Opening the Black Box: Identifying Common Practice Approaches in Urban and Rural Rape Crisis Centers

Abstract

This study sought to open the black box of services at rape crisis centers (RCCs), particularly related to counseling, to better understand what is available to survivors in urban and rural settings. Findings from a survey of directors and counselors in Texas RCCs reveal a number of strengths: supporting services for survivors of sexual assault and insights that can help to further advance the implementation of evidence-based trauma treatments in this sector. Although many areas of congruence were found between urban and rural settings, differences were noted that have implications for implementation of evidence-based trauma treatments.

Keywords

sexual assault rape crisis center mental health urban/rural differences

Introduction

Sexual violence is a serious problem in the United States, with national surveillance data indicating that 18.3% of American women have experienced rape and 44.6% of American women have experienced other forms of sexual violence in their lifetime (Black et al., 2011). Other recent studies have found prevalence rates from 7-44% (Basile, Breiding, & Smith, 2016; Black et al., 2011; Fedina, Holmes, & Backes, 2018). The impacts of sexual violence can include significant mental and physical health consequences, such as depression and posttraumatic stress disorder (PTSD), high rates of substance use, increased self-blame, and difficulties in daily functioning in social and work settings (Alvidrez, Shumway, Morazes, & Boccellari, 2011; Regehr, Alaggia, Dennis, Pitts, & Saini, 2013). Survivors of sexual violence report a range of service needs including crisis intervention, advocacy, and mental health treatment, and they see rape crisis centers (RCCs) as the most helpful services for meeting their needs after experiencing a sexual assault (Macy, Rizo, Johns, & Ermentrout, 2013; Ullman & Townsend, 2007). Yet, little is known about the service sector charged with supporting survivors of sexual assault as they face short- and long-term consequences of violence (Macy, Giattina, Sangster, Crosby, & Montijo, 2009; Martin, 2005).

This research study seeks to illuminate the black box, by identifying current organizational and provider characteristics of RCCs, the theoretical and intervention modalities utilized, the services provided, and how they differ in urban and rural contexts.

Texas was selected as the site for this study for several reasons. First, Texas has been a national leader with a long history of engagement in the violence against women movement. Activists in Austin developed the first RCC in the state in 1974 and the first battered women’s center in 1977, both of which were among the first such programs in the country (SAFE, 2018). Our partner agency in this project is the Texas Association Against Sexual Assault (TAASA), which came to fruition as a result of a coalition of RCC advocates coming together after a meeting of the National Coalition Against Sexual Assault in Austin, Texas in 1980. These women identified the need for a statewide organization for RCCs in Texas to relieve the isolation of organizations and agencies providing services for rape survivors, who often did not have peers in their communities with whom to work toward systems and cultural change. Early efforts for this organization were focused on education and passing legislation to support sexual assault survivors.

Second, Texas agencies are serving a significant number of survivors. A statewide assessment of sexual assault in Texas found that approximately 1.9 million adults (13% of the state’s population) had experienced sexual assault, with women reporting significantly higher rates (20%) than men (5%) in the sample (Busch-Armendariz, Bell, DiNitto, & Neff, 2003). It is estimated that about 26,000 sexual assaults occur annually in Texas (Busch, Camp, & Kellison, 2006). In addition, it is a large state, both in terms of population (28.3 million, 2017) and geography (268,597 sq mi), and is culturally and ethnically diverse. According to the U.S. Census Bureau (2018), Texas is 42.6% White non-Hispanic, 39.1% Hispanic/Latino, 12.6% Black/African American, 4.8% Asian, 1.9% multiple ethnicities, and 1% American Indian (U.S. Census Bureau, 2018). It also has a large number of RCCs (N = 83) in urban and rural locations, enriching the potential relevance of the findings for RCCs in other states.

Background

RCCs

RCCs fill a critical gap in services for survivors of sexual violence. They often work alongside services such as law enforcement, health care, mental health, and public welfare to meet the needs of survivors and communities postassault (Martin, 2005). RCCs provide counseling, advocacy, and legal and hospital accompaniment, with evidence suggesting that survivors of sexual violence who access RCC services have improved health and well-being, and rate these services as more helpful and less retraumatizing than other services (Campbell, Wasco, Ahrens, Sefl, & Barnes, 2001; Macy et al., 2013; Wasco et al., 2004).

While there is evidence that RCCs are effective in serving survivors, little is known regarding the service sector itself, including the types of services and populations with which it engages. Macy et al. (2009) described the sector as a “black box,” with well-articulated goals, but little clarity regarding the steps agencies take to achieve them. This opaqueness is particularly entrenched in the RCC service sector because of its grassroots nature, which has led to variation in terms of structure, services, and delivery mechanisms across agencies (Koss & Harvey, 1991; Macy et al., 2013). Where we do have information regarding the RCC sector, data are frequently lumped together with domestic violence agencies, which have overlapping but not entirely equal populations, services, and aims (Macy et al., 2009). However, one clear dynamic within the RCC sector is the serious resource constraints faced by agencies seeking to serve survivors of sexual violence. Agencies that are understaffed and overcommitted face high rates of staff burnout and turnover, creating barriers to the implementation of optimal services for survivors (Macy et al., 2009; Maier, 2011; Ullman & Townsend, 2007).

