Vicarious Trauma – How rape affects you

Trauma is contagious. Anyone helping a rape survivor can be overwhelmed emotionally by what he or she hears and could even begin to experience, to a lesser degree, the same terror, rage, helplessness and despair as the survivor. This is called vicarious trauma or traumatisation. Hearing stories of trauma can also awake the personal memories of suffering that the helper might have had in the past. So engaging in this work presents some risk to the helper’s psychological and emotional health. This risk is often severely underestimated by health care providers as individuals and by their organisations or institutions.

Each person working regularly with survivors needs support in order to avoid “compassion fatigue” or being drained and burnt out by these continuous intense interactions. In the same way that survivors cannot recover alone, therapists, counsellors and medical personal and even police and prosecutors can never work alone, and should not have to.

Common feelings experienced by people working with survivors are as follows:

Fear of being raped themselves
Loss of faith in men or in humanity
A sense of shared helplessness with the survivor
The same rage that a survivor feels
The same grief that a survivor feels
Guilt at not having suffered as much themselves
Identifying with the perpetrator or trying not to identify with the survivor

These feelings lead to certain clear difficulties in helping survivors as a consequence of slowly and progressively becoming “contaminated” by the trauma of rape. Day after day dealing with the same kind of trauma, the same terrible stories, can deeply affect anyone.
Fear of rape can lead to problems with personal and physical intimacy and even sexual dysfunction.

A loss of faith in people can lead to becoming fearful and mistrustful of others and pessimistic or cynical about the human race in general. This can change one’s worldview and sense of meaning in life quite drastically.

Feeling some of the survivor’s helplessness could mean that the helper begins to devalue her own knowledge, skill or capacity to be of help in the face of such terrible suffering and to believe that in fact nothing can be done by anyone, or she may assume the role of rescuer, and even violate professional boundaries for the sake of playing this role.

Feeling the same rage could cause the helper to become angry with colleagues, “the system” and the cruelty in men, or to become afraid of the survivor who is full of rage and allow herself to be manipulated or become overwhelmed by the survivor’s behaviour.
In feeling the survivor’s grief the helper might succumb to despair.

Guilt about not having suffered could cause a helper to have difficulty enjoying the pleasures and comforts of her own life, or she may feel her own actions are inadequate or limited
Helpers who struggle not to identify with the survivor often feel highly skeptical of the survivor’s story, or minimise the extent of the abuse, or try to rationalise why or how it happened, or feel disgusted or judgmental of the survivor, or fascinated by the sexual aspects of the rape.

The list as it goes on becomes more and more frightening. We start to realise the risk we take in reaching out to survivors and simply doing our jobs day by day. There are three aspects to this risk. The first is a lack of awareness of the risk and the need for support that each of us has when working with rape survivors. We soldier on and on and don’t even realise that we’ve lost our psychological health. Some people even begin to suffer a form of post traumatic stress disorder and start dreaming about being raped. They have difficulty putting the stories they have heard and the rape survivors they have seen out of their minds when they are at home. Certain things trigger an involuntary response of memory. Some have trouble sleeping and eating properly and are constantly preoccupied by the demands being made on them. Physical health begins to deteriorate and stress headaches, upset digestion, aching backs and constant colds add their tell tale signs to the picture. Alcohol consumption increases, too many cigarettes are smoked and impulsive spending sprees eat away at ones resources and sense of reward. So being aware of the need for support is vital.

The second aspect is an organisation that doesn’t understand the risks you face and does not do what it can to protect you. Any organisation that takes its clients or patients’ needs seriously and aims to deliver a good service should have a very clear acknowledgement that vicarious trauma is an occupational hazard for those directly involved in treating survivors. It should nurture and support service delivery staff and volunteers in the following ways:

Openly acknowledge the need for support and develop structures to offer it
Have a clear operating philosophy behind its service delivery goals
Work expectations must be clear and realistic and agreed by all personnel
There needs to be regular feedback and supervision that is supportive
Effort and achievement must be recognised
The working environment should be comfortable and attractive. Even small things like music from a radio, a fresh coat of paint, a vase of flowers or colorful pictures on the wall, or mats on the floor, or cushions on chairs, or bright curtains and magazines to read in a waiting area can make a huge difference to everyone, staff and clients alike. Many local communities, churches and schools are eager to help in this way.
Communication, feedback and support should happen both up and down the organisational hierarchy as well as with peers on the same level.
In service training and development should be continuous
A focus on team work and support should be encouraged and developed
Written and accessible protocols and procedures must be defined
Adequate time off for illness and vacation must be available
A system whereby individuals can vary the work they do and swap rotations to do this should be set up
Opportunities for advancement and clear rewards and incentives

