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Practice Profile

Psychotherapies for Victims of Sexual Assault

Evidence Ratings for Outcomes:

Effective - More than one Meta-Analysis Mental Health & Behavioral Health - Trauma/PTSD

Practice Description

Practice Goals
Psychotherapeutic interventions for adult sexual assault victims are designed to reduce psychological distress, symptoms of post-traumatic stress disorder (PTSD), and rape trauma through counseling, structured or unstructured interaction, training programs, or predetermined treatment plans. Most treatments include individual cognitive behavioral approaches, such as cognitive-behavioral therapy or insight/experiential therapy. The goals of psychological therapy for victims of sexual assault include (1) preventing and reducing PTSD/trauma symptoms, anxiety, depression, and other psychopathologies; and (2) improving social adjustment and self-esteem.

Target Population
The vast majority of rape and sexual assault victims are female. A recent examination of the National Crime Victimization Survey found that between 2005 and 2010, there were 2.1 victimizations per 1,000 females age 12 and older in the United States. Females age 34 or younger, who lived in lower income households and in rural areas, reported the highest rates of sexual violence during that time (Planty et al. 2013). Psychotherapeutic interventions can be provided to victims of sexual abuse and assault who are experiencing rape trauma or PTSD. Symptoms of PTSD can be categorized into three groups: (1) re-experiencing intrusive thoughts, emotions, or physiological distress upon exposure to cues of the event; (2) avoidance of thoughts or stimuli that are reminiscent of the event; and (3) biological, emotional, or cognitive arousal (Regehr et al. 2013). Sexual assault victims also report high rates of depression, difficulty concentrating, uncontrollable grief, low self-esteem, self-destructive behavior, suicidal thoughts, addictive behavior, impaired social and occupational functioning, sexual avoidance, and psychological disorders such as panic attacks (Chard 1995).

Practice Components
Psychotherapeutic treatment generally includes two basic components: (1) development and maintenance of a trusting relationship with a therapist; and (2) recounting one’s story about the assault in treatment so that the therapist can help the individual overcome the debilitating symptoms resulting from PTSD.

In most modalities of psychotherapeutic treatment, therapists attempt to help victims make sense of their memories and reduce or eliminate PTSD symptoms, including thoughts, flashbacks, guilt, and fears associated with the victim’s response to the assault. The practice can also teach sexual assault victims other skills, such as anger management, assertiveness, and communication. Therapists usually focus more on the current situation and its solution, concentrating on a person's views and beliefs about their life.

Therapy models that focus on helping victims recover from trauma can be categorized into three frameworks:

  • The cognitive-behavioral model assumes that a person is both the producer and product of her environment; therefore, treatment is aimed at changing a person’s behaviors within her environment. The model incorporates cognitive, behavioral, and social learning theory components. Examples of specific cognitive-behavioral approaches include exposure therapy or prolonged exposure, stress inoculation training, eye movement desensitization reprocessing, cognitive processing therapy, and assertiveness training.
  • Psychodynamic psychotherapy focuses on several aspects, such as expression of emotions, exploration of avoidance of distressing emotions, examining past experiences, identification of defense mechanisms, and working through interpersonal relationships. An important part of psychodynamic psychotherapy is bringing the person’s conflict and psychic tensions from the unconscious into the conscious to encourage healthier functioning.
  • Supportive psychotherapy or supportive counseling may be provided in individual or group settings, and allows an individual to share her traumatic experience and the symptoms that resulted from the event. Supportive approaches aim to normalize experience, instill hope, increase interpersonal learning, and decrease an individual’s sense of isolation.
The selection of a specific treatment method depends on the particular characteristics of the victim, such as the extent of PTSD symptoms. The characteristics of treatment (including the duration, number of sessions, treatment setting, and the therapist’s experience) will vary depending on the type of therapy.

