Abstract
The goal of the present study was to refine sexual assault therapy through the examination of the level of agreement between survivor and therapist assessments of key recovery-promoting therapeutic interventions. This is the first study to explore the level of agreement between those who partake in the treatment process from either position. Semistructured interviews were conducted in this qualitative study with 10 survivors and 10 experienced therapists. The results document considerable concurrence between them regarding relational and trauma processing treatment components alike. Together, these reports outline key effective interventions, both common and specific in nature, concomitantly supported by both groups.
Sexual assault has been widely linked to severe psychological sequelae (Elliot et al., 2004; Moor & Farchi, 2012; Moor et al., 2013; Ullman et al., 2007; Yuan et al., 2006). Hence, recovery from this trauma often requires professional help (Foa & Rothbaum, 1998; Koss & Harvey, 1991; Rothbaum, 1998; Tarquinio et al., 2012) nestled in a supportive relationship (Gold, 2001; Herman, 1992; Moor, 2007, 2010; Paivio & Laurent, 2001). Receiving sustained mental health support potentially decreases psychological symptomatology in the aftermath of sexual assault (Campbell et al., 1999).
Prior research, mostly quantitative, has assessed the effectiveness of trauma-focused therapeutic methods for recovery from sexual assault (for overview see Vickerman & Margolin, 2017). Evidence-based interventions for most effective sexual assault treatment include EMDR (Eye Movement Desensitization and Reprocessing) (Edmond et al., 1999; Edmond et al., 2016; Hutchins & Mason, 2017; Power et al., 2002) and CBT/PE (cognitive behavioral/prolonged exposure) (Foa & Rothbaum, 1998; Jaycox et al., 2002). Most studies, however, did not ask survivors or therapists what they deemed to be the most beneficial, recovery-promoting elements of therapy.
Of the existing qualitative studies in the field, most have examined the needs of survivors from first responders, such as rape crisis centers or law enforcement following disclosure of the assault (e.g., Gagnon et al., 2018; Kirkner et al., 2017; Munro-Kramer et al., 2017; Starzynski et al., 2017; Ullman, 2014; Ullman & Townsend, 2008). These accounts identified various valuable elements of the support encounters. However, very few attempted to ascertain explicit, healing-promoting components of the process that takes place in psychotherapy, concentrating instead on reactions of the helping professions to disclosure of assault and the like. Additionally, none has cross-matched survivor and therapist perceptions to determine their degree of concurrence. To the degree that such correspondence is documented, the claim for efficacy of any such formulations gains credence. Said differently, to the extent that both the receiver and provider of treatment recognize the value of a range of treatment interventions, in the sense of both common active ingredients as well as specific treatment modalities (Wilen et al., 2017), these shared viewpoints can be indicative of what should take place in therapy.
In accordance with calls to investigate what therapists and, above all, clients have to say about their treatment (e.g., Campbell et al., 2009; Gagnon et al., 2018; Kirkner et al., 2017), this study examined the reflections of 20 women, half of whom are survivors who experienced a successful course of therapy and the other half therapists with extensive experience in the field, on what constitutes optimal postassault treatment. The primary aim of the study was to establish the level of agreement between survivor and therapist assessments of key recovery-promoting interventions, so as to ascertain whether survivors confirm therapists’ views. To the best of our knowledge, this is the first study to examine the issue. A high level of concurrence would support the use of these joint recommendations by therapists to assess their own beliefs about which components of therapy are helpful to survivors. Such self-appraisal is particularly critical given that client and therapist views of what works in therapy do not necessarily align (Bachelor, 2013).
Several studies have examined the process of disclosing the assault to support providers in order to identify effective response patterns. In these studies, survivors were generally questioned about the response desired upon divulging their assault, and support providers were queried about how to best respond to such disclosure. The picture emerging from these studies reveals that survivors long for unwavering and blame-free belief in their accounts (Gagnon et al., 2018; Munro-Kramer et al., 2017) as well as unlimited space to talk about their experience (Kirkner et al., 2017). They further expressed a need for empathy and compassion, echoed by the supporters’ recommendations for active listening, as well as empathic empowerment, aimed at making survivors feel understood and valued (Ullman & Townsend, 2008). Both perspectives stressed the importance of anti-blaming messages that convey belief that the assault was in no way the survivor's fault, coupled with positive communication (Gagnon et al., 2018). Validation by support providers, defined as refraining from any judgment, normalizing postassault reactions, and dispelling stigma (Munro-Kramer et al., 2017), was also identified by all as being most empowering, as was the respect for the survivor's autonomy (Kirkner et al., 2017).
