Chapter 6 Mental Health Needs
Victims of crime are at increased risk of suffering from physical and mental health problems in the days, months, and years following their trauma. In order to minimize these negative effects of crime, service providers should follow several basic steps. First, a core needs assessment must be conducted. Second, care must be taken not to retraumatize the victim by the criminal or juvenile justice system process. Third, the psychological, social, and health effects of trauma identified in the needs assessment must be addressed. Fourth, for those in need, scientifically-supported multisession interventions should be implemented.
Upon completion of this section, students will understand the following concepts:
Victimization can obliterate the most fundamental assumptions that people rely upon in order to function each day of their lives--that they are immune from harm; that events in this world are predictable and just; and that they are worthwhile, decent individuals. Failure to intervene with crime victims rapidly and appropriately can compound emotional and physical distress resulting from assaultive violence.
In 1982, the President's Task Force on Victims of Crime (President's Task Force, 1982) concluded that the criminal justice system's treatment of crime victims was a national disgrace and specifically noted that violent crime produces psychological and physical injuries. The President's Task Force also called on the mental health community to--
Why Should the Criminal Justice System Concern Itself
With Crime Victims' Crime-Related Psychological Trauma?
Crime-related psychological trauma impairs the ability and/or willingness of many crime victims to cooperate with the criminal justice system.
The President's Task Force argued that victims must be treated better by the criminal justice system because it cannot accomplish its mission without the cooperation of victims. At every key stage of the criminal or juvenile justice system process--from contemplating making a report to police, to attending a parole hearing--interactions can be stressful for victims and often exacerbate crime-related psychological trauma.
Victims whose crime-related fear makes them reluctant to report crimes to police or who are too terrified to testify effectively make it impossible for the criminal justice system to accomplish its mission. Thus, it is important to understand the following dynamics that may hamper the criminal justice process:
Effective partnerships among the criminal and juvenile justice systems, victim assistance personnel, and trained mental health professionals can help victims with crime-related psychological trauma and with justice system-related stress. By helping victims through such partnerships, the criminal and juvenile justice systems also help themselves become more effective in curbing and reducing crime.
As Kilpatrick and Otto (1987) noted, several psychological theories are useful in understanding why victims might develop psychological trauma and why interactions with the criminal justice system are usually stressful for victim. This section describes one theory that has particular relevance for understanding why the criminal justice system is so stressful for many victims.
CLASSICAL CONDITIONING THEORY
The Russian physiologist, Ivan Pavlov, first described a basic type of learning called classical conditioning (Pavlov 1906). Briefly described, classical conditioning occurs when a neutral stimulus is paired with a stimulus that produces a particular response. For example, if food is placed in a dog's mouth, a salivation response naturally occurs. If the neutral stimulus of a bell ringing is presented to the dog at approximately the same time that the food stimulus is presented, the bell stimulus (conditioned stimulus) will acquire the capacity to produce a conditioned response of salivation similar to the unconditioned response of salivation produced by the unconditioned stimulus of food. What does this have to do with crime-related mental health problems or the criminal justice system?
Classical conditioning theory predicts that any stimuli present at the time of a violent crime are potential conditioned stimuli that will produce conditioned fear, anxiety, and other negative emotions when the victim encounters them. Thus, characteristics of the assailant (i.e., age, race, attire, distinctive features), or characteristics of the setting (i.e., time of day, where the attack occurred, features of the setting) might become conditioned stimuli.
Classical conditioning theory also suggests that negative emotional responses conditioned to a particular stimulus can generalize to similar stimuli. Thus, a woman who exhibits a conditioned fear response to the sight of her rapist might also experience fear to the stimulus of men who resemble the rapist through the process of stimulus generalization. Eventually, this stimulus generalization process may result in the rape victim showing conditioned fear to all men.
The most common response to crime-related conditioned stimuli is avoidance behavior. Thus, there is a natural tendency for crime victims to avoid contact with crime-related conditioned stimuli and to escape from situations that bring them in contact with such stimuli.
