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The Trauma of Intimate Partner Sexual Violence
A research report
The aim of this report was to explore the current research on Intimate Partner Sexual Violence (IPSV) and discuss the theories of trauma and grief in relation to IPSV. Research on IPSV, trauma and grief was drawn from many sources including academic journals, research reports, books and websites. The report details issues that need to be taken into consideration by counsellors when dealing with clients with IPSV, specifically the need to consider the whole context of the issue, and to know when to refer the client for more specialised psychological help. Given the relatively recent recognition of the issue of IPSV it is worth monitoring the literature for advances in specific counselling recommendations.
1. INTIMATE PARTNER SEXUAL VIOLENCE
1.1 Defining the Issue
1.2 Incidence and Prevalence
1.3 Research Limitations
1.4 Effects of Intimate Partner Sexual Violence
1.4.1 Physical Effects
1.4.2 Psychological Effects
2. TRAUMA, GRIEF AND INTIMATE PARTNER SEXUAL VIOLENCE
2.1.1 Trauma Theory
2.1.2 Symptoms of Trauma
2.1.3 Treatment of Trauma
2.2.1 Defining Grief
2.2.2 Grief Symptoms and Behaviours
2.2.3 Treatment of Grief
2.3 Trauma and Grief
2.4 Intimate Partner Sexual Violence, Trauma and Grief
3. CONSIDERATION FOR COUNSELLING
3.1 For Counsellors
3.2 For Clients
Appendix 1 Post Traumatic Stress Disorder
Intimate Partner Sexual Violence (IPSV) is any form of sexual violence that occurs within an intimate relationship. It can cause traumatic reactions that have a huge impact on the life of victims. This report will explore a wide range of research and will define what IPSV is and look at its prevalence and effects, as well as limitations to the research. Trauma and grief theory and how they apply to IPSV and considerations for counselling will also be explored.
1. 0 INTIMATE PARTNER SEXUAL VIOLENCE
1.1 Defining the Issue
Intimate Partner Sexual Violence (IPSV) is sexual violence perpetrated against a person by a past or current intimate partner. It is also known as wife or partner rape, but includes sexual violence that may not fit the definition of rape. IPSV is generally one part of a wider pattern of abuse that can include battery, emotional and psychological abuse and geographic and social isolation. (Easteal & McOrmond-Plummer, 2006)
1.2 Incidence and Prevalence
The statistics for the prevalence of IPSV or partner rape have not changed since the seminal studies in the 1980s and 1990s, and have been found to be similar across western nations. It has been found that 10-14% of ever married women have been raped by a current or previous partner and 34% have experienced unwanted sex that may not have, at the time of the studies, met the criteria for rape. 20-70% of battered women have been found to have suffered one or more incident of sexual assault by a partner. (Bergen, 2006) Research has also shown that sexual violence against women by intimates is likely to be chronic in nature, often occurring twenty times or more. (Bergen, 2006)
1.3 Research Limitations
There are limitations that may affect the reliability of the research, although this is likely to have resulted in an underestimation of the prevalence of IPSV. Much of this comes down to the way terms are defined and the effect that has on restricting population groups and types of sexual violence. Other surveys, such as the Australian Bureau of Statistics Crime and Safety Surveys, grossly under-represent some population groups, including Indigenous Australians and those from non-English speaking backgrounds. (Heenan, 2004)
1.4 The Effects of IPSV
1.4.1 The Physical Effects
IPSV has been shown to cause a wide range of physical injury, particularly if there is co-occurring battery. Physical effects of IPSV include sexual injuries such as tearing and stretching of the genitals, urinary tract infections, sexually transmitted diseases including HIV and Hepatitis B, miscarriage, still birth and infertility. There is also an increased risk of unwanted pregnancy. (Women's Health Goulburn North East, 2008)
1.4.2 The Psychological Effects
IPSV meets the Australian Psychological Society’s (APS) definition of a potentially traumatic event in that it is a threat to physical and/or psychological wellbeing and can result in cognitive, emotional, behavioural and physical symptoms. (Australian Psychological Society) As IPSV is generally chronic there is a greater possibility of developing more than a simple trauma reaction. Post Traumatic Stress Disorder (PTSD) as a common consequence of IPSV. Other psychological effects of IPSV can include grief reactions, depression and anxiety. (McOrmond-Plummer)
2.0 TRAUMA, GRIEF AND IPSV
2.1.1 Trauma Theory
