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Chapter 10

The Mental Health Impact of Crime:

Fundamentals in Counseling and Advocacy

Abstract: The President's Task Force on Victims of Crime in 1982 called on the mental health community to study crime-related psychological trauma, to develop psychological treatment programs for crime victims, and to work with victim services to insure that crime victims have access to competent psychological treatment. Considerable progress has been made since 1982. This chapter discusses the types of trauma likely to be experienced by crime victims, the factors that influence victim recovery from crime-related trauma, what crime victims expect from the criminal justice system, and how criminal justice professionals can respond to the mental health needs of crime victims.

Learning Objectives: Upon completion of this chapter, students will understand the following concepts:

1. Identification of the major types of immediate and short-term trauma associated with crime victimization.

2. Identification of long-term crime-related psychological trauma.

3. Why the criminal justice system should concern itself with crime-related psychological trauma of crime victims.

4. Previctimization and postvictimization that are important to consider in victim recovery.

5. How the criminal justice system can address the needs of traumatized crime victims.

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 as well as 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 insure that crime victims have access to competent psychological treatment.
• Study crime-related psychological trauma.
• Establish training programs for practitioners who work with crime victims.

Short-term Crime-related Psychological Trauma

• Short-term trauma is defined as that which occurs during and 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 some significant recovery sometime between one and three months after the crime (Kilpatrick, Veronen & Resick, 1979; Norris & Kaniasty, 1994; Rothbaum, Foa, Riggs, Murdock & Walsch, 1992).
• Few crime victims are anticipating a violent assault at the time it occurs, so most are shocked, surprised, and terrified when it happens.
• They often have feelings of unreality, thinking, "this can't be happening to me."

Many violent crime victims also describe experiencing extremely high levels of physiological anxiety:

• Rapid heart rate.
• Hyperventilation.

Cognitive symptoms of anxiety include:

• Feeling terrified or helpless (Veronen, Kilpatrick & 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 & Resick, 1979; Kilpatrick, Resick & Veronen, 1981; Norris & Kaniasty, 1994).

• This distress disrupts their ability to concentrate and to perform simple mental activities that require concentration.
• They are preoccupied with the crime (e.g., 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 pre-crime beliefs that the world is a safe place where you can trust other people, and where people get the things they deserve out of life (e.g., Janoff-Bulman & Frieze, 1983; McCann & Pearlman, 1990).

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 Report in 1982, so it is only possible to provide a brief review of the major types of long-term crime-related psychological trauma.

Post-traumatic Stress Disorder (PTSD)

The DSM-IV diagnosis of PTSD refers to a characteristic set of symptoms that develop after exposure to an extreme stressor (APA, 1994).

Sexual assault, physical attack, robbery, mugging, being kidnaped, 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. When exposed to these stressor events, the person's response must (according to the DSM-IV) involve intense fear, helplessness, or horror. Characteristic symptoms after the traumatic event include:

1. 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.)

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

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

4. Duration of at least one month of symptoms.

5. 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 common reaction to violent crime (e.g., Kilpatrick, Saunders, Veronen, Best & Von, 1987; Kilpatrick & Resnick, 1993; Kendall-Tackett, Williams & Finkelhor, 1993; Breslau, Davis & Andreski, 1991; Resnick & Kilpatrick, 1994; Freedy et al., 1994). This research has 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%).
• The same study found that crime 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 criminal justice system than among nonreporting victims (Kilpatrick & Resnick, 1991; Freedy et al., 1994).
• Importantly, there is also evidence 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., in press).
• Long-term, crime-related psychological trauma is not limited to PTSD. Compared to people without a history of criminal victimization, people with criminal victimization have been found to have significantly higher rates of major depression.

These findings have been identified in a number of studies including: (Sorenson et al., 1987; Atkeson et al., 1982; Ellis, Calhoun & Atkeson, 1980; Kilpatrick, Edmunds & Seymour, 1992; Frank & Stewart, 1984; Saunders et al., 1992), 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 & Winfield-Laird, 1986; Kilpatrick et al., 1994; Sorenson et al., 1987), and 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 victims' 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, Skinner, Abel & Tracy, 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.

The negative changes in pre-crime beliefs and attributions about the world that are short-term problems often become long-term problems (e.g., Kilpatrick & Otto, 1987; Resick, 1993; Resick & Schnicke, 1993). Compared to non-victims, crime victims also experience increased risk of future victimization.