A final classical conditioning mechanism with important implications for understanding the behavior of crime victims is second-order conditioning. If a neutral stimulus is paired with a conditioned stimulus (without presenting the unconditioned stimulus), this neutral stimulus becomes a second order conditioned stimulus that can also produce a conditioned response. Thus, any stimuli present at the same time a crime-related conditioned stimulus is present can become a second-order conditioned stimulus that also evokes fear, other negative emotions, and a strong tendency to engage in avoidance behavior. This is important for practitioners because police, prosecutors, and victim service providers may become associated as a second-order conditioned stimulus.
CLASSICAL CONDITIONING AND VICTIMS' REACTIONS
TO THE CRIMINAL JUSTICE SYSTEM
Application of these classical conditioning principles to victims' interactions with the criminal or juvenile justice system helps victim service professionals understand why the criminal justice system is so stressful for many victims.
First, involvement with the criminal justice system requires crime victims to encounter many cognitive and environmental stimuli that remind them of the crime such as the following:
Second, encountering all these crime-related conditioned stimuli often results in avoidance behavior on the part of the victims. Such avoidance behavior is generated by conditioned fear and anxiety, not by apathy. Avoidance can lead victims to cancel or not show up for appointments with criminal or juvenile justice system officials or victim advocates.
OTHER SOURCES OF STRESS
Aside from conditioning, other reasons that interacting with the criminal justice system can be stressful for victims include:
Most victims view the criminal justice system as representative of society as a whole, and whether they are believed and taken seriously by the system indicates to them whether they are believed and taken seriously by society.
A victim service provider's first priority is to assure a crime victim's current safety. That is, safety is the victim's most basic need. While apparently obvious, victim service providers sometimes neglect to assess for this. For example, very little immediate danger may exist for an elderly individual who returns home after a week's vacation to find her house broken into and the thieves long gone. However, a female victim of domestic violence may well be in continuous danger, even if she has left her partner or home. Once safety has been verified and/or obtained, other basic needs must be assessed. These include food, shelter, and minimal resources such as clothing and personal hygiene products. Additional areas worthy of consideration include transportation, social support, and future income. If basic needs are not met, the victim service provider will have very little success in addressing the psychological and health effects of violence. Indeed, when safety, shelter, and food are unavailable, counseling or preventive health care are not terribly relevant.
After a basic needs assessment has been conducted and basic needs addressed, service providers must ensure that victims are not revictimized by the criminal or juvenile justice system. That is, the justice system and its representatives should do their best to address the needs of crime victims. Anything less is tantamount to revictimization. The "Types of Crime Victim Most Likely to Need Mental Health Counseling" section of this chapter will address how victim assistance practitioners can determine which crime victims are most likely to need and benefit from referral to a mental health counselor.
HOW CAN THE JUSTICE SYSTEM ADDRESS THE NEEDS
OF TRAUMATIZED CRIME VICTIMS?
Kilpatrick (1986) provided the following list of suggestions about how justice system personnel can avoid producing additional trauma to crime victims:
After conducting a basic needs assessment and ensuring that the justice system is not revictimizing the crime victim, attention can be directed to measuring the mental and medical health outcomes of crime.
Short-Term Crime-Related Psychological Trauma
Short-term trauma is defined as that which occurs during or immediately after the crime until about three months post-crime. This time frame for short- versus long-term trauma is based on several studies showing that most crime victims achieve significant recovery sometime between one and three months after the crime (Kilpatrick, Veronen, and Resick 1979; Norris and Kaniasty 1994; Rothbaum et al. 1992).
Such physiological and emotional reactions are normal "flight or fight" responses that occur in dangerous situations. In the days, weeks, and first two or three months after the crime, most violent crime victims continue to have high levels of fear, anxiety, and generalized distress (Kilpatrick, Veronen, and Resick 1979; Kilpatrick, Resick, and Veronen 1981; Norris and Kaniasty 1994). The following are examples of distress that may disrupt violent crime victims' ability to concentrate and to perform simple mental activities requiring concentration:
Long-Term Crime-Related Psychological Trauma
Crime-related psychological trauma is not limited to a few days, weeks, or months after a violent crime. Nor is the psychological trauma experienced only by the crime victim. The scientific literature concerning long-term psychological trauma has grown enormously since the publication of the President's Task Force on Victims of Crime Report in 1982. What follows is a brief review of the major types of long-term crime-related psychological trauma.