Mental Health Treatment Needs of Sexual Assault Survivors

Survivors of sexual violence seeking assistance from RCCs report a variety of needs including mental health treatment. The traumatic impact of sexual violence has become a focus for scholarship and intervention, with evidence pointing to serious consequences in terms of mental and physical health and social functioning. Survivors of sexual violence face a unique risk of experiencing PTSD (Ullman & Brecklin, 2003; Walsh, Galea, & Koenen, 2012). The lifetime prevalence of PTSD associated with sexual violence ranges between 26.6% and 45.2%. PTSD has serious psychological and emotional consequences and has been identified as an important factor that increases a survivor’s risk of future sexual violence victimization (Ullman & Brecklin, 2003; Walsh, Galea, & Koenen, 2012). For survivors of sexual violence, a PTSD diagnosis is also a contributor to negative physical health outcomes, as well as future relationship and parenting difficulties (Ullman & Brecklin, 2003). Encouragingly, scholars have identified a group of effective therapeutic interventions to decrease PTSD symptomology among sexual violence survivors. Meta-analyses comparing Cognitive Processing Therapy (CPT), Prolonged Exposure Therapy (PE), and Eye Movement Desensitization and Reprocessing Therapy (EMDR) have been found effective, with none demonstrating superiority in reducing PTSD symptomology among survivors (Bisson & Andrews, 2007; Regehr et al., 2013). Each of these treatments has been given an “A” rating by the International Society for Traumatic Stress Studies based on the amount and quality of evidence to support their effectiveness in treating PTSD (Foa, Keane, Friedman, & Cohen, 2009). Data suggest that counselors in RCCs have similar attitudes toward evidence-based practices as other mental health providers (Edmond & Voth Schrag, 2017), and that there is very limited use of EMDR in this sector (Edmond, Lawrence, & Voth Schrag, 2016). However, there is little evidence regarding the range of mental health treatments implemented within the RCC service sector, or the service sector’s theoretical and philosophical orientation. Finally, little is known regarding any differences in the availability of evidence-based trauma treatments for survivors by differences in agency geographic location.

Urban/Rural Service Setting Differences

Data suggest that agency setting may significantly affect the delivery of social services. The majority of services for victims of all kinds are situated in, and fit to, an urban context (Van Hightower & Gorton, 2002). Accordingly, very few researchers take rurality into account when reporting sexual assault prevalence or examining program effectiveness. Yet, the cultural and economic characteristics of rural areas may be distinct from cities, and rural survivors of sexual assault face many challenges that their urban counterparts do not (Lewis, 2003). These challenges often stem from the lack of social, medical, and legal services prepared to address sexual assault. There are few RCCs in rural areas (Lewis, 2003). Practically speaking, a smaller population translates to a lower tax base to publicly fund such services. Lack of transportation and isolation complicate the delivery of the public services that are available, and emergency response times tend to be longer in rural areas (Stommes & Brown, 2002). Smaller or critical access hospitals may not be equipped with rape kits or on-site advocates to address sexual assault (Krishnan, Hilbert, & Pase, 2001). Mental health services are rare in rural areas (Randall, 2005), which means that survivors of sexual assault who are at risk for developing PTSD may not have access to the treatment they need. In addition, in a review of the literature, Annan (2006) found that aspects of rural life, including close-knit communities where survivors are likely to be in long-term contact with perpetrators and law enforcement practices that may affect confidentiality of reporting, play roles in survivors’ postassault service experiences.

Despite the unique characteristics and challenges associated with service delivery in rural areas, few studies to date have specifically examined service differences between rural and urban RCCs. Such services are often cohoused with domestic violence programs, and this seems to be more typical in rural areas where there may be fewer public funds to justify separate services (Lewis, 2003). Even so, most rural women do not live in a county with either type of program (Peek-Asa et al., 2011). Peek-Asa and colleagues (2011) found that women in rural Iowa lived an average of 40 miles from any type of service that addressed violence against women, including the nearest domestic violence shelter, sexual assault services, and family planning agency. Logan, Evans, Stevenson, and Jordan (2005) and Logan, Stevenson, Evans, and Leukefled (2004) explored the perceptions of survivors accessing services in urban and rural settings. Similar experiences between the two groups included identification of access and availability of services as a challenge. Rural survivors uniquely noted limited available phone, transportation, and housing resources as a barrier to effective services. In Texas, the vast geographical size of the state intensifies these dynamics for rural programs that are often covering multiple counties that transcend 200 miles. Some parts of the state are so remote and sparsely populated that they are categorized as frontier, meaning they have fewer than seven people per square mile. There are 64 counties in Texas designated as frontier and only 37% of them have a rural hospital (Parsi, 2018). Understanding how rural RCCs differ from their urban counterparts is therefore an important component of describing the landscape of RCCs and drawing conclusions regarding how to best support this critical service sector.

Research Questions

To address serious gaps in our understanding of the RCC service sector, the current study addressed the following research questions:

Research Question 1: What theoretical and intervention modalities do RCC counselors use?

Research Question 2: To what degree do RCC counselors use evidence-based trauma treatments?

Research Question 3: What differences are there in organizational, counselor, or service characteristics between rural and urban RCCs?

Method

Sample and Procedures

Data were collected through a statewide, quantitative, cross-sectional web-based survey sent to all RCCs in the state of Texas in 2013. The survey was developed with two modules: one was for executive directors, which focused primarily on organizational characteristics; the other module was designed for staff who provide counseling services. The TAASA provided the research team with a list of 83 member agencies in the state that provide sexual assault services. Each agency listed was sent an invitation to participate through postal mail and an email sent to the executive director. The invitation provided the director with an electronic link to the survey for his or her module, with a separate link to be shared with counseling staff. Individual participants were eligible to receive a US$20 gift card; agencies that provided a response from both a director and at least one counselor were entered into a drawing for US$500, which was donated directly to the agency. This study received institutional review board (IRB) approval from Washington University in St. Louis.

The current study uses data from both the director and counselor modules. The counselor sample encompasses those who indicated that counseling tasks were included in their job description, with 76 counselors representing 47 agencies (57% agency response rate). The director sample included 63 directors representing 54 agencies (65% agency response rate). Collectively, data were obtained from 60 RCCs, for an overall agency response rate of 72%.