Most crime victims think that the criminal justice system should be responsible for providing them with counseling for crime-related psychological trauma (Freedy, Resnick, Kilpatrick, Dansky, & Tidwell, 1994; Amick-McMullan et al., 1991; Kilpatrick, Amick & 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.
• In contrast to their expectations that access to counseling should be provided, 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 (Freedy et al., 1994).
• 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 criminal justice system to provide them with access to counseling, but most victims -- including those with crime related PTSD -- say they don't get the counseling they need.

Criminal justice system professionals and other victim advocates encounter crime victims with crime-related psychological trauma every day. Few criminal justice system professionals and other victim advocates are trained mental health professionals, so they often have questions about how they can best deal with victims to reduce their psychological trauma. Because they are not mental health professionals, criminal justice system professionals or other victim advocates are not expected to provide specialized mental health treatment to victims with crime-related psychological trauma.

However, criminal 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, criminal 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. Here is a brief description of the major types of "mainstream" mental health professionals and their training.

• 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 knowledge 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.

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 treatment of rape victims is probably applicable to 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. However, there are specialized treatments that 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. Readers interested in learning more about specialized treatment procedures should consult the following references (Briere, 1992; Calhoun & Atkeson, 1991; Falsetti & Resnick, in press; Foa, Rothbaum, Riggs, & Murdock, 1991; Foa, Rothbaum & Steketee, 1993; Kilpatrick, Veronen, & Resick, 1982; McCann & Pearlman, 1990; Resick & Schnicke, 1993).

Length and Timing of Treatment

How long treatment should be 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 release of offenders.

Not all crime victims need or can benefit from specialized mental health counseling. Research has contributed to our understanding of which victims who are most likely to develop crime-related psychological trauma and who are most likely to require consultation with a trained mental health professional.

Of course, these are general guidelines. Not all victims with these characteristics need mental health counseling, and some victims without these characteristics do need counseling. A more detailed treatment of this topic is contained in the following references: (Hanson et al., 1995); Lurigio and Resick, 1990; 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. It is reasonable to assume that 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 (Lurigio and Davis, 1989; Calhoun and Atkeson, 1982; Kilpatrick and Resnick, 1993).

Prior victimization history has been consistently found to increase the likelihood of psychological trauma following a new crime (Burnam et al., 1988; Kilpatrick, Resnick, Saunders and Best, in press; Resnick, 1987). Specifically, victims with a prior victimization history 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 (see Lurigio and Resick, 1990, review; Kilpatrick, Resnick, Saunders and Best, in press; 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 risk of developing PTSD after experiencing a stressful, violent crime. However, a history of major depression did increase the risk that PTSD would develop, but only if the crime was highly stressful. This suggests that 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., 1989; Lurigio and Resick, 1990; Kilpatrick et al, in press; Kilpatrick and Resnick, 1993; Weaver and Clum, 1995; Resnick et al., 1993).

In general, violent crime such as rape, aggravated assault, homicide and alcohol-related vehicular homicide produce more crime-related psychological distress than property crimes like burglary. Also, victims' appraisals of how dangerous the crime was are related to crime related psychological trauma. (See Weaver and Crum's review, 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 how serious and dangerous the crime is constitutes the most important factor in determining crime-related psychological trauma.

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 (e.g. Hanson et al., 1995); Lurigio and Resick, 1990; Kaniasty and Norris, 1992). Consequently, it is important to determine the extent and supportiveness of a crime victim's potential social support network. Victims with little social support are probably more likely to need professional counseling.

The second major postvictimization 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 (e.g., 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; Lurigio and Resick, 1990; Resick, 1988). A positive experience, however, is largely reliant on treatment of victims that is comprehensive, sensitive and inclusive.

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. It is also reasonable to assume that being believed and treated well by the criminal justice system could make things better for victims, notwithstanding the inherently stressful nature of the criminal justice system.

Kilpatrick (1986) provided the following list of suggestions about how criminal 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 whom the victim can count on for emotional support.
• Inquire about any specific fears or concerns the victims may have about trial and testimony.
• Inform and consult with victims about potential plea-bargain 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.
• Tell victims you are sorry that the crime happened and ask how you can help.

Self Examination Chapter 10

The Mental Health Impact of Crime:

Fundamentals in Counseling and Advocacy

1) Identify three possible victim reactions that constitute short-term crime related trauma.

2) What are the five characteristic symptoms of post-traumatic stress disorder?

3) Are there any previctimization characteristics that might affect how a victim reacts following a crime? If you, please describe.

4) Name 3 factors related to the crime or postvictimization factors that influence victim recovery from crime related psychological trauma.

5) How can the criminal justice system address the mental health needs of crime victims?

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