POSTTRAUMATIC STRESS DISORDER (PTSD)
The Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV, APA 1994) contains a symptom-based definition of all psychological disorders, along with specific criteria required to make diagnoses. A DSM-IV diagnosis of PTSD refers to a characteristic set of symptoms that develop after exposure to an extreme stressor. Sexual assault, physical attack, robbery, mugging, kidnapping, child sexual assault, observing the serious injury or death of another person due to violent assault, and learning about the violent personal assault or death of a family member or close friend are specifically mentioned in the DSM-IV as types of stressors that are capable of producing PTSD. If when exposed to these stressor events, a person responds with intense fear, helplessness, or horror, a PTSD diagnosis may be in order. The following are characteristic symptoms after the traumatic event:
There are substantial research data from adults indicating that crime-related PTSD is a frequent reaction to violent crime (Kilpatrick, Saunders, Veronen, Best, and Von 1987; Kilpatrick and Resnick 1993; Kendall-Tackett, Williams, and Finkelhor 1993; Breslau et al. 1991; Resnick and Kilpatrick 1994; Freedy et al. 1994). This research found--
Importantly, evidence shows that many crime victims with PTSD do not spontaneously recover without treatment and that some crime victims have PTSD years after they were victimized (Kilpatrick et al., 1987; Resnick et al., 1993; Hanson et al., 1995).
DEPRESSION AND OTHER PROBLEMS
Long-term, crime-related psychological trauma is not limited to PTSD. Compared to people without a history of criminal victimization, those who have been victimized have significantly higher rates of major depression, panic symptoms, and substance use. For example, using National Women's Study data from sexual and/or physical assault victims, Kilpatrick, Edmunds, and Seymour (1992) and Acierno, Byrne, Resnick, and Kilpatrick (1998) found the following:
These findings have been identified in a number of studies including (Sorenson et al. 1987; Atkeson et al. 1982; Ellis, Calhoun, and Atkeson, 1980; Kilpatrick, Edmunds, and Seymour, 1992; Frank and Stewart 1984; Saunders et al. 1992). The following studies have found these mental health problems as a result of criminal victimization:
In addition to these mental disorders and mental health problems, violent crime often results in profound changes in other aspects of the victim's life. Many victims experience problems in their relationships with family and friends. Among the relationship problems they can experience is difficulty in sexual relations with their partner (Becker et al. 1982; Becker et al. 1986; Resick 1986; Saunders et al. 1992). Often because of their high levels of crime-related fear, many victims change their lifestyles substantially and restrict their usual activities. Moreover, negative belief systems and attributions present shortly after the crime endure and become problematic over time (i.e., Kilpatrick and Otto 1987; Resick 1993; Resick and Schnicke 1993). Compared to nonvictims, crime victims also experience increased risk of future victimization (Kilpatrick, Resnick, Saunders, and Best 1998).
THE HEALTH EFFECTS OF TRAUMA
Violent assault has the potential to produce acute physical injury and/or health problems related to increased stress. In addition to rapid or acute effects, assaultive violence may also have long-term negative health effects. Several mechanisms/mediating factors that potentially increase risk of a victim's assault-related health problems have been outlined by Resnick, Acierno, and Kilpatrick (1997).
Following criminal victimization, the victim is at increased risk of the following physical illnesses:
Health care use increases in years following victimization. For example, Koss et al. (1991) found the following increases in health care utilization in rape victims:
Clearly, both the mental and medical health outcomes of violent crime are devastating to a significant number of victims. However, some of these negative outcomes might be preventable to some degree. As such, early intervention to prevent suffering is justified.
Should Know About the Mental Health Treatment of Crime Victims
Dean Kilpatrick, Director of the National Crime Victims' Research and Treatment Center at the Medical University of South Carolina, offers ten guidelines for criminal justice and victim service professionals that can increase their understanding of, and development of policies related to, the mental health treatment of crime victims:
1. Crime victims and their family members can experience immediate, short-terms, and long-term crime-related mental health problems. Victims may require treatment for immediate, short-term and long-term psychological injuries.
2. Neither all crimes nor all victims are alike. Considerable individual variation exists among crime victims in the types of psychological injuries they are likely to sustain, and how long it will take them to reconstruct their lives, with or without treatment.