Instrument

The construction of the survey modules was informed by the Consolidated Framework for Implementation Research (CFIR), which identifies multiple domains that have been found to influence the implementation of evidence-based treatments (Damschroder et al., 2009). The domains of interest for this article are inner setting (organizational setting and structure) and characteristics of individuals (executive directors and counselors). This article is one of several from this data set and will focus on data related to participant demographics, organizational characteristics, services provided, populations served, counselor theoretical perspectives, and intervention modalities employed. Specific lists of potential intervention modalities and theoretical perspectives were developed in consultation with TAASA staff and RCC counselors, who provided feedback on the range of services available in Texas RCCs. Identified intervention modalities were Cognitive Behavioral Therapy, CPT, Creative Therapies (art/play), Dialectical Behavioral Therapy, EMDR Therapy, Empowerment, Family Therapy, Feminist Therapy, Mindfulness, Prolonged Exposure, Psychodynamic Treatment, Substance Abuse Treatment, Trauma-Focused Cognitive Behavioral Therapy, Somatic Experiencing, trauma therapy using kinesthetic and interoceptive imagery (Payne, Levine, & Crane-Godreau, 2015), and Sensorimotor Therapy, which addresses the effects of trauma on the body (Ogden & Minton, 2000). The team identified potential theoretical perspectives including Attachment, which suggests that emotional bonds are based in the “attachment and behavioral system” (Cassidy & Shaver, 1999); Cognitive Behavioral, which identifies associations between distorted thinking, emotional reactions, and patterns of behavior (Kendall & Hollon, 2013); Empowerment, which seeks to increase an individual’s access to and influence over power and resources (Zimmerman, 2000); Family Systems, which suggests that individuals must be considered in the emotional unit of their families (Broderick, 1993); Feminist, which seeks to understand violence in the context of gender inequality (Disch & Hawkesworth, 2016); General Systems, which suggests that human systems influence individuals’ outcomes (Forder, 1976); Psychodynamic, which views personality in terms of unconsciousness and consciousness (Guntrip, 1995); Social Learning, which suggests that humans learn by watching others (Bandura, 1978); Strengths Based, which emphasizes the self-determination and inherent strengths within individuals (Saleebey, 1996); and Stress and Coping, which emphasizes the importance of appraisal and coping in individuals’ stress processes (Lazarus, 1966).

Analysis and missing items

Analysis included descriptive statistics, chi-square, and t tests for differences between urban and rural agencies. Although 76 counselors began the survey and provided key demographic data, there was some attrition over the course of the survey. Thus, percentages of respondents using the theoretical perspectives and intervention modalities listed are calculated out of 66 for theoretical perspectives and out of 65 for intervention modalities. The remaining respondents were treated as missing and excluded from the analysis of intervention types and theoretical preferences. No differences were observed between those with missing and nonmissing items on theoretical orientation or intervention modalities used by agency location (urban/rural setting) or practitioner educational attainment. Similarly, 58 directors completed questions regarding agency services. Thus, percentages of agencies providing specific services to populations are out of those 58 respondents. Agencies with missing services data were significantly more likely to be rural than urban, χ²(1) = 5.97, p < .05. No differences were observed between missing and nonmissing agencies on agency type (RCC/combination) or director educational attainment.

Results

Participant Characteristics

Directors were predominately female (97%), with 81% identifying as White, 11% as Hispanic/Latino, and 4.76% African American. They were 52 years old on average (SD = 10.88) and had substantial longevity in their work, with nearly 13 years in this field (SD = 7.36) and nine in their current position (SD = 6.49). Half of the directors possessed an advanced degree, while the other half were basically split between those with a bachelor’s degree (25%) and those without a bachelor’s degree (24%). The most commonly identified discipline for directors was social work (27%), followed by psychology (22%) and Business or Administration (20%). Counselors were predominately female (95%), and more ethnically diverse than directors (67% White, 23% Hispanic, 4% African American, and 4% more than one race/ethnicity). Counselors had an average tenure of almost three years in their current agency and nearly eight years of experience in this field. Their level of educational attainment was very similar to the directors, with 54% holding advanced degrees, 22% bachelor’s, and 24% with no degrees. A majority (over 60%) were currently licensed or pursuing licensure in their professional field, with social work being the primary discipline (34%), followed by counseling (30%). Counselors without a college degree were, on average, older (49.5 years) than those with a BA (35.3 years) or advanced degree (36.7 years), F(2, 71) = 10.24, p = .001. There was no difference in years of experience or age of counselors by race. However, those who identified as White were more likely to report having an advanced degree (62%) than those who identified as Hispanic (41%) or as another race (25%), χ²(4) = 15.40, p < .01. See Table 1 for director and counselor characteristics.

Table 1.

Differences in Director and Counselor Characteristics by Urban and Rural Setting.