While much of this is good procedure for any healthy organisation it is especially important for organisations whose staff are at risk for vicarious trauma. Consider the question, is there a difference in the occupational hazard of industrial machinery that cuts off a finger and the occupational hazard that causes you to lose sleep, lose faith in humanity, alienate you from your intimate partner and become dependent on alcohol, drugs or overeating?

You need to do all you can to insist on your organisation’s support. Make requests through all the right channels, lobby continuously, participate in setting up immediate support structures for you and your team and demand worker’s compensation for any expense relating to your own vicarious trauma! And don’t underestimate the untold and expensive damage that is caused by every rape that happens.

The third aspect is very simple. A helper experiencing one or more of the common feelings relating to vicarious trauma is no good to the survivor. In fact that helper is a risk to the survivor in that secondary trauma to the survivor is a very real probability.

Rape Trauma Syndrome – How rape may affect your patient

No person exposed to severe trauma is immune to suffering and the signs of that suffering are referred to as symptoms. When these symptoms can be grouped as a pattern over time, they are referred to as a syndrome. Once the pattern becomes entrenched or unlikely to change, and affect a person’s functioning in a permanent way it is referred to as a disorder and is regarded as a mental illness.
Rape Trauma Syndrome (RTS) is the medical term given to the response that survivors have to rape. It is very important to note that RTS is the natural response of a psychologically healthy person to the trauma of rape so these symptoms do not constitute a mental disorder or illness.

The most powerful factor in determining psychological suffering or damage is the character of the traumatic event itself. Individual personality characteristics count for little in the face of overwhelming events. Physical harm or injuries are also not as great a factor since individuals with little or no physical harm may yet be severely affected by their exposure to a traumatic situation. Before looking at the effects of rape it is therefore important to first examine the character of the trauma that is rape.

Not only is there the element of surprise, the threat of death and the threat of injury, there is also the violation of the person that is synonymous with rape. This violation is physical, emotional and moral and associated with the closest human intimacy of sexual contact. The intention of the rapist is to profane this most private aspect of the person and render his victim utterly helpless. The character of the event is thus connected to the perpetrator’s apparent need to terrorise, dominate and humiliate the victim. The victim is therefore most likely to see his actions as motivated by deliberate malice, a malice impossible for her to understand. Rape by its very nature is intentionally designed to produce psychological trauma. It is form of organised social violence comparable only to the combat of war, being but the private expression of the same force. We get nowhere in our understanding of Rape Trauma Syndrome if we think of rape as simply being unwanted sex. Where combat veterans suffer Post Traumatic Stress Disorder, rape survivors experience similar symptoms on a physical, behavioural and psychological level.

PHYSICAL SYMPTOMS OF RAPE TRAUMA SYNDROME

Physical symptoms are those things which manifest in or upon the survivor’s body that are evident to her and under physical examination by a nurse or doctor. Some of these are only present immediately after the rape while others only appear at a later stage.

Immediately after a rape, survivors often experience shock. They are likely to feel cold, faint, become mentally confused (disorientated), tremble, feel nauseous and sometimes vomit.
Pregnancy.
Gynaecological problems. Irregular, heavier and/or painful periods. Vaginal discharges, bladder infections. Sexually transmitted diseases.
Bleeding and/or infections from tears or cuts in the vagina or rectum.
A soreness of the body. There may also be bruising, grazes, cuts or other injuries.
Nausea and/or vomiting.
Throat irritations and/or soreness due to forced oral sex.
Tension headaches.
Pain in the lower back and/or in the stomach.
Sleep disturbances. This may be difficulty in sleeping or feeling exhausted and needing to sleep more than usual.
Eating disturbances. This may be not eating or eating less or needing to eat more than usual.

BEHAVIOURAL SYMPTOMS OF RAPE TRAUMA SYNDROME

Behavioural symptoms are those things the survivor does, expresses or feels that are generally visible to others. This includes observable reactions, patterns of behaviour, lifestyle changes and changes in relationships.

