Ageton, Sexual Assault Among Adolescents; Burnam, Sexual Assault and Mental Disorders in a Community Population; R.J. Gelles & M.A. Straus, "The Medical and Psychological Cost of Family Violence," in Physical Violence in American Families: Risk Factors and Adaptations to Violence in 8,145 Families, M.A. Straus & R.J. Gelles, Transaction, 1990:425-430; Saunders, B.E., et. al., Prevalence, Case Characteristics, and Long Term Psychological Effects of Child Sexual Assault: A National Survey, Presented at the annual meeting of the American Orthopsychiatric Association in Toronto, Ontario, March 1991; Stein, J.A. et. al., "Long-term Psychological Sequelae of Child Sexual Abuse: The Los Angeles Epidemiologic Catchment Area Study," in Lasting Effects of Child Sexual Abuse, G.E. Wyatt & G.J. Powell, Sage Publications, 1988:135-154; Kilpatrick, Rape in America: A Report to the Nation.

31 The Confidentiality of Communications Between Sexual Assault or Domestic Violence Victims and

Their Counselors, Report to Congress, Washington, D.C.: U.S. Department of Justice, Violence Against

Women Office, 1995.

32 Id. at 3-5.

33 Williams, L.M., "Recall of Childhood Trauma: A Perspective Study of Women's Memories of Child Sexual Abuse," Journal of Consulting and Clinical Psychology, Vol. 62 No.6, 1994:1167-1176.

34 American Psychological Association, Professional Psychology: Research and Practice, American Psychological Association, Vol.28 No.4, 1997:338-340.

35 Herman, J., Trauma and Recovery, New York: Basic Books, 1992: 9, 86-87.

36 Feldman-Summers, S., "The Experience of 'Forgetting' Childhood Abuse: A National Survey of Psychologists," Journal of Consulting and Clinical Psychology, 1994: 62, 636-639

37 See Shahzade v. Gregory (Civil Action No. 92-2139-EFH), U.S. District Court for Massachusetts, May 8, 1997; S.V. v. R.V. (Civil Action No. 94-0856), Texas Supreme Court, March 14, 1997; Borawick v. Shay, U.S. Court of Appeals for the Second Circuit (68 F.3d. 597, 1995. Decision affirmed by the U.S. Supreme Court, May 28, 1997.)

38 Lord, J.H., "Survivor Grief Following a Drunk Driving Crash," Death Studies, 11, 413-435.

39 Finkelhor, D. and Berliner, L, "Research on the Treatment of Sexually Abused Children: A Review and Recommendations," CHILD, November 1995.

40 Kilpatrick, D. and B. Saunders, Prevalence and Consequences of Child Victimization, Research Preview, Washington, D.C.: National Institute of Justice, April 1997.

41 New Haven Public Schools, Report on the SAHA, 1991-92: Final Report, New Haven, Connecticut: Social Development Project Evaluation, 1992.

42 Richters, J.E., and P. Martinez, "The NIMH Community Violence Project II: Children's Distress Symptoms Associated with Violence." Psychiatry, Vol. 56: 22-35.

43 Carlson, B.E., "Children's Observations of Interparental Violence," in Battered Women and Their Families, A. R. Roberts, Ed., New York: Springer, 1984.

44 Miller, T.R., M.A. Cohen, B. Wiersema, Victim Costs and Consequences: A New Look, Washington, D.C.: U.S. Department of Justice, National Institute of Justice, 1996, NCJ 155282.

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