Building trust between survivor and support provider was also deemed crucial by the former, for the sake of fostering change in her view of what she endured and enabling her to find ways to reduce self-blame (Starzynski et al., 2017). This trust is furthered by a sense of being listened to (Moor, 2007). Equally important is allowing the client to choose the most suitable methods of intervention, so as to foster a sense of control over the recovery process (Kirkner et al., 2017; Munro-Kramer et al., 2017; Ullman & Townsend, 2008). This freedom of choice is particularly important given the multiple possibilities for intervention following assault disclosure. Moreover, taking control over the process can help survivors regain strength and sense of safety that may have been lost in the assault (Munro-Kramer et al., 2017; Starzynski et al., 2017).
A handful of qualitative studies investigated interventions that go beyond reactions to disclosure (Ullman, 2014: Ullman & Townsend, 2008). Ullman and Townsend (2008) examined intervention methods used by rape crisis advocates in responding to survivors. Over two-thirds included empowerment in their narratives of support. Close to one-third (28%) of advocates said they used client-centered approaches and 16% used cognitive behavioral (CBT) interventions. A little over a third (36%) also employed psychodynamic, trauma-focused, and crisis counseling procedures.
With respect to helpful sources of support, survivors predominantly identified counselors as being the most helpful support providers, followed by close friends, and lastly family members of various degrees of closeness (Ahrens et al., 2009). Mental health counselors were viewed most positively to the extent that they provided emotional support (Starzynski & Ullman, 2014), which, in turn, resulted in less severe psychopathology (Dworkin et al., 2019). This was particularly true when the reactions were interpreted as a sign of caring, an attempt to help survivors heal, or an attempt to protect them from future harm (Ahrens et al., 2009). The importance of the relational aspect of treatment was emphasized primarily by experienced therapists, in contrast to less seasoned therapists who reported encountering difficulties in this regard, although not minimizing its importance (Ullman, 2014).
Numerous quantitative studies have examined evidence-based protocols. In an extensive literature review, Vickerman and Margolin (2017) documented empirical support for several trauma focused treatments for women who were sexually assaulted. These include: CPT (cognitive processing therapy); PE; and EMDR. All three methods share in common a focus on trauma processing, albeit from somewhat divergent angles, and exhibit rather similar levels of effectiveness in relieving posttraumatic stress disorder (PTSD) symptoms. Further support for such interventions was provided by Ehring et al. (2014) in their review of the literature, wherein trauma-focused treatments were proven more efficacious than nontrauma-focused interventions, particularly in individual settings.
Various studies have demonstrated the effectiveness of each of these treatment modalities separately. For example, a case series design showed that EMDR therapy was effective in treating sexual abuse traumatic experiences within a short number of sessions. A 3-month follow-up further substantiated the findings (Hutchins & Mason, 2017). Edmond et al. (2016) provided further evidence that the therapeutic benefits of short-term EMDR treatment for survivors are maintained over an 18-month period.
CPT was also shown to alleviate symptoms in females who were sexually assaulted (Resick & Schnicke, 1992). Assessed at pretreatment, posttreatment, and 3- and 6-month follow-up, the survivors showed substantial improvement from pre to posttreatment, after 12 short weeks, on both PTSD and depression measures, while maintaining their improvement for 6 months. Similar findings were reported in a later study (Resick et al., 2012) in which PE as well as CPT resulted in lasting changes in PTSD symptoms among female sexual assault survivors over an extended period of time.
Some select studies examined the comparable efficacy of these various trauma-focused therapies as applied to sexual assault survivors. For example, in a comparative study of improvement in posttraumatic symptoms following EMDR treatment versus PE, 70% of EMDR clients showed improvement, compared to only 29% of those treated with PE (Ironson et al., 2002). Relative superiority was also noted in the treatment of sexual assault survivors with CPT. While not differing from PE in the reduction of postassault PTSD and depression, CPT was shown to resolve self-blame where PE fell short (Resick et al., 2002). Indeed, Foa and McNally (1996) acknowledge that exposure therapy may not be as effective in lessening self-blame. CBT was likewise shown to effectively reduce self-blame and shame following sexual assault (Foa et al., 1999).