Meta-Analysis Outcomes

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Effective - More than one Meta-Analysis Mental Health & Behavioral Health - Trauma/PTSD
Taylor and Harvey (2009) found that psychotherapeutic approaches had a significant, large effect (Hedge’s g=0.94) with regards to the treatment of trauma and post-traumatic stress disorder (PTSD) of sexual assault victims. The review by Regehr and colleagues (2013) estimated the effect of psychotherapeutic treatment using a different methodology, although the results were similar. They found that treatment programs had a statistically significant positive effect on PTSD symptoms (SMD= -1.54) compared to control groups. This suggests that psychotherapeutic interventions can be associated with decreased symptoms of trauma and PTSD in victims of sexual assault and rape. Please note: the overall effect size reported for Regehr and colleagues (2013) was calculated by CrimeSolutions.gov Study Reviewers by combining individual study-level effect sizes provided in the published review.
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Meta-Analysis Methodology

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Meta-Analysis Snapshot
 Literature Coverage DatesNumber of StudiesNumber of Study Participants
Meta-Analysis 11991 - 20058694
Meta-Analysis 21991 - 20056405

Meta-Analysis 1

Taylor and Harvey (2009) set out to evaluate treatment outcome studies of different types of psychotherapeutic approaches for sexual assault victims experiencing post-traumatic stress disorder (PTSD) or rape trauma symptoms. Therapy was defined as any intervention designed to reduce psychological distress, symptoms of PTSD, and rape trauma through counseling, structured or unstructured interaction, training programs, or predetermined treatment plans. Studies were included in the meta-analysis based on the following criteria: (1) interventions met the definition of therapy; (2) the study examined treatment outcomes of people who had experienced sexual assault and PTSD or rape trauma; (3) the results were based on quantitative findings; (4) the study was written in English; (5) the study was not a case report; (6) the majority of the treated sample had been sexually assaulted; (7) sufficient data was available to calculate effect sizes; and (8) studies reported independent datasets to ensure that each study was coded only once.

A literature search was conducted using a wide variety of sources, including studies that were published in peer-reviewed journals, as well as other studies not published in journals (such as government or private agency sources or dissertations). Of the 89 studies identified, 23 met the criteria for inclusion in the meta-analysis. Several studies with the same datasets were linked to preserve the independence of the research. In total, 15 outcome studies representing diverse treatment approaches were selected for inclusion in the meta-analysis; these studies comprised 25 treatment conditions. Of the 15 total studies, two meta-analyses were conducted based on study design: one meta-analysis for independent samples designs that included comparison groups (eight studies) and one meta-analysis for repeated measures designs that did not include comparison groups (seven studies). The outcomes reported here are only for the meta-analysis of the independent samples designs.

The studies that used independent samples designs were published between 1991 and 2005. They examined a variety of treatment types, including prolonged exposure, stress inoculation training, supportive counseling, brief prevention program, imagery rehearsal therapy, cognitive processing therapy, and eye movement desensitization reprocessing. Participants in the studies were drawn from community samples in the United States and Western Europe. There were 383 treatment participants and 311 control participants (total=694 study participants), all of whom were female. The majority of the sample population was white or Caucasian with an undergraduate education. Most participants were between the ages of 27.5 years and 33.5 years. 

Using a fixed effects model, independent samples treatment effects were represented by standardized mean difference scores. Because studies with small sample sizes were included in the analysis, an effect size statistic (Hedge’s g) was used that adjusted for small sample size. All studies used multiple outcome measures; therefore, effect sizes for each measure were averaged to give a single effect size per study. Each study contributed only one effect size to the overall analysis. One exception was when six measurement domains (PTSD/trauma, other anxiety, depression, social, self-concept/self-esteem, and overall/other pathology) were considered, given that only measures assessing the same psychological constructs could be pooled. In this instance, all outcome measures in a single domain were averaged to give a mean effect size.



Meta-Analysis 2

Regehr and colleagues (2013) conducted a meta-analysis to examine the effectiveness of psychotherapeutic interventions in reducing symptoms of distress and trauma in victims of sexual assault and rape. The authors conducted a comprehensive search for studies that met the following eligibility criteria: (1) the allocation of study participants to experiment or control groups was by random allocation or quasi-experimental parallel cohort design; (2) participants were adults who had experienced sexual assault or rape as adults; and (3) the interventions specifically focused on victims of sexual assault or rape. Search methods to identify eligible studies included electronic searches, inspection of reference lists of all relevant articles, personal communication with experts in the field, and hand searches of journals. Special attention was also paid to identify relevant studies from within the grey literature.