Crying more than usual.
Difficulty concentrating.
Being restless, agitated and unable to relax or feeling listless and unmotivated.
Not wanting to socialise or see anybody or socialising more than usual, so as to fill up every minute of the day.
Not wanting to be alone.
Stuttering or stammering.
Avoiding anything that reminds the survivor of the rape.
Being more easily frightened or startled than usual.
Being very alert and watchful.
Becoming easily upset by small things.
Relationship problems, with family, friends, lovers and spouses. Irritability, withdrawal and dependence are factors which effect this.
Fear of sex, loss of interest in sex or loss of sexual pleasure.
Changes in lifestyle such as moving house, changing jobs, not functioning at work or at school or changes to her appearance.
Drop in school, occupational or work performance.
Increased substance abuse.
Increased washing or bathing.
Behaving as if the rape didn’t occur, trying to live life as it was before the rape, this is called denial.
Suicide attempts and other self-destructive behaviour such as substance abuse or self mutilation.

PSYCHOLOGICAL SYMPTOMS OF RAPE TRAUMA SYNDROME

Psychological symptoms are much less visible and can in fact be completely hidden to others so survivors need to offer this information or be carefully and sensitively questioned in order to elicit them. They generally refer to inner thoughts, ideas and emotions.

Increased fear and anxiety.
Self-blame and guilt.
Helplessness, no longer feeling in control of her life.
Humiliation and shame.
Lowering of her self esteem
Feeling dirty or contaminated by the rape
Anger
Feeling alone and that no one understands.
Losing hope in the future.
Emotional numbness.
Confusion
Loss of memory.
Constantly thinking about the rape.
Having flashbacks to the rape, feeling like it is happening again.
Nightmares
Depression.
Becoming suicidal.

There are many influences on the manner in which each individual survivor of sexual violence copes and on the length of time the symptoms may be present. These factors include:

Support systems
The relationship with the offender
The degree of the violence used
Social and cultural influences
Previous experience with stress
Ability to cope with stress
Attitude of those immediately contacted after the assault
The age and developmental stage of the survivor (adolescent survivors are more vulnerable)

It is important that we recognise that survivors will not respond in the same ways, as comparing two case histories can show. While most survivors will experience these symptoms, some survivors may only experience a few of these symptoms while others may experience none at all. We must be careful not to judge whether someone has been raped by the number of symptoms that they display. Because most survivors are afraid to tell anyone that they have been raped it is often not easy to observe their reaction, or recognise them without the survivor’s own account – and this she is unlikely to give easily.

It has been observed through clinical studies that almost all rape survivors suffer severe and long lasting emotional trauma. The most significant factors that cause this appear to be a combination of the following features of the assault experience.
It is sudden
It is perceived as life threatening
Its apparent purpose is to violate the survivor’s physical integrity and/or render her helpless.
The survivor is forced to participate in the crime.
The survivor cannot prevent the assault or control the assailant, her normal coping strategies have failed. Thus she becomes a victim of someone else’s aggression.

The trauma is usually compounded by the myths, prejudice and stigma associated with rape. Survivors who have internalised these myths have to fight feelings of guilt and shame. The burden can be overwhelming especially if the people they come into contact with reinforce those myths and prejudices.

This is why it is essential that all legal, medical and police procedures must not cause further trauma to survivors who must be given all possible support to overcome and survive the ordeal. Courts are now beginning to use evidence of this kind in the trial stage of a court case as well as at the sentencing stage where the effect that the rape has had on the victim’s life is taken into consideration when sentencing the perpetrator. However it is plain to see that there are distinct psychological clues, left in the survivor’s mind, that add up to evidence of trauma of a very particular character that we know as the crime of rape.

Secondary Trauma

The Extended Psychological Event

Rape survivors may turn to a variety of services in their community for assistance such as the police, medical facilities, mental health organisations, courts and religious institutions. The responses of these services can deeply affect the rape survivor’s well-being and influence her ability to recover from the trauma. If they are negative they can increase the level of trauma she experiences and make her recovery even more difficult. Rape survivors are often denied help by their community services and sometimes the help they do receive leaves them feeling doubted, blamed and retraumatised. These negative experiences are called the second rape or secondary trauma or secondary victimisation. In other words, victim’s well-being may be affected not only by the rape but also by the help seeking interactions after the assault. The trauma of rape extends far beyond the actual assault and any helping intervention strategy must address the particular difficulties faced by rape survivors and prevent secondary trauma.