Given this cluster of evidence-based findings, Hensley (2002) proposes that postassault PTSD be treated initially with exposure approaches like PE, followed by cognitive therapies for the further resolution of self-blame. The present study can be seen as taking this suggestion one step further and augmenting these generally quantitative findings by complementing them with qualitative testimonies from clients as well as therapists regarding the value of a gamut of specific treatment elements across approaches. In this way, therapists can obtain a comprehensive sense of what combination of interventions will best serve their clients who had suffered sexual assault.
In sum, this study responded to calls from the field for in-depth research into what essentially happens when victims of sexual assault encounter mental health professionals (Gagnon et al., 2018; Hensley, 2002; Kirkner et al., 2017). To that end, both survivors who underwent a helpful course of therapy and experienced therapists, who have been working with survivors for many years, were asked to identify the specific components of therapy that promote improved mental health in survivors. Beyond advancing the formulation of optimal psychotherapy, these findings can also potentially assist other support providers in working with survivors of sexual trauma (Starzynski et al., 2017).
Method
Participants
Two groups of women participated in this thematic qualitative study, 10 sexual assault survivors who self-identified as being recovered and 10 expert therapists with extensive experience in the field. The two groups were independent of each other. The decision to employ an exclusively female sample was based on the sample's rather small size, along with women's predominance among sexual assault survivors. A case in point is Elliot et al.'s (2004) study in which sexual assault was reported by 22% of women compared to 3.8% of men in a sample of 941 participants from the general population. Similar results were obtained from a more recent investigation of a student population (Hines et al., 2012). That all participating therapists were women reflects the predominance of women in the current practice of psychotherapy (Farber et al., 2005; Snyder et al., 2000), especially in this domain.
The survivors participating in this study ranged in age from 25 to 35 years, with a mean age of 29 years. Nine of them self-defined as heterosexuals and one as a lesbian. Three were married, two were in long-term committed relationships—one of whom was the lesbian participant—four were single and not in any relationship, and one was a divorcee in a new relationship at the time of the study.
Eight of the survivors were sexually abused as children, between the ages of 4 and 17 years, with the abuse ranging in duration from 1 to 10 years, and the median being 4 years. Two of the eight were revictimized sexually in adulthood, and an additional two participants were raped in adulthood only. The choice to include survivors of varying ages at time of the assault was founded on the shared fundamental nature of this victimization across ages. In terms of the perpetrator's identity, three were brothers, three were acquaintances, two were partners, and the remaining two were a relative and a stranger.
All survivors underwent therapy that they experienced as being successful in promoting recovery, which they generally defined as a growing ability to live their lives with minimal interference from the assault/s, coupled with a considerable reduction in posttraumatic symptoms. The length of the different therapies ranged from a year and a half to 5 years (with one outlier being in therapy for 12 years), and they were of varied methods, including EMDR, CBT, and psychodynamic psychotherapy. Seven of the participants’ therapists were psychologists and three were MSWs (Master's of Social Work). Half of all therapists had received designated training for treating survivors of sexual assault.
The 10 therapists who participated in this study had extensive experience treating adult survivors of all forms of sexual assault, from a single attack in adulthood to prolonged childhood abuse, perpetrated by strangers or family members alike. Four participants were psychologists and six were MSWs, and they employed a variety of treatment modalities. Six reported having over 20 years of experience in the therapeutic field, three between 10 and 20 years and one about 3 years. Around three-quarters of the therapists had special training for treating this population, with absence of such training being due to having started working in the field before such opportunities became available. Seven of the therapists currently administer trainings or serve as mentors in the field of sexual assault treatment. All have had the experience of accompanying clients to various degrees of recovery, which they defined quite similarly to the survivors as the ability to live one's life without being managed by the trauma. The therapists distinguished between survivors of single assaults, for whom they have seen healing close to the point of complete freedom from symptoms, compared to survivors of multiple adult trauma and, even more so, to survivors of prolonged childhood abuse for whom recovery was a longer, ongoing process.
Procedure and Measures
The participants were recruited by way of convenience sampling through an invitation published on various social networks. The online invitations for survivors stated that we were seeking to interview women over the age of 18 years who had been sexually assaulted at any age and were currently recovered as a result of successful therapy. This invitation was published on various survivor online forums, rape crisis center sites, and informal sites such as Facebook. Responses were followed by phone calls to each respondent to ensure her suitability for the study. The therapists were recruited by an online invitation seeking therapists with extensive experience in treating sexual assault survivors by any means of psychotherapy. The calls were made via social networks, mailing lists of therapists in the field, direct contacts with support centers and word-of-mouth distribution through acquaintances, organizations, and the participating therapists themselves, using the snowball method. Participation was voluntary and no monetary incentives for participation were offered to participants of either group. All procedures were approved by the Tel Hai College institutional review board.