Agency directors	Total sample	Rural47.62% of total	Urban52.38% of total
Female	96.83% (61)	93.33% (28)	100.00% (33)
Respondent race
White	80.95% (51)	86.67% (26)	75.76% (25)
Hispanic/Latino	11.11% (7)	6.67% (2)	15.15% (5)
Asian	1.59% (1)	3.33% (1)	0.00% (0)
Black/African American	4.76% (3)	3.33% (1)	6.06% (2)
More than one race	1.59% (1)	0.00% (0)	3.03% (1)
Age^†	51.85/10.88	49.24/12.57	54.15/8.71
Years in the VAW field*	12.85/7.36	10.38/5.98	15.03/7.84
Years in current position	8.83/6.49	8.21/7.03	9.40/6.02
Educational attainment
Less than bachelor’s degree	23.81% (15)	33.33% (10)	15.15% (5)
Bachelor’s degree	25.40% (16)	23.33% (7)	27.27% (9)
Advanced degree	50.79% (32)	43.33% (13)	57.58% (19)
Occupational/academic discipline
Social work	26.67% (16)	25.00% (7)	28.12% (9)
Criminal justice	10.00% (6)	17.86% (5)	3.12% (1)
Psychology/counseling	21.67% (13)	25.00% (7)	18.75% (6)
Business/administration	20.00% (12)	14.29% (4)	25.00% (8)
Health care	6.67% (4)	7.14% (2)	6.25% (2)
Job title	8.33% (5)	3.57% (1)	12.50% (4)
Other	6.67% (4)	7.14% (2)	6.25% (2)
Counselors		Rural40.79% of total	Urban59.21% of total
Female^†	94.67% (71)	100.0% (31)	90.91% (40)
Respondent race
White	66.67% (50)	61.29% (19)	70.45% (31)
Hispanic/Latino	22.67% (17)	19.35% (6)	25.00% (11)
Black/African American	4.00% (3)	6.45% (2)	2.27% (1)
More than one race	4.00% (3)	6.45% (2)	2.27% (1)
Other	2.67% (2)	6.45% (2)	0.00% (0)
Age	39.51/12.10	41.80/13.65	37.95/10.81
Years of experience	7.76/6.22	6.58/5.58	8.58/6.55
Years at current agency	2.98/3.51	3.80/3.97	2.97/3.33
Educational attainment**
Less than bachelor’s degree	23.68% (18)	41.94% (13)	11.11% (5)
Bachelor’s degree	22.37% (17)	22.58% (7)	22.22% (10)
Advanced degree	53.95% (41)	35.48% (11)	66.67% (30)
Occupational/academic discipline
Social work	34.21% (26)	22.58% (7)	42.22% (19)
Psychology	7.89% (6)	9.68% (3)	6.67% (3)
Counseling	30.26% (23)	25.81% (8)	33.33% (15)
Education	3.95% (3)	6.45% (2)	2.22% (1)
Divinity/theology	2.63% (2)	6.45% (2)	0.00% (0)
Job title	17.11% (13)	22.58% (7)	13.33% (6)
Other	3.95% (3)	6.45% (2)	2.22% (1)
Licensure status*
Not certified or licensed	38.16% (29)	58.06% (18)	24.44% (11)
Currently pursing	19.74% (15)	16.13% (5)	22.22% (10)
Currently certified/licensed	42.11% (32)	25.81% (8)	53.33% (24)

Note. For urban/rural differences: ^†p < .10. *p < .05. **p < .01.

Organizational Characteristics and Services

These are mature organizations, averaging 28 years of operation, covering 4.57 counties, with approximately 26 full-time staff members. Of the participating agencies, the majority (77%) can be characterized as dual programs that address both sexual assault and intimate partner violence; only 20% are stand-alone RCCs and 3% identified as Victim Services or Child Advocacy Centers (Table 2). Responding agencies included similar numbers of rural (48%) and urban/suburban (52%) locations. Nearly all of these agencies are addressing rape/sexual assault (99%), adult survivors of child sexual abuse (95%), and intimate partner violence (95%). Other related issues addressed include stalking (90%), sexual harassment (84%), child sexual abuse (78%), and nonintimate partner physical assault (60%). They are all serving adult women and 98% report serving adult men. The vast majority also serve adolescents (97%), children (91%), and families (90%). Most agencies (88%) indicated that they serve lesbian, gay, bisexual, and transgender (LGBT) survivors. On average, each organization serves 630 adult and 191 child survivors yearly. All of the agencies are providing general advocacy and court accompaniment to survivors. Crisis intervention (98%) and hospital accompaniment (93%) are almost always provided. In terms of counseling services, 86% provide individual counseling and 76% provide group counseling. Most agencies (84%) also provide legal advocacy services to survivors.

Table 2.

Issues Addressed, Populations Served, and Services Provided in Urban and Rural RCCs.

Organizational characteristics	% (freq.) orM/SD	Rural47.62%	Urban52.38%
Organizational structure*
Rape crisis center (stand-alone)	19.35% (12)	6.90 (2)	32.26 (10)
Combination IPV/RCC agency	76.67% (46)	89.66 (26)	64.62 (20)
Other	3.33% (2)	3.45 (1)	3.23 (1)
Agency issues addressed^a
Rape/sexual assault	98.97% (57)	100.00% (25)	96.97% (32)
IPV	94.83% (55)	96.00% (24)	93.94% (31)
Adult survivors of child sexual abuse	94.83% (55)	92.00% (23)	96.97% (32)
Stalking	89.66% (52)	88.00% (22)	90.91% (30)
Sexual harassment	84.48% (49)	84.00% (21)	84.85% (28)
Child sexual abuse	77.59% (45)	72.00% (18)	81.82% (27)
Physical assault (non-IPV)	60.34% (35)	60.00% (15)	60.61% (20)
Populations served^a
Women	100.00% (58)	100.00% (25)	100.00% (33)
Men	98.28% (57)	96.00% (24)	100.00% (33)
Adolescents	96.55% (56)	96.00% (24)	96.97% (32)
Children	91.38% (53)	96.00% (24)	87.88% (29)
Families	89.66% (52)	84.00% (21)	93.94% (31)
LGBT	87.93% (51)	84.00% (21)	90.91% (30)
Services provided to survivors of sexual violence^a
General advocacy	100.00% (58)	100.00% (25)	100.00% (33)
Court accompaniment	100.00% (58)	100.00% (25)	100.00% (33)
Crisis intervention	98.28% (57)	100.00% (25)	96.97% (32)
Hospital accompaniment	93.10% (54)	96.00% (24)	90.91% (30)
Individual counseling	86.21% (50)	84.00% (21)	87.88% (29)
Legal advocacy*	84.48% (49)	96.00% (24)	75.76% (25)
Group counseling	76.00% (19)	81.82% (27)	79.31% (26)

Note. For urban/rural differences: *p < .05. RCC = rape crisis center; IPV = intimate partner violence; LGBT = lesbian, gay, bisexual, and transgender.