3. Child victims often require special consideration because their crime-related psychological injuries may not show up for years after the crime incident. Provision of treatment to currently symptom-free children is often done to prevent development of future mental health problems.
4. For many crime victims, elimination of crime-related psychological injuries is not a realistic treatment goal. Rather, helping victims to learn to cope is the main objective.
5. At times of stress (including criminal justice system-induced stress), victims are likely to have exacerbations of psychological injuries. They can benefit from "booster treatment" at such times.
6. Most mental health professionals have limited training and/or expertise in the assessment and treatment of crime victims' mental health problems.
7. It is reasonable to require mental health treatment providers to document why they think a mental health problem is crime-related, and to describe problem areas that they are attempting to address with treatment. Prevention of future problems is an acceptable goal for treatment.
8. Crime-related posttraumatic stress disorder is clearly an important goal for treatment. So are other mental health disorders that were either not present before the crime, or that were exacerbated after the crime, as well as other areas of functioning that deteriorated after the crime.
9. Don't spend a lot of time and/or resources attempting to determine whether short-term and/or "cheap" treatment is reasonable. Focus efforts on long-term treatment or inpatient treatment. Peer review is your friend for these costly types of treatment.
10. Getting consumer feedback from crime victims about their satisfaction with their mental health treatment is a great idea.
GENERAL ISSUES ABOUT EFFECTIVENESS AND SAFETY
Victim advocates who encounter individual victims of crime or groups of victims who are victims of mass casualty incidents (i.e., bombings or school shootings) have an understandable desire to do something to immediately help these victims. Likewise, mental health professionals often feel compelled to do something to help even if it is unclear exactly what is the most effective thing to do. The notion that all victims and interviewers should be offered some type of early intervention, particularly in mass casualty incidents, has become accepted practice untested by critical research.
Kilpatrick (1999) recently observed that it is difficult to conduct good research evaluating the effectiveness of psychological interventions designed for use in the immediate or short term aftermath of violent crimes such as crisis intervention psychological debriefing, or critical incident stress debriefing. Kilpatrick argued, however, that it is critically important to conduct this type of research in order to determine what works, what doesn't work, and whether some types of interventions work better for some victims than for others.
This is not to say that victim assistance professionals or mental health professionals should do nothing to help victims unless a research study has shown a particular intervention to be effective. However, it is important to recognize "sacred cows," to distinguish between
interventions that are popular and those that have been rigorously tested, and to ask proponents of any new interventions to demonstrate the effectiveness and safety of the treatment they advocate.
Psychological debriefing (PD) interventions, including critical incident stress debriefing (Dyregrov 1989; Mitchell 1983) are widely marketed and used in this and other countries. In PD, participants are encouraged to describe the traumatic event including specifics of what occurred, their thoughts, and their feelings. Emotional responses are considered in detail. Participants are then reassured that their responses are normal, prepared for future emotional reactions, and advised as to how to deal with them.
Unfortunately, PD has not been fully studied using rigorous experimental methodology, and initial claims of efficacy appear to have been overstated. In a review of controlled studies, Rose and Bisson (1998) found that none used random assignment to treatment groups. Of the six studies reviewed, PD resulted in significant improvement in two studies, worsened symptoms in two studies, and produced results no different than a comparison condition in two studies. They concluded that "early optimism for . . . debriefing was misplaced and that there is an urgent need for randomized controlled trials of group debriefing and other early interventions."
On a more optimistic note, a review by Sherman (1998) demonstrated that multisession cognitive and behaviorally-based psychological interventions are effective in reducing the symptoms that follow traumatic stressors. Note, however, that these treatments were not "crisis" interventions. Rather, these treatments generally required multiple sessions occurring over weeks or months. Given the lack of empirical support for the critical incident stress debriefing model of crisis intervention, therefore, adoption of more general crisis intervention strategies is probably preferable.
Most crime victims think that the criminal justice system should be responsible for providing them with counseling for crime-related psychological trauma (Freedy et al. 1994; Amick-McMullan, Kilpatrick, and Resnick 1991; Kilpatrick, Amick, and Resnick 1990).