The interviewees chose their interview location, which was not limited by its distance from our location. Among the survivors, eight interviews were conducted at their homes and two at a rape crisis center. Eight of the therapist interviews were conducted in the participants’ office or workplace and two interviews were held at the participants’ homes. Interviews with survivors were conducted over a period of 2 months and with therapists over three.
All interviews commenced with an explanation about the study and a declaration that the interviews would be recorded and transcribed for analysis, to which the participants were asked to consent. We also specified the means that would be taken to safeguard the transcripts and ensure participant anonymity, including concealing any potentially identifying details and displaying pseudonyms only. All interviewees signed an informed consent form after being assured that they could discontinue their participation at any stage and, likewise, refuse to answer specific questions. Participants were encouraged to talk to us before we began the interview about anything that was unclear regarding the study or how the data would be used. Survivors were also provided with information regarding support contact should it be required. However, no one made such contact at any point.
The semistructured interviews generally took the form of open conversations guided loosely by our questions, progressing in the direction chosen by the interviewees. Participants were informed that they could request a break at any time. If it was necessary to expand upon topics that emerged during the interview, the relevant preplanned questions were asked at the end of the interview. The interview format for survivors consisted of three parts: general, personal information, such as age, marital status, place of residence, and sexual orientation; questions about the assault or assaults they sustained and the impact on their lives; and specific treatment components that they associated with their recovery. The therapists’ interview also began with informative questions, primarily regarding their professional credentials, followed by an open-ended question regarding how they experienced treating survivors of sexual assault in general, after which they too were asked to specify what they considered to be the precise therapeutic elements that promote healing. All participants in both groups were very cooperative, with many of the survivors also expressing a willingness to be contacted again, if need be. Many of the therapists mentioned that the interview contributed to them personally on a professional level, adding that they considered studies of this kind very important.
Data Analysis
Data coding and analysis were guided by Braun and Clarke's (2006) thematic analysis approach, designed to identify commonly recurring themes across the data set. Seen as a steppingstone to pinpointing patterns in the data (Saldaña, 2013), the coding process aimed at identifying themes and subthemes in relation to what respondents from both groups perceived to be the most fundamental features of optimal sexual assault therapy. Repeated close readings of the transcripts enabled the researchers to create codes, identify and compile a list of themes and subthemes, and group together thematically similar material, creating a list of themes that predominated across the transcripts.
Out of three possible methods for developing thematic codes, namely, theory-driven, prior data-driven, and raw data-driven (Boyatzis, 1998), we employed a combination of the latter two. As theoretical accounts (e.g., Herman, 1992; Koss & Harvey, 1991; Moor, 2009) have suggested that trauma therapy comprise relational and processing components, all interviews were deductively coded for everything related to these two categories. Each incidence that embodied relational components of treatment was coded as “therapeutic relationship.” Likewise, each statement relating to the processing of the trauma was documented and coded as such. Within each of these two categories a series of inductive codes were identified during the multiple readings of the data, yielding a series of inductive codes that were assigned to each meta-theme. These codes related to all therapeutic elements that were identified consistently throughout the interview data. The codes were then assigned to the larger categories based on whether they were deemed to be relational or processing in nature, covering all text previously identified as these categories.
A team of four researchers analyzed the data in the following sequence. All four researchers did an initial reading of the interview transcripts for preliminary familiarization with the data, followed by a more detailed review. The researchers were then paired, and each pair was assigned to code either the survivors’ or the therapists’ transcripts, creating two code lists. Several trials of interview coding and refinement were executed to develop a codebook covering individual interviews and themes. Next, each two coders sorted the different codes into potential themes and collated all the relevant coded data extracts within the identified themes. Then each pair of coders examined transcripts from the other set to assess the accuracy of the codes and themes suggested by the first pair of coders. Throughout the coding process, researchers created memos within transcripts to highlight relationships or inconsistencies within and between the survivors’ and therapists’ interviews. The themes identified in the transcripts of each group, namely, survivors and therapists, were then compared to detect similarities and differences, both independently by each coder and through a discussion among the four researchers. The comparison was performed for all themes and subthemes, so as to group together similar themes for each of the two subsections. Through discussion and review of the transcripts and coding notes, the authors agreed on the major themes, subthemes, and quotes that supported each theme and/or subtheme common to both groups. Disagreements were discussed by the researchers until reaching consensus (Patton, 2002). Finally, a refinement of the specifics of each theme was undertaken, generating clear names and descriptions for each.