Percentage is out of the 58 respondents answering any of these questions.

Theoretical Perspectives and Interventions Used

The primary theoretical perspectives endorsed by RCC counselors were empowerment (92%), strengths based (91%), stress and coping (89%), and cognitive behavioral (86%; Table 3). The least frequently endorsed theoretical perspectives include feminist (50%), psychodynamic (52%), and attachment theories (62%). Of the 10 listed theoretical perspectives, counselors endorsed using an average of 7.6 at least “some of the time,” (SD = 2.30). Empowerment is the most commonly employed intervention approach in RCCs, with 78% of counselors indicating that they use it sometimes, often, or most often. This was followed in frequency of use by Cognitive Behavioral Therapy (62%) and Trauma-Focused Cognitive Behavioral Therapy (62%). Over half of the counselors (54%) report using Creative Therapies (art/play) in their practice with survivors of sexual violence. Among the remaining evidence-based trauma treatments, 44% of counselors use CPT, 26% Dialectical Behavioral Therapy, 15% Prolonged Exposure, and 11% EMDR (Table 4). Of the 15 listed intervention approaches, counselors endorsed using an average of 5.78 at least “a fair amount” of the time with clients (SD = 3.88). Consistently, a greater number of counselors reported using an intervention than reported having training in that intervention (Figure 1).

Table 3.

Theoretical Perspectives of Counselors in Urban and Rural RCCs.

	% (freq.) orM/SD	Rural setting	Urban setting
Theoretical perspectives (sometimes, often, or most of the time; % out of 66)
Empowerment**	92.42% (61)	82.14% (23)	100.00% (38)
Strengths based	90.91% (60)	85.71% (24)	94.74% (36)
Stress and coping	89.39% (59)	85.71% (24)	92.11% (35)
Cognitive behavioral	86.36% (57)	85.71% (24)	86.84% (33)
Family systems	81.82% (54)	85.71% (24)	78.95% (30)
General systems^†	81.82% (54)	71.43% (20)	89.47% (34)
Social learning	74.24% (49)	75.00% (21)	73.68% (28)
Attachment	62.12% (41)	64.29% (18)	60.53% (23)
Psychodynamic^†	51.52% (34)	39.29% (11)	60.53% (23)
Feminist*	50.00% (33)	35.71% (10)	60.53% (23)

Note. RCC = rape crisis center.

†

p < .10. *p < .05. **p < .01.

Table 4.

Intervention Modalities and Training Background of Counselors in Urban and Rural RCCs.

Intervention modalities (sometimes, often, or most of the time)(% out of 65)			Training in intervention (“a fair amount” or “a great deal”)(% out of 65)
	Total sample	Rural counselors	Urban counselors	Total sample	Rural counselors	Urban counselors
Empowerment	78.46% (51)*	64.29% (18)	89.19% (33)	66.15% (43)^†	55.56% (15)	73.68% (28)
Cognitive behavioral therapy	61.54% (40)^†	50.00% (14)	70.27% (26)	52.31% (34)*	37.04% (10)	63.16% (24)
TF-CBT	61.54% (40)	57.14% (16)	64.86% (24)	52.31% (34)	44.44% (12)	57.89% (22)
Creative therapies (art/play)	53.85% (35)*	39.29% (11)	64.86% (24)	43.08% (28)^†	29.63% (8)	52.63% (20)
Family therapy	46.15% (30)	53.57% (15)	40.54% (15)	41.54% (27)	33.33% (9)	47.37% (18)
Cognitive processing therapy	43.08% (28)	35.71% (10)	48.65% (18)	35.38% (23)	29.63% (8)	39.47% (15)
Mindfulness	38.46% (25)	28.57% (8)	45.95% (17)	29.23% (19)*	14.81% (4)	39.47% (15)
Feminist therapy	38.46% (25)	28.57% (8)	45.95% (17)	29.23% (19)	22.22% (6)	34.21% (13)
Psychodynamic	35.38% (23)*	21.43% (6)	45.95% (17)	33.85% (22)**	14.81% (4)	47.37% (18)
Substance abuse treatment	27.69% (18)	25.00% (7)	29.73% (11)	21.54% (14)	11.11% (3)	28.95% (11)
Somatic experiencing	26.15% (17)	21.43% (6)	29.73% (11)	18.46% (12)	14.81% (4)	21.05% (8)
Dialectical behavioral therapy	26.15% (17)	25.00% (7)	27.03% (10)	15.38% (10)	11.11% (3)	18.42% (7)
Sensorimotor	15.38% (10)	17.86% (5)	13.51% (5)	12.31% (8)	11.11% (3)	13.16% (5)
Prolonged exposure	15.38% (10)	17.86% (5)	13.51% (5)	15.38% (10)	18.52% (5)	13.16% (5)
EMDR	10.77% (7)	10.71% (3)	10.81% (4)	7.69% (5)	4.70% (1)	5.26% (2)

Note. For urban/rural differences: ^†p < .10. *p < .05. **p < .01. RCC = rape crisis center; TF-CBT = trauma-focused cognitive behavioral therapy; EMDR = eye movement desensitization and reprocessing therapy.

Figure 1.

Comparison between use of an intervention and training in that intervention.