When rape victim’s needs are not met by the very people they turn to for help the effects can be quite devastating. Because traumatic incidents invariably cause damage to relationships, people in the survivor’s world have the power to influence the eventual outcome of the trauma. In the aftermath of rape survivor’s are extremely vulnerable. Their sense of self has been shattered and their faith in the world as a safe place has been destroyed. Rebuilding some form of trust, even if it is minimal, is the primary task of anyone wanting to help a rape survivor.

Secondary victimisation has been defined as “the victim-blaming attitudes, behaviours and practices engaged in by community service providers, which further the rape event resulting in additional trauma for the rape survivors”. But it is not the only cause of extending the trauma for survivors. Secondary trauma stems from three main causes:

An acceptance of certain myths and stereotypes about rape leads to personnel treating victims in an insensitive manner
Personnel refuse to provide any assistance at all or refuse some form of assistance
Even if assistance is offered and even if it is offered in a sensitive manner the procedures themselves are traumatic

If service providers ascribe to myths about rape, such as believing that women often provoke rape by the way they dress or are prone to lie about having been raped as a form of revenge, they may tell the survivors that she is not a credible witness, that her story is not believable or even just give her a sense of being doubted. A rape survivor may have her case dismissed, not taken seriously, might not be referred for a forensic examination or medical treatment, may not be fully informed of the health risks associated with rape and even if they want these services they are denied. And finally when women are offered services the services themselves cause distress: the police statement and counselling services because it causes her to relive the rape experience by retelling it, the forensic examination because it probes and exposes her body in the same way as the rape did even if the motivation is completely different and the court case because it introduces the survivor to an adversarial situation – the battle ground of the court room.

When women go public with stories of rape, they place a great deal of trust in our social systems and in doing so risk disbelief, scorn, shame, humiliation and refusals of help. For men reporting rape the risks are the same and in some instances even greater as men are expected to be able to defend themselves from harm and may even be ridiculed for having been raped. The implications for recovery are very clear – a negative experience leads to a much poorer outcome. Therefore preventing secondary victimisation and trauma must be a key focus in any intervention with rape survivors. Men, women from poorer communities and those raped by someone known to them are at greater risk for secondary victimisation.

Preventing secondary trauma involves the conscious use of the “principles of empowerment”: safety, restored control, respect and ongoing support. If service providers are able to encompass these principles in their work then they go some way towards fulfilling the primary task of rebuilding the trust. An awareness of the damage caused by secondary victimisation lead to the development of a set of minimum standards for service delivery by the Department of Social Development. Rape Crisis has taken these standards and grouped them under the headings of the four principles of empowerment as follows:

Safety:

Physical, emotional and mental
Reassurance of physical safety from further harm
Reassurance about confidentiality
Making the victim feel comfortable
Explaining upcoming procedures in detail
Offering to call a family member or other trusted person

Restoring control:

Give information to the victim
Receive information from the victim
Involve the victim in all decisions that affect him or her
Ensure that interventions happen with victim’s informed consent
Inform victim of his or her legal rights

Respect:

Treat the person with respect for their dignity
Affirm their strengths
Speak in their own language where possible
Listen attentively
Adhere to their wishes as far as possible
Respect diversity of language, culture, religion, race, sexual orientation and gender

Ongoing support:

Treat the person in a caring manner
Offer access to available resources
Offer emotional support to victims
Offer practical support to victims
Involve family members or other trusted person in supporting the victim
Refer victims to other relevant services for further assistance
Accompany victim in stressful situations

Using these principles and applying them consciously involves service providers in becoming aware of their own biases and moral judgements. One of the simplest and most direct ways of doing this is to consider how far from the “ideal” most rape cases are from a legal perspective. The following is a description of “the perfect case” for the system, one that allows everyone’s job to be a lot easier than it may otherwise be:

“… the perfect case would be one in which all the information checks out, there are police witnesses to the crime, the victim can provide a good description of the assailant, there is supporting medical evidence including sperm and injuries, the story remains completely consistent and unchanging, the victim was forced to accompany the assailant, was previously minding her own business, a virgin, sober, stable emotionally, upset by the rape, did not know the assailant who has a prison record and a long list of current charges against him.”