Results
The results are grouped into two major themes, representing the primary aspects of therapy for sexual assault trauma: (1) Specific components of the therapeutic relationship that contribute to the recovery from sexual assault and (2) precise trauma processing interventions that additionally foster healing (see Table 1). Each of the two major themes were divided into numerous subthemes arranged in order of relative significance and presented from both the survivors’ and therapists’ perspectives sequentially. A very small minority of themes ( < 5%) were identified separately by only one group. However, as they did not contribute much to the overall picture, we removed them from the data set so as to focus on our objective of identifying shared perceptions. Names and other identifying details of the participants were changed to protect confidentiality.
Interventions: Major Themes and Subthemes.
Part I: The Therapeutic Relationship
The Centrality of the Therapeutic Relationship
All the participants in the study, survivors and therapists alike, identified the therapeutic relationship as the most significant aspect of therapy and its progress. Moreover, it was cited by survivors as one of the major reasons for staying in therapy. This component of treatment preceded all other elements, being viewed as a necessary foundation for successful treatment.
Hannah (survivor): “I started therapy exhausted, having no power to fight anymore. I felt that all I needed was someone to stroke me and tell me I was in a safe place. And that's what she did. And, in retrospect, I know she used various methods but that didn't interest me at the time. All I cared about was how soft spoken she was, how pleasant her voice, and that she looked at me and told me she was there for me.”
Rene (therapist): “I think that the most important part of therapy with survivors is the therapeutic relationship. To me, that surpasses everything else. No technique and no method can be compared in my eyes to the therapeutic relationship.”
Counteracting the Peritraumatic Dehumanization
All the interviewees indicated that therapy must provide a corrective experience to the peritraumatic dehumanization that denies the survivor of her full humanness as a means for regaining the sense of human dignity that may have thus been lost.
Lia (Survivor): “The therapist made me feel that I am a person with valid needs and desires … that I may refuse anything whenever I need to … as opposed to the loss of my humanity when they looked at me as an object and not a human being … I remember telling her (the therapist) that I felt like a person with special needs and her response was ‘maybe just a person with needs?' And it made me realize that I have legitimate needs.”
Anna (Therapist): “I think about it a lot, about putting a dimension of humanity into the therapeutic relationship. To make the survivor feel that she is not an object, that she counts. I think that one of the most detrimental elements of sexual offenses is the inherent objectification and dehumanization, which treatment therefore must counter, especially since many survivors might have also encountered previous treatments where they were disregarded and mistreated as well.”
Nonjudgmental Empathy
The empathic position in the therapeutic relationship conveys essential understanding and caring according to all survivors and therapists. The therapists also emphasized the importance of refraining from judging the survivors in any way, noting that lack of compassion and empathy was frequently cited as a cause for dropout from treatment.
Lily (survivor): “She was really helpful to me and I had a very warm empathic relationship with her. … Her empathy, in particular, is what helped me the most. It really helped me to feel valuable. … She really made me feel good.”
Shira (therapist): “The ability to really be there for them and love them … to be totally empathetic towards everything they went through, to make them feel that someone is carrying their pain with them, without any judgment. Important to say things like, I am with you, I believe you, I appreciate you, I don't think you’re small, I don't think you’re guilty.”
Trust Restoration
According to all interviewees, survivors and therapists alike, the therapeutic relationship can go a long way in restoring the survivor's potentially diminished faith in others, allowing her to begin trusting again, as well as to feel safe to open up, and confront the horrors she experienced.
Tania (survivor): “At first, I had a terrible fear of trust. I needed reassurance, but with time I realized that this is a very trustworthy connection. I really felt like I could count on her to be there for me, and that contributed so much to my sense of trust and confidence, and that meant so much to me.”
Dana (therapist): “I think that the first phase of therapy is important for building and establishing a sense of security. Because sexual trauma often leads to not being able to trust anyone. The degree to which they come to trust us determines the success of therapy.”
Renewing the Sense of Control
Regaining the sense of control that is so often lost during sexual assault and its aftermath was identified by all survivors and therapists as a central benefit of the therapeutic relationship. The therapist's attunement to the survivor's pace and needs, while offering her certain control over the therapeutic process and refraining from imposing any part of the procedure upon her, were identified by all survivors as central means to accomplishing this end.