Psychological traumatisation occurs when a person’s internal and external resources are unable to cope with an external threat. (Herman, 2001)It is not the traumatic event that causes the problem but how the individual reacts to it, which is why individuals dealing with the same experience may have differing responses. (Australian Psychological Society) Modern trauma theory is widely believed to have developed from the treatment of psychologically traumatised troops from the First and Second World Wars and the Vietnam War. (Griffiths & Larkey, 2010) (Herman, 2001) Prior to the development of PTSD and Acute Stress Disorder diagnoses, traumatic reactions resulting from combat were variously known as shell-shock and combat fatigue and widely believed to be a result of emotional weakness. The next level of development came out of the feminist movement of the 1970s. By taking the issues of domestic and sexual violence out of the privacy of the home the effects of the violence were publically acknowledged for the first time. Researchers found that the symptoms of women who had been raped or battered and soldiers who had been in combat were in many cases similar. (Herman, 2001)It was this discovery that led to the development of PTSD as a recognised psychological diagnosis. Some researchers suggest that traumatic reactions be “understood as a spectrum of conditions rather than a single disorder” (Herman, 2001, p. 119) (Griffiths & Larkey, 2010) and that this spectrum ranges from brief stress reactions that resolve without intervention, to PTSD, to what Herman calls complex-PTSD, which encompasses the “complex syndrome of prolonged, repeated trauma.” (Herman, 2001, p. 119)
2.1.2 The Symptoms of Trauma
The APS describes the symptoms of trauma as falling into four categories; physical, cognitive, behavioural and emotional, and can include such things as excessive alertness, disturbed sleep, intrusive thoughts and memories of the event, nightmares, social isolation and withdrawal and anxiety and panic. (Australian Psychological Society) Think of a person who has been through a car accident. They may seem numb or detached from what happened, have a few sleepless nights, see the accident replay in their mind and avoid driving completely or under similar circumstances or routes to those connected to the accident. With support of family and friends these symptoms will probably be short lived and resolve quickly as the person makes sense of what happened. (Australian Psychological Society) Traumatic reactions that are persistent or debilitating may qualify for a diagnosis of Acute Stress Disorder or PTSD. (Griffiths & Larkey, 2010) Information about PTSD can be found in Appendix 1.
2.1.3 Treatment of Trauma
Simple trauma reactions resolve spontaneously, requiring no formal treatment. Critical Incident Stress Debriefing (CISD) has been used as a preventative against more severe trauma reactions, particularly for emergency personnel; however there is no conclusive evidence of its efficacy. (Griffiths & Larkey, 2010) The APS states that “structured psychological interventions such as psychological debriefing should not be offered on a routine basis.” (Australian Psychological Society)Instead, monitoring a person’s mental state and offering information and social support is the preferred course of action. (Australian Psychological Society)
People who experience more severe traumatic reactions may require professional support from a counsellor. Treatment can involve ensuring the safety of the person, helping them build their narrative of the traumatic event, including not just what happened but how they felt about it, and integrating the experience into their life in a way that is meaningful to the client. (Herman, 2001) Clients who exhibit signs of PTSD should be referred to a specialist in dealing with trauma, usually a psychologist or psychiatrist.
2.2.1 Grief Theory
Grief is the emotional reactions related to loss. The loss can be through bereavement, change of life-cycle or development stage, family breakdown or disability. While the death of a loved one is an obvious loss, the losses involved with family breakdown, for example, may not be considered as ‘real’ losses by some. However the grief that they cause is very real and can be debilitating. (Griffiths & Larkey, 2010)
2.2.2 Symptoms of Grief
There are a wide range of symptoms related to grief. They can be emotional, somatic (physical) and cognitive. Emotional symptoms of normal grief include sadness, anger and relief. Physical symptoms can include tightness in the chest and a lack of energy. Cognitive symptoms may include confusion and disbelief. Behaviours associated with grieving can include crying, social withdrawal and isolation, dreams and nightmares related to the loss and carrying reminders of what was lost. The symptoms and behaviours listed are only some of what may be seen in someone having a grief reaction. It is not necessary for one person to experience them all and two people grieving the same loss may have very different symptom and behaviour patterns. (Griffiths & Larkey, 2010) (Machin, 2009)
2.2.3 Treating Grief
Normal grief reactions resolve over time without intervention. People must be given the opportunity to develop and use their own coping strategies. If the grieving process is prolonged or particularly debilitating then counselling may be appropriate. (Griffiths & Larkey, 2010) (Machin, 2009)
2.3 Trauma and Grief
Trauma and grief can be inextricably linked. Some losses are traumatic in nature, such as deaths through suicide, natural disasters and accidents. Many traumatic experiences involve losses. A rape victim may lose their senses of personal security and control of their body. Many of the symptoms of grief and trauma reactions are similar, and both normal grief and simple trauma can resolve by themselves if a person has adequate social support and coping strategies. However, people who have survived a traumatic experience may not identify the things they have lost or understand the need to grieve for them. In this case professional counselling can help.