Differences Between Rural and Urban RCCs

Although there were no statistical differences between urban and rural agencies in issues addressed, people, or number of counties served, there were a number of differences in terms of organizational and staff characteristics, and theoretical and intervention approaches utilized (Table 5). Urban agencies reported significantly larger budgets, with 58% of urban agencies having budgets above US$1,000,000, compared with 29% of rural agencies, χ²(3) = 8.47, p < .05. Most rural programs (42%) reported budgets between US$250,001 and US$500,000, compared with less than 10% of urban RCCs. However, there was only one significant difference in sources of funding, with rural programs actually receiving a larger percentage of their budget from the Health and Human Services Commission (HHSC); rural agencies received an average of 26.5% of their budget from HHSC, compared with 9.69% for urban agencies, t(48) = 4.62, p < .05. Urban agencies also had significantly greater numbers of employees, with an average of 35.8 full-time equivalent (FTE) staff compared with 12.8 FTE for rural agencies, t(56) = −3.25, p < .05. Similarly, urban agencies had significantly more direct practice volunteers than rural agencies, t(56) = −3.40, p < .05, while counselors in rural agencies had significantly longer tenure in their current job, t(55) = 2.32, p < .05. The only significant difference in services provided was that more rural agencies provided legal advocacy, 96% versus 76%, χ²(1) = 4.45, p < .05.

Table 5.

Differences in Organizational Characteristics by Agency Setting.

Organizational characteristics	Full sample % (freq.) orM/SD	Rural % (freq.) orM/SD	Urban % (freq.) orM/SD
Age of agency (years)*	28.15/8.03	25.93/7.45	30.16/1.43
Counties served	4.57/6.70	4.12/2.98	4.91/8.54
Agency annual budget*
US$100,000-US$250,000	5.54% (3)	4.17% (1)	6.45% (2)
US$250,001-US$500,000	23.64% (13)	41.67% (10)	9.68% (3)
US$500,001-US$1,000,000	25.45% (14)	25.00% (6)	25.81% (8)
>US$1,000,000	45.45% (25)	29.17% (7)	58.06% (18)
Number of paid staff (FTE)**	25.91/28.80	12.84/8.68	35.82/34.44
Staff offering counseling services (FTE)^†	4.40/5.50	3.04/3.56	5.42/5.77
Direct practice staff tenure*	5.91/4.10	7.33/5.34	4.88/2.52
Volunteers working with survivors**	27.29/677.56	9.96/11.92	40.42/43.56
Survivors of sexual violence served annually
Adult survivors	630.22/1,626.73	234.77/319.63	940.93/2,120.25
Child survivors	191.16/351.37	110.11/118.24	250.38/445.65
Survivors of sexual violence served annually
via individual counseling	200.02/271.16	139.65/223.32	244.74/297.94
via group counseling	70.66/131.63	69.00/174.62	71.89/91.48

Note. FTE = full-time equivalent.

†

p < .10. *p < .05. **p < .01.

Although directors in both urban and rural programs had a long tenure in their current positions (15.03 years vs. 10.38 years), directors in urban agencies had significantly longer tenure, t(61) = 2.63, p < .05. Counselors in urban areas were more likely to possess an advanced degree (67% vs. 35%), whereas those in rural areas were more likely not to have a degree, 42% vs. 11%, χ²(2) = 10.67, p < .05. Urban counselors were also more likely to be licensed or pursuing licensure (75%) than their rural counterparts, 42%, χ²(2) = 9.09, p < .05.

Significantly, more urban counselors endorsed empowerment, 100% vs. 82%, χ²(1) = 7.34, p < .05, and feminist theoretical perspectives, 61% vs. 36%, χ²(1) = 5.0, p < .05, than their rural counterparts. Similarly, urban counselors employ empowerment interventions, 89% vs. 64%, χ²(1) = 5.85, p < .05; creative therapies, 65% vs. 40%, χ²(1) = 4.20, p < .05; and psychodynamic therapy, 46% vs. 21%, χ²(1) = 4.19, p < .05, more frequently than rural counselors. Compared with their rural counterparts, more urban providers reported a fair amount or a great deal of training in Cognitive Behavioral Therapy, 63% vs. 37%, χ²(1) = 4.32, p < .05; mindfulness techniques, 40% vs. 15%, χ²(1) = 4.64, p < .05; and psychodynamic techniques, 47% vs. 15%; χ²(1) = 7.47, p < .01. No difference was observed in the number of theoretical perspectives endorsed or the number of interventions utilized between urban and rural counselors.

Discussion

This study sought to open the black box of services at RCCs, particularly those related to counseling, to better understand the resources being made available to survivors in both urban and rural settings. The findings reveal a number of important strengths within the field that support the needs of survivors of sexual assault and provide insights that can help to further advance the implementation of evidence-based trauma treatments in this service sector. Although many areas of congruence were found between urban and rural settings, important differences were also noted.

RCCs in Texas are mature organizations with directors and counselors who have a remarkable degree of longevity in their agencies and experience in this field. This is particularly impressive, considering the degree of stress and vicarious trauma associated with working with trauma survivors (Slattery & Goodman, 2009). They are addressing a broad spectrum of interpersonal violence across the life span, providing services immediately after a traumatic event (hospital/legal/court accompaniment and advocacy) and through the process of recovery (trauma-focused counseling).