Shirly (survivor): “I had to resume feeling that I am in control of my situation, of my body, of what was happening to me … and her (the therapist) being there for me through all of it, helped me get there. This seems to me the most important thing, to feel in control of my life, so this is possibly the most important thing I got from therapy.”
Sharon (therapist): “One of the principles of dealing with sexual assault survivors is to proceed step by step, considering what is right for them, not to coerce them into anything. In the sexual assault, the victim's basic needs are not taken into account, as it is forced upon her, and therefore treatment must refrain from that. So, I always have to be very careful not to force anything, to check constantly, every single moment—appropriate, inappropriate … so that they feel in control. It means so much to them to be asked what is right for them. It's a very empowering experience.”
Breaking the Silence
Eight therapists and nine survivors referred to the central role played by therapy in breaking the secrecy and silence surrounding the assault, with the therapist acting as a supporting witness. Beforehand, she might not have had anyone to whom she could reveal the assault or assaults, and now for the first time, she does. Disclosure was defined by many as a turning point of great importance, bringing with it a sense of great relief.
Lily (survivor): “I was actually sexually abused in the fifth grade by someone I knew and lived with this secret until I was 19 and entered therapy. I kept the secret because there was no one to help me. … Breaking the secret in therapy was like I was reborn.”
Tammy (therapist): “There is so much harm in keeping the secret and therapy that doesn't encourage breaking the secret is literally harmful. Once the survivor gets to feel that it is not a secret anymore, it ceases to take up such a painful place in her being. … She is so relieved.”
Naming and Normalizing
All the survivors mentioned how meaningful it was for them to have the therapist name and normalize their experience; for example, naming the peritraumatic reactions of dissociation or freezing, along with their ramifications. Eight therapists echoed this understanding as well. Being helped to realize that their reactions are typical in the aftermath of sexual assault, and are shared by many others, was described by survivors as being soothing, reassuring, and empowering.
Lia (survivor): “A lot of work was devoted to normalizing situations. One by one we named them … the patterns that kept me from collapsing. She (the therapist) quickly recognized them all and normalized them. For example, letting me know that my intense reactions were normal was so soothing, allowing me to stop feel so abnormal like I felt for a year. Just like when she helped me to realize that I did not just give up during the assault, as I saw it, but to understand that I froze as so many do. That helped so much.”
Shira (therapist): “First of all, normalize the situation. That is, to tell her that many others who have gone through similar things have the same symptoms. … And that gives it a name, too. That allows her to realize that she is not crazy in any way, that the intrusive thoughts and flashbacks are typical reactions that characterize situations like hers. It creates a very meaningful switch in her care, that she can understand what is going on.”
Freeing From Self-Blame
The majority of the participants in both groups, namely, eight therapists and seven survivors, identified the release from self-blame as a major goal of treatment. This process entails helping survivors recognize the source and mechanism of the self-blame, reconstructing blaming cognitions, and increasing self-compassion to the point of realization that nothing of what happened was their fault.
Dafni (survivor): “Unequivocally what helped me release the feeling of guilt and shame was the emotional connection that was made during the treatment. … She (therapist) knew first of all how to diminish guilt. As soon as she noticed that I started to blame myself, she would help me seek other explanations. She would reframe the incident to show me that it was not my fault and that the abuse should not have happened in any way. This really empowered me, and I was able to find tenderness within me.”
Anna (therapist): “Self-blame is so central that it must be dealt with. In this respect I work a lot with therapy scheme techniques. … So, when self-blame comes up, we try to reconstruct it in order to get rid of it. I can literally tell my patient, ‘I won't listen to this (self-blame) anymore, I’m not willing to hear it … ' At other times you have to try to understand what she is feeling and from there to release the guilt.”
Release From Shame
In numbers equivalent to those concerning self-blame, both therapists and survivors viewed release from shame as another crucial component of treatment. This entails focusing on the deep emotional experience of shame and being able to meet it without judging or condemning the self. The therapist reflects the client's feelings and helps her gain self-empathy and worth.
Tania (survivor): “I was so ashamed, in every part of me. This was a constant feeling. … What set me free was the process of rebuilding my identity in therapy, connecting the pieces of the puzzle and realizing that it was something that was done to me, but it is not me nor does it define me. Everything fell into place after that.”
Ruth (therapist): “The emotion of shame is often is so powerful, so ingrained, that it is not enough to just say ‘you have no reason to be ashamed.’ That is why I really like using mindful self-compassion that is very helpful in this context.”