2.4 IPSV, Trauma and Grief
IPSV is traumatic and results in losses that need to be grieved over. The trauma of IPSV is related not just to the sexual violence and any other co-occurring abuse but to the intimate nature of the relationship in which it occurred. The betrayal by an intimate partner can result in the breakdown and loss of the relationship, a loss of financial security and the loss of ideals and dreams about love and relationships.
3.0 CONSIDERATIONS FOR COUNSELLING
3.1 For Counsellors
Victims of IPSV may enter counselling for many reasons. If they identify their experience as primarily domestic violence or sexual assault related they may contact a service specific to that issue, such as a rape crisis centre or domestic violence refuge. Counsellors at both of these services need to be aware of the specific issues related to IPSV. It is important that IPSV is not treated as either a domestic violence issue or a sexual assault issue but as a combination of both. Either/or attitudes can leave the client feeling that their needs are not being met. (Hite, 2009)
Victims of IPSV may present for counselling for complaints such as depression and anxiety without linking it to what happened to them. It is important for counsellors to explore the possibility of IPSV, especially if the client discloses relationship violence, although some mental health professionals are divided on the counsellor naming the experience for the client. (Herman, 2001)
Perhaps the most important consideration for counsellors is to know when to refer a client for more specialist support. If a client shows signs of PTSD they need to be seen by a psychologist or psychiatrist specialising in the treatment of trauma. (Griffiths & Larkey, 2010) If a counsellor has already built a therapeutic relationship with the client this needs to be handled delicately and with the input of the client.
3.2 For Clients
Clients who have been victims of IPSV need to consider the best way to have their specific needs met. This may require being in touch with both sexual assault and domestic violence services. Ideally they should be able to find a service that deals with all issues related to IPSV without having to shop around. Clients also need to be aware that it is appropriate to ask a counsellor if they have experience working with IPSV and what their views about sexual violence within a relationship are. Above all clients need to know they have the right to find a counsellor with whom they are comfortable and able to disclose to.
IPSV is a traumatic experience that can have far ranging psychological consequences. The trauma lies not just in the nature of the experience but also in the nature of the relationship between the victim and the perpetrator. The trauma of IPSV results in losses that need to be acknowledged and grieved for by the victim. Counsellors need to consider the nature of the traumatic event and then needs of the client to ensure they receive the best outcome possible.
APPENDIX 1 POST TRAUMATIC STRESS DISORDER
Post Traumatic Stress Disorder is a traumatic response that lasts for longer than a month and causes significant impairment. It can develop after experiencing or witnessing events that pose a severe threat to physical and/or psychological wellbeing, such as serious accidents, natural disasters and interpersonal violence such as physical and sexual assaults. PTSD is classified as an anxiety disorder in the DSM-IVTR. (Herman, 2001) (Australian Psychological Society, 2007)
Symptoms of PTSD
Symptoms of PTSD fall into three categories; hyper-arousal; intrusion or re-experiencing; and constriction or avoidance and are similar to, although more severe than, the symptoms of a normal traumatic reaction. Hyper-arousal symptoms are the result of the mind and body being constantly on alert for danger. In a hyper-aroused state a person “startles easily, reacts irritably to small provocations and sleeps poorly.” (Herman, 2001, p. 35) At the time of the traumatic event these are physiologically based reactions that try to protect a person from danger. If these symptoms persist after the event is over and the person is safe then they are maladaptive and can cause impairment in everyday life. (Australian Psychological Society, 2007) (Herman, 2001)
Intrusion symptoms include flashbacks which may include a feeling of re-experiencing the traumatic event physically and/or emotionally or may take the form of a movie or soundtrack in the mind, nightmares, and intrusive memories of the trauma. The memories are not like the normal linear sequenced memories of everyday life. Instead they are very fixed with a person recounting them in a manner that shows little emotion and using the same phrasing and intonation each time. Traumatic memories are said to have a frozen quality. (Herman, 2001)
Constriction or avoidance symptoms can be likened to an animal freezing when caught in the headlights of a car. Perceptions can be distorted, pain and emotions numbed and the sense of time altered. There may be a feeling of not being real or of watching events rather than being a part of them. In a severe form this is termed dissociation and can resemble a hypnotic trance. The most extreme form of dissociation is that of Dissociative Identity Disorder, previously called Multiple Personality Disorder. Like hyper-arousal symptoms, constriction and dissociation at the time of trauma is a defence mechanism aimed at protecting the person for enduring the full emotional force of the traumatic event. After the traumatic event is over dissociation is maladaptive and makes the integration of the whole experience into a person’s sense of being impossible. (Herman, 2001)
Treatment of PTSD is done in three stages; establishing safety; remembrance and mourning; and reconnection. (Herman, 2001)The safety stage refers both to safety from further trauma and safety within the traumatised person themself, taking into account suicidal ideation, self-harming behaviours and drug and alcohol abuse. The remembrance and mourning stage refers to the person developing their narrative, including the details of the traumatic event, their reactions to it and how they felt about it, and grieving the losses that have occurred due to the trauma. This allows the experience to be fully integrated into their life. Finally, the reconnection stage is about reconnecting with life fully. (Herman, 2001) Healing from PTSD is not a linear process and the traumatised person may move back and forth between stages. (Easteal & McOrmond-Plummer, 2006) Even after the reconnection stage is considered to be completed, even years later, PTSD symptoms can reoccur. This is possibly an indication that some part of the trauma has not been fully integrated and further healing work needs to be done. (Herman, 2001) (Courtis, 2008)
Working with clients with PTSD requires specialist training and is normally done by a psychologist or psychiatrist who specialises in treating trauma.