The search process yielded the inclusion of six studies that included 405 participants. The average age of women included in the review was 32.2 years, although the age range was large. The race/ethnicity was reported in five studies, and approximately 75 percent of the women were white, 20 percent were African American, and the remainder was Hispanic or other. Four of the six included studies were randomized controlled trials and the other two studies were quasi-experimental designs. All six studies were conducted in large urban settings across the United States, including Philadelphia, Penn.; St. Louis, Mo.; and Atlanta, Ga. Across the six studies, six interventions were assessed including stress inoculation training, prolonged exposure, supportive counseling or supportive psychotherapy, cognitive processing therapy, assertiveness training, and eye movement desensitization and reprocessing.

Three primary outcomes were assessed in the six included studies: PTSD symptoms, depression symptoms, and anxiety symptoms. The standardized mean difference between the treatment and comparison groups was estimated based on the reported means and standard deviations for each group. Given the small sample sizes in both the treatment and comparison groups, the authors calculated Hedges’ g, which is similar to Cohen’s d but includes an adjustment for small sample bias. Inverse variance methods were used to weight each effect size by the inverse of its variance to obtain an overall estimate.

When examining the effect of psychotherapeutic treatment on PTSD symptoms, the authors examined the effect sizes of four randomized controlled trials (RCTs) separately from the effect sizes of two quasi-experimental designs (QEDs). However, CrimeSolutions.gov Study Reviewers were able to combine the separate effect sizes and calculate an overall mean effect size for measures of PTSD symptoms. The Reviewers used the individual study-level effect sizes and confidence intervals that were reported by the authors in the review.

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Cost

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There is no cost information available for this practice.
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Evidence-Base (Meta-Analyses Reviewed)

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These sources were used in the development of the practice profile:

Meta-Analysis 1
Taylor, Joanne E., and Shane T. Harvey. 2009. “Effects of Psychotherapies With People Who Have Been Sexually Assaulted: A Meta-Analysis.” Aggression and Violent Behavior 14:273–85.

Meta-Analysis 2
Regehr, Cheryl, Ramon Alaggia, Jane Dennis, Annabel Pitts, and Michael Saini. 2013. “Interventions to Reduce Distress in Adult Victims of Sexual Violence and Rape: A Systematic Review.” Campbell Systematic Reviews 3.
http://campbellcollaboration.org/lib/download/2577/
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Additional References

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These sources were used in the development of the practice profile:

Chard, Kathleen M. 1995. “A Meta-Analysis of Posttraumatic Stress Disorder Treatment Outcome Studies of Sexually Victimized Women.” PhD dissertation, Indiana University.

Planty, Michael, Lynn Langton, Christopher Krebs, Marcus Berzofsky, and Hope Smiley-McDonald. 2013. Female Victims of Sexual Violence, 1994-2010. Washington, D.C.: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.
http://www.bjs.gov/content/pub/pdf/fvsv9410.pdf
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Related Programs

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Following are CrimeSolutions.gov-rated programs that are related to this practice:

Eye Movement Desensitization and Reprocessing (EMDR) Promising - One study
A therapeutic approach designed to help individuals who have experienced traumatic stress to reprocess and adaptively store dysfunctionally stored traumatic memories. The program is rated Promising. There were significant pre–post gains on all outcome measures for the treatment and comparison group that received the active listening approach. However, the differential improvement on depression, anxiety, PTSD and impact resulted in greater pre–post changes for the treatment group.

Trauma Affect Regulation: Guide for Education and Therapy (TARGET) Effective - More than one study
A manualized, trauma-focused psychotherapy for adolescents and adults suffering from posttraumatic stress disorder. The program is rated Effective. There were significant reductions in measures of PTSD symptoms and anxiety for the treatment group compared to the control group.

Prolonged Exposure Therapy Effective - More than one study
A cognitive–behavioral treatment program for individuals suffering from posttraumatic stress disorder. The program is rated Effective. The program reduced the severity of PTSD and depression; anxiety; trauma-related guilt; and improved social functioning.

Cognitive-Processing Therapy for Female Victims of Sexual Assault Effective - One study
This is a cognitive therapeutic program that is intended to assist female victims of sexual assault with posttraumatic stress disorder (PTSD). The program is rated Promising. Both PTSD and depression symptoms decreased with cognitive treatment, when compared with the control group.
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Practice Snapshot

Age: 21 - 45

Gender: Female

Race/Ethnicity: Black, Hispanic, Other, White

Targeted Population: Females, Victims of Crime

Settings: Inpatient/Outpatient, Other Community Setting

Practice Type: Cognitive Behavioral Treatment, Gender-Specific Programming, Individual Therapy, Victim Programs

Unit of Analysis: Persons