Containment of the Traumatic Narrative
Seven survivors and an equal number of therapists (7) asserted that the survivor must experience the therapist's presence as containing and unwavering. She must be made to feel that the therapist can deal with everything that needs to be said, that the therapist is capable of containing her pain and hearing her story without disconnecting. Only then can she feel free to delve into the pain and horror of her attack.
Hannah (survivor): “I immediately felt that she (therapist) would contain it all, and it meant so much to me. As soon as I sat down in front of her, I started crying … and it took several sessions until I could speak it. It was as if she felt the enormity of containment that I needed from her. I was on the verge of a total collapse. Everything was so dark. I felt so alone, and she was unequivocally there.”
Nora (therapist): “ …. not to be afraid of it, not to be afraid of it … to be firmly with her in all of it. Never give up, be beside her as she faces the greatest horrors and the deepest despair … you know, be willing to talk about death, loss, self-harm. Not to be alarmed, not to be alarmed by the aggressive parts that might be there at some point. Simply be there.”
Flexing the Boundaries
Most of the interviewees, about three-fourths of each of the two groups, referred to the importance of flexing therapeutic boundaries while not foregoing them entirely. The therapists acknowledged this need; the survivors appreciated its fulfillment.
Sarah (survivor): “It is so meaningful knowing that she is there for me whenever I need her. Even if we set a date for Tuesday, but today I have to talk to her urgently, so she might be able to find me some time tomorrow morning. I mean, I know she is there. The boundaries are not so fixed, unlike medical settings and the like.”
Anna (therapist): “It's not regular therapy. …. Yes, you have to keep the boundaries, but often regular contact is not enough. Frequently, part of the holding is done in texting, emails, and other forms of communication, like over the phone, of course. So, this is really one of the most meaningful aspects of the work, the space of connection and support.”
Part II: Trauma Processing Interventions
The Importance of Processing the Trauma
All interviewees, both therapists and survivors alike, noted the crucial importance of processing the trauma for the sake of its reconstruction and subsequent reduction of posttraumatic symptoms. The primary objective of this process is to merge the fragmented memories into a coherent narrative by means of the various interventions listed below, endorsed by all as being effective.
Sarah (Survivor): “We processed it with EMDR, which was very impactful. The eye movement would bring up a whole lot. Let's say I would remember something and then I might have a flashback, and she (the therapist) would help the process to move on. It was important for me to remember the details of the event because everything was fragmented, so it helped to clarify and make sense of what was going on.”
Rene (Therapist): “The trauma processing phase is aimed at going deeper into the traumatic narrative, to actually begin to face the traumatic memories, and to reduce their impact on all kinds of post-traumatic reactions such as emotional flooding or detachment. In essence to lessen the trauma's dominance over her life.”
Repeatedly Telling Her Story
Repeatedly telling and retelling the story of the assault can make it possible for the survivor to connect its fragmented representations into a coherent whole, to find words to relay the narrative, and to link together images that had no words or emotions without images, to integrate and consolidate the traumatic narrative, in the presence of a supportive and empowering other.
Dafni (survivor): “And I finally told her what happened, one by one. I hadn't told it until then! She (the therapist) made sure to give me all the time I needed to tell everything. And she was there with me, and I saw her experience it with me. And since then I started getting better. It was an unbelievably empowering experience.”
Tammy (therapist): “Tell it. First of all, tell the whole story, in every possible detail, as many times as necessary. Sometimes it needs to be told more than once, twice, or many more, repeatedly returning to it with the aim of creating continuity, logic and meaning in the traumatic memories, for the sake of ultimately letting them go.”
Processing Flashbacks
The processing of the trauma also aimed at reconnecting with memories that have been cut off. This was achieved not only by repeatedly going over the narrative but also by dealing with flashbacks.
Nina (survivor): “During the processing I would often experience flashbacks. And being with her (the therapist) in this situation, telling her what's going on, being in control of the situation, helped me to make sense of it and everything that happened.”
Elinor (therapist): “We work with the flashbacks, and we do it in two steps. We both aim at increasing the ability to contain them, to remain grounded through them, without having to dissociate … and then to make sense of them and integrate their contents into the emerging abuse narrative.”
Dealing with Dissociation
Different tools were identified for dealing with the dissociation that occurs either during treatment or outside of it, such as grounding, present orientation, and breathing exercises (see elaboration below). The tools help identify dissociation when it begins and delineate how to deal with it at all times.