Complex Post Traumatic Stress Disorder
Chronic trauma is said to be trauma that has occurred over a prolonged period of time, possibly months or years. Examples of prolonged trauma are captivity, such as for prisoners of war or in concentration camps, child abuse and domestic violence. While survivors of this type of trauma are frequently diagnosed with PTSD they also tend to have other, co-occurring or co-morbid mental disorders. Judith Lewis Herman proposed that these survivors deserved a diagnosis that reflected not just the extra mental health consequences they suffered but that acknowledged the on-going nature of the trauma they experienced. She proposed that this symptom pattern be called Complex-PTSD (CPTSD). (Herman, 2001)
Symptoms of CPTSD
While survivors of chronic traumatisation may display the symptoms of simple PTSD they often present with other mental health issues such as anxiety or panic attacks and depression. If chronic traumatisation is not considered they may collect diagnoses such as clinical depression or personality disorder without the root cause being addressed. Herman outlined seven categories she believed needed to be met for a diagnosis of CPTSD.
1) A history of subjection to totalitarian control over a prolonged period (months to years). Examples include hostages, prisoners of war, concentration-camp survivors and survivors of some religious cults. Examples also include those subjected to totalitarian systems in sexual and domestic life, including survivors of domestic battering, childhood physical or sexual abuse, and organized sexual exploitation.
2) Alterations of affect regulation, including
• persistent dysphoria
• chronic suicidal preoccupation
• explosive or extremely inhibited anger (may alternate)
• compulsive or extremely inhibited sexuality (may alternate)
3) Alterations in consciousness, including
• amnesia or hypermnesia for traumatic events
• transient dissociative episodes
• reliving experiences, either in the form of intrusive post-traumatic stress disorder symptoms or in the form of ruminative preoccupation
4) Alterations in self-perception, including
• sense of helplessness or paralysis of initiative
• shame, guilt and self-blame
• sense of defilement or stigma
• sense of complete difference from others (may include sense of specialness, utter aloneness, belief no other person can understand, or nonhuman identity)
5) Alterations of perception of perpetrator, including
• preoccupation with relationship with perpetrator (includes preoccupation with revenge)
• unrealistic attribution of total power to perpetrator (caution: victim’s assessment of power realities may be more realistic than clinician’s)
• idealization or paradoxical gratitude
• sense of special or supernatural relationship
• acceptance of belief system or rationalizations or perpetrator
6) Alterations in relationships with others, including
• isolation and withdrawal
• disruption in intimate relationships
• repeated search for rescuer (may alternate with isolation and withdrawal)
• persistent distrust
• repeated failures of self-protection
7) Alterations in systems of meaning
• loss of sustaining faith
• sense of hopelessness and despair
(Herman, 2001, p. 121)
These seven categories give a good overview of the symptoms of CPTSD. Both the American Psychiatric Association and the International Classification of Diseases are developing entries for their next diagnostic volumes to cover CPTSD, although both have chosen different names (disorder of extreme stress not otherwise specified and personality change from catastrophic experience, respectively). (Herman, 1992)
Treatment of CPTSD
Treatment of CPTSD is similar to that of simple PTSD. It is generally considered that treatment is likely to need to be of an extended duration, either continuously or sporadically. As with simple PTSD, CPTSD should be treated by someone specially trained in dealing with trauma, usually a psychologist or psychiatrist.
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