A national probability household sample of surviving family members of homicide victims (Kilpatrick et al. 1990) and a sample of South Carolina crime victims whose cases were recently adjudicated by the criminal justice system (Freedy et al. 1994) were asked if they thought the criminal justice system should be responsible for seeing that crime victims and their families receive access to psychological counseling and several other services.
This is particularly noteworthy because virtually all of these crime victims would have been eligible for crime victim compensation coverage for their mental health counseling. Clearly, a problem exists because most crime victims expect the justice system to provide them with access to counseling, but most victims--including those with crime-related PTSD--say they do not get the counseling they need.
Criminal and juvenile justice system professionals and victim advocates encounter crime victims with crime-related psychological trauma every day. Few justice system professionals and victim advocates are trained mental health professionals, so they often have questions about how they can best deal with victims to reduce psychological trauma. Because they are not mental health professionals, victim advocates are not expected to provide specialized mental health treatment to victims with crime-related psychological trauma.
However, criminal and juvenile justice system professionals and victim advocates do need to know about state-of-the-art specialized counseling procedures for crime-related psychological trauma. They also need to know how to help victims obtain access to adequate counseling. In order to appropriately refer crime victims to mental health counselors, justice professionals must be familiar with the training and credentials of the various professionals who may be available.
Mental health professionals differ with respect to the amount and type of training they received prior to getting their professional degree:
In addition to these "mainstream" mental health providers, certain other groups also provide counseling services to victims. These include pastoral counselors from the clergy and some nurses with special mental health training. Traditional healers from Native American cultures may not fit into these traditional mental health professional categories, but have specific expertise and training based on the expertise and mores of their culture.
Another important issue in evaluating the credentials of mental health professionals is whether they are licensed, certified, or registered in the state where services are being provided. These usually require passing an oral and written exam.
A final consideration in evaluating the credentials of mental health professionals is the extent of their specific knowledge and experience in working with crime victims. Unfortunately, there is no requirement that graduate training for any type of mental health professional include information about assessment and treatment of crime-related psychological trauma. Nor does the licensure process require possession of this knowledge and expertise. Thus, there is no guarantee that any given mental health professional will be knowledgeable about assessment and treatment of crime-related psychological trauma. Therefore, it is necessary to inquire about the extent of a mental health professional's expertise in this area.
ASSESSING MENTAL HEALTH PROFESSIONALS
Victim service providers should carefully assess mental health professionals prior to making referrals to victims whom they serve. The following ten questions provide a basis for determining the appropriateness of referrals, and also serve to ensure that victimized staff receive competent, appropriate care:
1. What are the provider's professional credentials?
2. Does the professional have any direct experience in assisting victims of violent crime, such as rape survivors, battered women, assault victims, and/or victims or surviving family members of DUI crashes and homicides?
3. Is the professional trained in disorders common to many survivors of crime and critical incidents, such as posttraumatic stress disorder (PTSD), rape trauma syndrome, or battered women's syndrome?
4. What are the professional's credentials relevant to continuing education training on victim-related issues (a vitae can provide this information)?
5. Has the state Crime Victim Compensation Program reimbursed the services of this professional in the past?
6. Does the professional actively participate in any local, state or national victim assistance or victim service coalitions?
7. Does the professional belong to or have any affiliation with organizations that specialize in mental health, trauma response or victimization?
8. What has been the experience of crime victims who have received mental health services from this professional in the past? Is there any official mechanism to obtain this type of personal evaluation feedback?
9. Does the professional accept payment from workers' compensation and/or victim compensation, and are services rendered on a sliding fee scale?
10. Does the professional have a standardized process for getting feedback from victim clients regarding their satisfaction with treatment?
There are literally hundreds of different psychotherapies, but relatively few are designed specifically for use with crime victims and have had their efficacy evaluated. Most of the research on efficacy of treatment for crime-related psychological trauma has been conducted with adult victims of rape rather than with child victims or with adult victims of other types of crimes. However, much of what has been learned from research on the treatment of rape victims is probably applicable to the treatment of other crime victims.