True to the grassroots history of this movement that valued women supporting women, nearly a quarter of the directors and counselors within these Texas RCCs have no college degrees, a characteristic that is even more prevalent in rural programs where directors are twice as likely, and their counselors 4 times as likely, to not have a college degree compared with their urban peers. Urban settings, on the contrary, appear to have followed the move toward increasing professionalization that has been a source of debate within the antiviolence against women movement. A primary critique of the professionalization of the movement has been a concern over the erosion of a feminist analysis that brings a sociopolitical understanding of the causes of violence against women as being rooted in patriarchal social control that systematically oppresses women and creates a rape culture (Ake & Arnold, 2017). One might then expect to see rural programs endorsing feminist theory and feminist therapy more strongly than urban RCCs, but that is not the case. In point of fact, only 35.71% of rural counselors reported using feminist theory, which is significantly lower than was found among urban counselors (60.53%). Use of feminist therapy was even lower, with 28.57% among rural counselors and 45.95% of urban counselors. This suggests real differences in agency culture between settings.

In Texas, as in many other parts of the United States, rural communities tend to be more politically conservative. This creates unique dynamics for agencies and providers who may feel disconnected from feminist movements that are historically aligned with liberal politics, or who may feel a need to limit their sociopolitical voice to avoid alienating potential funders and key community partners such as law enforcement or medical personnel. However, feminism also seems to be less influential in urban settings, providing further evidence that as this service sector has become more mainstream, it has moved away from a sociopolitical analysis of the root causes of violence against women.

The dominant theoretical perspectives to which RCC counselors across the state adhere most strongly are empowerment, strengths based, and stress and coping. Interestingly, urban RCC counselors were unanimous in endorsing empowerment, which significantly fewer rural counselors endorsed. Perhaps this is related to the connections between feminist and empowerment approaches. Overall, more than 90% of counselors report being guided by an empowerment perspective to treatment. Given the discrepancy between those endorsing empowerment as an orientation and those endorsing it as an intervention modality, empowerment seems to be operating more as a guiding framework and less as an operationalized intervention. This highlights important questions regarding how RCC counselors interpret and understand the outcomes of empowerment and what steps they take to implement “empowerment interventions.” Although efforts have been made to operationalize “empowerment” (i.e., Goodman et al., 2015; Gutierrez, Parsons, & Cox, 1998), there is still considerable variation in its use and application. To understand the interventions used in support of survivors and the extent to which those interventions are effectively meeting survivors’ needs, future work should explore how RCC counselors conceptualize and operationalize empowerment practice.

In keeping with advancements in our knowledge about trauma, cognitive behavioral theory was highly endorsed by both urban and rural programs. Cognitive behavioral theory is the dominant paradigm for most evidence-based trauma therapies, including EMDR, Prolonged Exposure, CPT, Trauma-Focused Cognitive Behavioral Therapy, and Dialectical Behavioral Therapy. Thus, counselors may have an established foundation of comfort, knowledge, and skills that could be built upon in efforts to advance the implementation of the evidence-based trauma treatments that are underutilized in RCCs. Identifying areas of congruence between existing services and evidence-based trauma treatments could help counselors envision implementing such services and decrease potential fears related to the burden of learning a new treatment approach.

It is worth noting that many RCC counselors are also incorporating adjunctive trauma treatments such as art and play therapy, and modalities that attend to mind–body connections such as mindfulness, somatic experiencing, and sensorimotor therapy. Although these approaches have not been shown to be effective treatments for PTSD, there is an emerging evidence base for their effectiveness in reducing stress, enhancing coping, and ameliorating other trauma symptoms (Chapman, Morabito, Ladakakos, Schreier, & Knudson, 2001; Hofmann, Sawyer, Witt, & Oh, 2010; Kim, Schneider, Kravitz, Mermier, & Burge, 2013).

Despite these strengths, the findings also reveal a significant underutilization of several evidence-based trauma treatments used to treat PTSD—EMDR, Prolonged Exposure, and CPT. This is particularly important considering the high prevalence rates of PTSD found among survivors of sexual violence. Furthermore, across all of these interventions, as well as others that were endorsed, there is a discrepancy between training and use of a treatment approach. Some counselors, no doubt eager to help survivors heal, are employing these methods without formal training, leaving open questions about the degree to which the intervention is being delivered with fidelity. While evidence-based trauma treatments have been shown to be robust and adaptable to meet the needs of different clients in different settings, fidelity has also been shown to significantly strengthen their effectiveness (Maxfield & Hyer, 2002; Schoenwald, Henggeler, Brondino, & Rowland, 2000).

From an intersectional perspective, a number of important observations can be made. A long-standing critique within the violence against women movement has been the degree to which it has been centered on White women, often to the exclusion of, and costs to, women of color and queer women (Ake & Arnold, 2017). The leadership of RCCs remains firmly in the hands of White women (81%), despite the demographics of the state—Texas is 42.6% White non-Hispanic. In rural programs, the numbers are even more disconcerting, with 86.67% of the leadership being White. This can have a profound impact on agency priorities, climate, culture, and degree to which survivors of color have access to culturally responsive services. Interestingly, there is more ethnic diversity among the counselors, and rural programs are more diverse than urban RCCs (61% White vs. 70% White), but people of color are still significantly underrepresented among the counseling staff. Furthermore, although the counselors of color have a comparable level of years of experience in this field, they are less likely to have an advanced degree, which reduces or eliminates their access to training in evidence-based trauma treatments. Given that these counselors of color are often serving survivors of color, those survivors are then less likely to have access to the most effective trauma treatments available, even though EMDR, Prolonged Exposure, and CPT have all been shown to be effective across survivors from a diverse range of ethnic populations, gender, age, and socioeconomic status.

This project uncovered several additional findings regarding the differences and similarities between urban and rural RCCs. Nearly 90% of rural agencies are combination programs that serve survivors of intimate partner violence as well as sexual assault, in comparison with 66% of urban agencies, which might account for the higher level of endorsement of family therapy among rural counselors (53.57% vs. 40.54%). The combination of IPV and sexual violence services was expected, given the lower population and tax base of rural areas, where it may be difficult to fully fund two separate programs. Rural agencies tend to have smaller budgets, less staff, and fewer volunteers, yet there were no significant differences between the actual number of clients served and the number of counties covered. Rural RCCs must do more with less, meeting the needs of survivors with less material and organizational support than their urban counterparts.

