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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:

• The importance of victim assistance professionals conducting an assessment of victims' basic needs.

• The psychological and social outcomes of trauma.

• The medical and health outcomes of trauma.

• Interventions for traumatized victims.

• Characteristics of victims most likely to require mental health counseling.

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--

• Develop immediate- and long-term psychological treatment programs for crime victims and their families.

• Work with victim services to ensure that crime victims have access to competent psychological treatment.

• Study crime-related psychological trauma.

• Establish training programs for practitioners who work with crime victims.

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:

• Victims' crime-related mental health problems.

• Which aspects of the criminal justice system process are stressful to victims.

• What can be done to help victims with their crime-related mental health problems.

• What can be done to help victims cope with justice system-related stress.

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?

• Kilpatrick, Veronen, and Resick (1982) noted that a violent criminal victimization is a real life classical conditioning experience in which being attacked is an unconditioned stimulus that produces unconditioned responses of fear, anxiety, terror, helplessness, pain, and other negative emotions.

• Any stimuli that are present during the attack are paired with the attack and become conditioned stimuli capable of producing conditioned responses of fear, anxiety, terror, helplessness, and other negative emotions.

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.

AVOIDANCE BEHAVIOR

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.

SECOND-ORDER CONDITIONING

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:

• Having to look at the defendant in the courtroom.

• Having to think about details of the crime when preparing to testify.

• Confronting a member of "second-order conditioned stimuli" in the form of police, victim/witness advocates, and prosecutors.

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:

• Victims lack information about that system and its procedures, and they fear the unknown.

• Victims are concerned about whether they will be believed and taken seriously by the criminal justice system.

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:

• Treat victims as human beings, not as evidence.

• Always provide victims with information about case status and prepare them for what will happen at trial.

• Pay close attention to any psychological trauma the victim may be experiencing.

• Arrange for someone to be present at the trial on whom the victim can count for emotional support.

• Inquire about any specific fears or concerns the victims may have about the trial and testimony.

• Inform and consult with victims about potential plea-bargain or diversion procedures.

• Give victims opportunity for input into proceedings when possible, including the opportunity to make a victim impact statement.

• Refer victims who need help with stress management to mental health professionals specifically trained to provide it.
• Receive training for the detection of possible warning signs of substance abuse and, when indicated, make appropriate referrals to mental health professionals who specialize in the assessment and treatment of substance abuse problems.

• Tell victims you are sorry that the crime happened and ask how you can help.

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).

• Few crime victims are anticipating a violent assault at the time it occurs; so most are shocked, surprised, and terrified when it happens.

• Crime victims often have feelings of unreality when an assault occurs and think, "This can't be happening to me."

• People who have been victimized in the past are at greater risk of developing emotional problems than newly victimized individuals. Victims do not "get used to it."

• Many violent crime victims describe experiencing extremely high levels of physiological anxiety, including rapid heart rate, hyperventilation, stomach distress.

• Crime victims often experience cognitive symptoms of anxiety including feeling terrified or helpless, guilty, out of control (Veronen, Kilpatrick, and Resick 1979; Kilpatrick, Resnick, Freedy et al. 1994).

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:

• They are preoccupied with the crime (i.e., they think about it a great deal of the time; they talk about it; they have flashbacks and bad dreams about it).

• They are often concerned about their safety from attack and about the safety of their family members.
• They are concerned that other people will not believe them or will think that they were to blame for what happened.

• Many victims also experience negative changes in their belief systems and no longer think that the world is a safe place where they can trust other people and where people get the things they deserve out of life (Janoff-Bulman and Frieze 1983; McCann and Pearlman 1990).

• For victims of some crimes, like child abuse or domestic violence, the trauma occurs many times over a period of weeks, months, or even years. Victims in such cases often experience the compounded traumatic effects of having to always worry about when the next attack will occur.

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:

• Persistent re-experiencing of the event (i.e., distressing dreams, distressing recollections, flashbacks, or emotional and/or physiological reactions when exposed to something that resembles the traumatic event).

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

• Persistent symptoms of increased arousal (i.e., sleep difficulties, outbursts of anger, difficulty concentrating, constantly being on guard, extreme startle response).

• Duration of at least one month of symptoms.

• Disturbance produces clinically significant distress or impairment in social, occupational or other important areas of functioning.

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--

• Rates of PTSD are much higher among those who have been victims of violent crime than among those who have been victims of other types of traumatic events. For example, Resnick et al. (1993) found that the lifetime prevalence of PTSD was significantly higher among crime victims than victims of other traumatic events (25.8% vs 9.4%).

• Resnick et al. (1993) also found that victims whose crimes resulted in physical injuries and who thought they might have been killed or seriously injured during the crime were much more likely to suffer from PTSD than victims whose crimes did not involve life threat or physical injury (45.2% vs 19%).

• Rates of PTSD appear to be higher among victims who report crimes to the justice system than among nonreporting victims, probably because these crimes are more serious or more likely to result in injury (Kilpatrick and Resnick, 1991; Freedy et al., 1994).

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:

• One-third to one-half of assault victims develop depression.

• Risk of alcohol abuse is increased by a factor of 4.

• Risk of drug use is increased by a factor of 3.5.

• Ninety-five percent of a clinic sample with panic disorder had a victimization history. Seventy percent of treatment-seeking trauma victims reported four or more panic symptoms.