Of course there are few, if any, survivors that meet these requirements completely and so each survivor represents hard work for the team. And if the team is tired or overworked or operating under stress they may not be as sensitive to the survivor’s needs as they would wish. And of course they are all subject to believing the myths about rape at some point or other even though we know they are not true. It takes a lot of thought and care and self-awareness to be completely unbiased and sensitive to every survivor, so it is important for service providers to know how they would like to be and to work out why they are not like that sometimes. Then they can work at it and help others around them to do so.

When it comes to the medical examination in particular, the intervention itself is traumatic anyway and so it is doubly important for service providers to be acutely aware of the potential for further harm to the survivor. The following quote by an emergency-room physician describes the essentials:

“The most important thing in medically examining someone who has been sexually assaulted is not to re-rape the victim. A cardinal rule of medicine is: Above all do no harm…and rape victims often experience an intense feeling of helplessness and loss of control. If you just look schematically at what a doctor does to the victim very shortly after the assault with a minimal degree of very passive consent: A stranger makes a very quick intimate contact and inserts an instrument into the vagina with very little control, or decision-making on the part of the victim; that is a symbolic set up of a psychological re-rape.”

“So when I do an examination I spend a lot of time preparing the victim; every step along the way I try to give back control to the victim. I might say, ‘We would like to do this and how we do it is your decision,’ and provide a large amount of information, much of which I am sure is never processed; but it still comes across as concern on our part. I try to make the victim an active participant to the fullest extent possible.”

Based on research findings, three further prevention approaches are recommended:

Increased involvement of rape crisis centres
Specialised training for all service providers
Development of multidisciplinary teams in systems offering integrated care to survivors

and Rape Crisis Cape Town would add two more:

Increased use of specially trained community based volunteers in victim support
Increased supervision and support to service providers

Rape crisis centres services are under utilised by survivors even though they are consistently effective in assisting victims to negotiate their pathway through the Criminal Justice System, in offering crisis intervention and advocacy services. Many rape survivors don’t know about these services and how they help survivors. Service providers need to refer rape survivors and inform them about local rape crisis centres. State service providers don’t usually get thorough and comprehensive training in issues of violence against women and victim support in their academic education and so must ensure that they are exposed to this at a later stage in order to gain an understanding of the issues and to learn the appropriate skills. Also rape care centres that bring together police, doctors, nurses, victim support volunteers, social workers and prosecutors to work as an integrated team assisting rape survivors are some of the most helpful services to rape survivors and avoid the stress associated with traveling from one service to the next and facing a different environment and attitude towards care every time they do so.

Community based victim support volunteers are also an important component of service provision for rape survivors. This model, where community members form a community-based organisation that organise the volunteers through recruitment, training, support and rosters, is exceptionally attractive. It seems to offer a solution to the challenge of preventing secondary trauma by offering support to victims as a parallel process alongside direct service provision by members of the Criminal Justice System. Volunteers offering practical and emotional support based at police stations, schools and hospitals also strengthen the community with tools, capacity and support that empowers the community against the tide of violence. They are perfectly positioned to restore some of the trust that has been damaged through violence. In the South African context community members do not always easily access professionals when they are needed most. They usually work during office hours, weekdays only and only counsel from their offices, which might be far from where the victim is. Within this context community volunteers are wonderful because they are able to bridge this gap. If correctly managed and well supported, they take a lot of the burden off service providers too, allowing personnel to perform their jobs knowing that the rape survivors is getting maximum support.

One last thing that makes service providers reluctant to engage with victims on an emotional level (which is often required if secondary trauma is to be prevented) is that they themselves do not get adequate support and supervision within their settings and therefore fall prey to vicarious trauma – in other words because they are not supported they begin to take on and experience some of the feelings experienced by the victims they treat. Small wonder that they attempt to distance themselves from victims and adopt the victim-blaming attitudes that allow them to remain removed.

Of course secondary trauma cannot always be prevented. It is for this reason that counsellors and others service providers helping a survivor some time after the rape must treat the process of going through the CJS as part of the trauma and not leave it out of the healing process.