As was previously noted, many mental health professionals who treat crime victims have no specific training or expertise in crime-related psychological trauma. Therefore, they tend to use generic treatment procedures rather than treatment specifically targeted to crime-related trauma. Some specialized treatments, however, have received some type of evaluation as to their effectiveness. Most work has been done developing and evaluating treatments for rape-related psychological trauma and/or for victims of various types of traumatic events who developed PTSD. The following references provide more information about specialized treatment procedures: Briere 1992; Calhoun and Atkeson 1991; Falsetti and Resnick, in press; Foa, Rothbaum, Riggs, and Murdock 1991; Foa, Rothbaum, and Steketee 1993; Kilpatrick, Veronen, and Resick 1982; McCann and Pearlman 1990; Resick and Schnicke 1993.
LENGTH AND TIMING OF TREATMENT
The length of treatment depends on a number of factors including the extent of the victim's crime-related psychological trauma and the amount of external social support the victim has. Most treatment should be relatively short term in nature, however. Crime-related psychological trauma does not end with the trial, so victims may need brief booster sessions at other stressful times in their lives, including during parole hearings or upon the release of offenders.
Not all crime victims need or can benefit from mental health counseling. Research has contributed to an understanding of which victims are most likely to develop crime-related psychological trauma and which are most likely to require consultation with trained mental health professionals, including counselors, clergy, healers, etc.
Of course, research only provides general guidelines. Not all victims with these characteristics need mental health counseling, and some victims without these characteristics do need counseling. More detailed treatments of this topic are contained in the following references: Hanson et al. 1995; Resnick and Kilpatrick 1994; Weaver and Clum 1995.
PREVICTIMIZATION CHARACTERISTICS OF VICTIMS
Before a crime occurs, victims differ in respect to their demographic characteristics, whether they have ever been a crime victim before, and how well adjusted they were before the crime. Some of these previctimization characteristics might influence the traumatic impact of a new violent crime experience.
In general, violent crimes such as rape, aggravated assault, homicide and alcohol-related vehicular homicide produce more crime-related psychological distress than property crimes such as burglary. Also, victims' appraisals of how dangerous the crime was are related to crime-related psychological trauma (Weaver and Crum 1995). In particular, a belief that one might have been seriously injured or killed in a crime is a more powerful predictor of distress than objective factors such as physical injury, force, and use of a weapon. Research evidence is clear that the most important factor in determining crime-related psychological trauma is the level of severity of the crime.
Two major postvictimization factors are thought to play an important role in victim recovery from crime-related psychological trauma. The first is social support. In general, most studies find that good relationships and support from family members and friends assist victims' recovery (Hanson et al. 1995). Consequently, determining the extent and supportiveness of a crime victim's potential social support network is important. Victims with little social support are probably more likely to need professional counseling.
The second major post-victimization factor is the degree and nature of exposure to the criminal justice system. Although participation in the criminal justice system is generally regarded as a negative factor in victims' recovery (Kelly 1990; President's Task Force on Victims' of Crime 1982; Symonds 1980), there are some data suggesting that involvement with the criminal justice system need not always have a negative effect (Kilpatrick and Otto 1987). A positive experience, however, is largely dependent upon comprehensive, sensitive and inclusive treatment of victims by criminal justice personnel. Indeed, criminal justice personnel must recognize that, by virtue of their association with the trauma and the perpetrator, they will often become "triggers" for negative emotions and distress in crime victims. As such, steps must be taken to counter the effects of these associations so that victims might view criminal justice system proceedings and staff as supportive and worthwhile, as opposed to purely aversive stimuli.
There is no question that the criminal justice system is stressful for victims. The whole point of making the criminal justice system more "victim friendly" is the assumption that doing so may actually reduce the trauma to the victims, thereby increasing their willingness to participate as effective witnesses for the prosecution. It is also reasonable to assume that being believed and treated well by the criminal justice system could improve the process for victims, notwithstanding the inherently stressful nature of the criminal justice system.
Trauma Assessment and Intervention Self-Examination
2. Identify three of the physical health problems victims of crime often experience.
3. Name two things the criminal or juvenile justice system should do to help victims of crime.
4. Why are psychotherapeutic debriefing interventions such as critical incident stress debriefing not recommended at this time?
5. What are the two postvictimization factors that are likely to affect a victim's recovery?
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