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:

• Thoughts of suicide (Kilpatrick et al. 1992; Saunders et al. 1992; Kilpatrick et al. 1985).

• Attempting suicide (Kilpatrick et al. 1985; Kilpatrick et al. 1992; Saunders et al. 1992).

• Developing alcohol or other drug abuse problems (Burnam et al. 1988; Cottler et al. 1992; George and Winfield-Laird 1986; Kilpatrick et al. 1994; Sorenson et al. 1987).

• Anxiety disorders such as panic disorder (Burnam et al. 1988; Saunders et al. 1992), agoraphobia (Burnam et al. 1988; Saunders et al. 1992), and obsessive compulsive disorder (Burnam et al. 1988; Saunders et al. 1992).

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).

• Physical injuries may lead to other health conditions such as heart attack, stroke, fractures from falling, dislocated joints, torn muscle tissue, or loss of dexterity resulting in job loss.

• Acute health problems such as sexually transmitted diseases (STDs) might develop into chronic infection, dysfunction, or systemic spread.

• Assault-related generalized stress might impair functioning of the immune, endocrine, or autonomic systems, which could increase the likelihood that a victim will contract a variety of infectious diseases, etc.

• Either assault-related stress or assault-related emotional problems could increase risk that the victim might engage in unhealthy behaviors such as smoking, excessive alcohol or other drug use, poor diet, lack of sleep, insufficient physical exercise, etc. These behaviors might contribute to future health problems, immune system problems, and might lead to chronic mental health problems.

• Victims who receive inappropriate health care services due to either underutilization by the victim or inadequate treatment by the health care provider, are at higher risk of needing additional restorative health care.

Following criminal victimization, the victim is at increased risk of the following physical illnesses:

• Cardiac distress.

• Irritable bowel syndrome.

• Chronic pain.

• Sexual dysfunction.

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:

• First year postrape: 18% increase in health care utilization.

• Second year postrape: 56% increase in health care utilization.

• Third year postrape: 31% increase in health care utilization.

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.

Interventions

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

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.

• Almost three out of four surviving family members of homicide victims (74%) and more than four out of five crime victims (83%) said the criminal justice system should provide access to counseling.

• A majority of surviving family members of homicide victims (50%) and crime victims (63%) said that they and their families did not have adequate access to psychological counseling.

• In the South Carolina crime victim study, only 27% of crime victims received psychological counseling.

• Even among those crime victims who developed crime-related PTSD, only slightly more than a third (36.7%) ever received any counseling.

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:

• Psychiatrists are medical doctors who receive an M.D. degree after completing four years of medical school. They also complete a one year internship and at least two additional years of specialized psychiatric residency training. In addition to providing psychotherapy, psychiatrists can prescribe medications.
• Clinical psychologists receive at least four years of graduate training that includes supervised experience in the assessment and treatment of clients. They also complete a one year internship prior to receiving a Ph.D. or Psy.D. degree. In most states, clinical psychologists must also complete at least one year's additional supervised experience after they receive their doctoral degree.

• Clinical social workers receive an M.S.W. degree after two years of graduate training including classes and field work. Some of this training involves supervised assessment and treatment of clients. Additional years of postgraduate training are often required to become a licensed clinical social worker, L.C.S.W.

• Marriage and family therapists must have at least a masters degree in some behavioral science field and two years of additional supervised clinical practice with couples and families.

• Masters degree clinical mental health counselors usually have two years of training that includes some type of supervised internship. These mental health counselors can be certified by the National Academy of Certified Clinical Mental Health Counselors. Additionally, many states provide an L.P.C. license, Licensed Professional Counselor.

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.

• Although there are some exceptions, most studies show that victims' demographic characteristics such as gender, race, and age have little (if any) impact on crime-related psychological trauma (Kilpatrick and Resnick 1993).

• Prior victimization has consistently been found to increase the likelihood of psychological trauma following a new crime (Burnam et al. 1988; Kilpatrick, Resnick, Saunders and Best 1998). Specifically, victims with a prior victimization history, including victims of chronic victimization, suffer more crime-related psychological trauma after experiencing a new crime than victims without prior victimization. This highlights the importance of inquiring about prior victimizations.

• The prior mental health history of the victim appears to be related to the extent of crime-related psychological trauma a victim experiences (Resnick and Kilpatrick 1990). Kilpatrick et al. (in press) found that women who had PTSD in the past were substantially more likely to get PTSD after experiencing a new crime than women who had not had PTSD previously.

• Resnick, Kilpatrick, Best, and Kramer (1992) found that prior history of most mental disorders did not increase the risk of developing PTSD after experiencing a stressful, violent crime. A history of major depression, however, did increase the risk that PTSD would develop, but only if the crime was highly stressful. This suggests that not only victims with PTSD or depression may be particularly vulnerable to crime-related psychological trauma, but also confirms the important role played by the stressful nature of the crime itself.

• Seriousness of the crimes has consistently been found to be related to the degree of crime-related psychological trauma (Kilpatrick et al, in press; Kilpatrick and Resnick 1993; Weaver and Clum 1995; Resnick et al. 1993).

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.

POSTVICTIMIZATION FACTORS

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.

Promising Practices

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

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

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

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

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

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

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

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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