Given financial and geographic limitations, it is not surprising that rural RCCs employ significantly fewer practitioners with advanced degrees than do urban agencies as it may be difficult to attract and retain workers with graduate degrees (Edmond & Voth Schrag, 2017). These differences are likely exacerbated in Texas, which has a comparably low rate of postsecondary education, with 41% of 25-35 year-olds with at least a certificate from a postsecondary institution in 2016 (Texas Higher Education Coordinating Board, 2018). Rural RCC directors are twice as likely, and their counselors 4 times as likely, to not have a college degree compared with their urban peers. That counselors in rural agencies were significantly less likely than their urban counterparts to possess advanced degrees is particularly noteworthy because it has direct implications for the kinds of interventions that they might employ with survivors of sexual assault. Many evidence-based trauma treatments expect counselors to have a master’s degree in social work, counseling, or a related field as a prerequisite for training. Similarly, rural counselors were less likely to be currently licensed or be pursing licensure (42% vs. 76%), which is also often a prerequisite to accessing training in evidence-based trauma treatments. Efforts should be made to test the assumption that only those with advanced degrees can effectively deliver evidence-based trauma treatments. Counselors in rural RCCs have extensive experience working with survivors and in places with geographies as vast as Texas, with long drives required between “neighboring” midsized communities, survivors in rural communities have limited options for seeking services elsewhere.

Operating budgets also affect the level of supervision and training opportunities an agency can offer its staff. Rural practitioners may have less access than their urban peers to the types of professional development and ongoing in-service training that support them in obtaining or maintaining licensure or to learning and applying new treatment modalities. It is possible that many rural agencies cannot afford to send their staff to continuing education classes or other professional seminars where such treatment options may be introduced. In particular, the cost of becoming trained in many evidence-based practices of trauma, which require multiple multiday in-person training sessions and ongoing consultation over a substantial period of time, can be prohibitively expensive for RCC budgets. This may be especially true, given the distance often involved in travel to training sites, for rural practitioners in places like Texas. In addition, rural programs are operating with fewer staff; consequently, having staff gone for multiple days to receive training can create challenges in coverage of services. However, rural agencies have longer staff tenure; therefore, training a staff member has sustainability implications that could have a longer term positive impact on an agency and the survivors they serve. Qualified trainers should consider providing low-cost or pro bono services to rural agencies seeking to support their counseling staff in the implementation of evidence-based treatments for trauma. In addition, the use of technology-based training approaches should be considered and tested as an alternative and affordable mechanism for delivering training in evidence-based trauma treatments to rural RCCs (Curran, Fleet, & Kirby, 2006).

Along with expanding access to training and consultation for the implementation of evidence-based trauma treatments, schools of social work or state sexual assault and domestic violence coalitions should continue to expand their web-based training and consultation offerings. States could also support trained MSW-level social workers with loan forgiveness or access to free licensure supervision for serving in low-resourced rural areas. These counselors could bring knowledge regarding evidence-based treatments and support the training and supervision of colleagues without the same level of educational training.

Limitations

Several limitations should be kept in mind when considering the results of the current study. It reflects data from a small sample of providers and directors working in agencies who are members of the state sexual assault coalition in Texas. As such, they may be different from providers in other states, or from providers working with sexual assault survivors in agencies that are not affiliated with state coalitions. In addition, the data are all self-report, reflecting the practice approaches that counselors indicate that they are using without any means of assessing treatment fidelity or effectiveness of treatment provided. The relatively small sample size could also mean that the study is underpowered to detect some differences between urban and rural settings.

Conclusion

This study revealed an RCC service sector that provides critical services to women, children, and men in the wake of experiences of sexual assault. Agencies serve a large number of survivors annually and demonstrate important strengths, including impressive staff longevity and a wide range of service offerings. These can be built upon to enhance services for survivors of sexual violence, including the uptake of evidence-based trauma treatments. Differences between rural and urban agencies in treatment modalities and organizational and staff dynamics provide an opportunity to tailor implementation efforts to specific agency contexts to better meet the needs of agencies and the survivors they serve.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention (Grant No. 1R49CE001510).

ORCID iD

Rachel J. Voth Schrag

Author Biographies

Tonya E. Edmond, PhD, LCSW, is a professor and the associate dean for diversity, inclusion, and equity in the Brown School of Social Work at Washington University in St. Louis. She is a faculty affiliate with the Center for Violence and Injury Prevention, with research focused on testing the effectiveness of interventions for survivors of interpersonal violence. As a former practitioner with 15 years of experience working in rape crisis centers, she is committed to strengthening services for survivors through research and teaching, advancing the development of trauma-informed systems of care, and the implementation of evidence-based trauma treatments.

Rachel J. Voth Schrag, PhD, LCSW, is an assistant professor in the Arlington School of Social Work at the University of Texas. Her research seeks to expand access to effective services for survivors of violence against women. She earned her MSW and PhD from the Brown School of Social Work at Washington University in St. Louis, and her BSW from Bethel College in Newton, KS. Her practice experience includes child and adolescent mental health case management and as a counselor, advocate, and supervisor in an agency addressing the economic and social needs of survivors of intimate partner violence.

Annah K. Bender, PhD, MSW, is a research faculty member at the University of Missouri–St. Louis, where she directs the Research Office in the College of Nursing. Her research interests lie at the intersection of health and mental health among individuals who have experienced trauma, such as intimate partner and sexual violence. She completed her PhD in Social Work in 2015 at the Brown School, Washington University in St. Louis.

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