Nina (survivor): “In dissociation there is a crazy sense of uncontrollability, and she (the therapist) has given me tools to control it. She gave me tools for returning to the present and to my body. How to be grounded, to feel my feet, to feel the body sitting on the chair, notice my breathing, my thoughts and connect.”
Sharon (therapist): “… when I notice that she (the survivor) is very disconnected I reflect that to her, telling her that I see she is disconnected, and I help her to become grounded … through leading her back to the here and now by way of questions or remarks that reorient her to the present.”
Emotion Regulation
All the therapists stressed the importance of developing emotion regulation for the sake of easing the trauma processing. The survivors unanimously echoed this need as well. Amassing regulation capacities strengthened the survivor's ability to cope while processing the difficult material. Emotion regulation also assisted in containing symptomatic manifestation of the trauma outside of treatment.
Nina (survivor): “In one of my first sessions with her, she told me that we would make a list of the feelings that are most difficult for me to bear. Then she told me to go home, and every time I felt something, I had to write it down. I really remember writing down everything, and she gave me practical tools for what to do when I felt one of those feelings.”
Anna (therapist): “It's important to use a set of regulating tools. For example, a container to store the bothersome materials, which makes it possible to put them in and out. All the grounding techniques like paying attention to everything she hears and sees around her in the here and now, mindfulness. It is imperative to use the tools that fit each client the best.”
Staying Present
There are tools of regulation whose purpose is to divert the survivor's thoughts and others that aim at enabling the survivor to stay with the situation, without needing to escape from it. This aspect of therapy teaches the survivor that she can withstand the difficult situations without falling apart or needing to escape.
Tania (survivor): “… I developed the ability to be in a state of mindfulness, that is, to stay with things as they are … to recognize an association and yet be you, not to be alarmed and go back to detachment.”
Elinor (therapist): “The survivor learns how to be present with something that feels uncomfortable. She comes to realize that she can stay with it and do something about it. For example, one of the things she learns is that there's a thing called the window of tolerance, which is actually an area where she can endure emotion. Once she recognizes that she is about to exceed it she can do something active to regulate herself.
Discussion
The goal of this qualitative study was to contribute to the formulation of optimal sexual assault treatment for women. Both survivors who underwent therapy that furthered their recovery and highly experienced therapists in the field were asked which precise components of therapy foster the most favorable treatment results. The data from the two groups were then compared, with results demonstrating near unanimous agreement between the two groups. The significantly high level of concurrence regarding the efficacy of specific interventions underscores their usefulness in the effective treatment of this population (Bachelor, 2013; Duncan & Miller, 2000). This is the first study to explore this topic from such an angle.
The broad picture that emerged from comparing both perspectives places the therapeutic relationship at the heart of treatment (e.g., Cloitre et al., 2004; Hensley, 2002; Herman, 1992; Koss & Harvey, 1991; Moor, 2007; Paivio & Laurent, 2001). Because sexual assault is a dehumanizing interpersonal trauma, the relationship that develops in therapy is essential for providing a corrective experience and restoring the survivor's human dignity and value (Moor et al., 2013; Olio & Cornell, 1993). In this space, the survivor can come to realize that she is now free to express her needs and expect to have them fully respected. She can reclaim the status of a subject after being rendered an object (Moor, 2007). Breaking the secrecy thus becomes possible, along with the processing of even the most difficult memories and feelings that may arise during treatment.
Within this relationship, the therapist empathically validates the survivor's experience, naming and normalizing it, thereby relieving her of the fear of losing her grip on normalcy and repudiating her self-blame. Recognition and validation of what actually took place is likewise achieved (Moor, 2010; Olio & Cornell, 1993). Empathetic responses are also key to the development of self-empathy, compassion, and self-acceptance, as well as a sense of self-worth (Moor, 2007; Paivio & Laurent, 2001). Moreover, possibly for the very first time, the survivor is freed from any guilt or shame that she might have internalized from the critical social environment as well as from prevalent rape myths (Campbell, 2005; Gagnon et al., 2018; Moor, 2007; Suarez & Gadalla, 2010). Subsequently, the internal blaming voices are silenced and replaced by self-compassion.
Both groups of participants also agreed on the importance to recovery of restoring the lost sense of control, in line with similar recommendations regarding interaction with support providers (Duncan & Miller, 2000; Munro-Kramer et al., 2017; Starzynski et al., 2017). It appears that all support encounters, therapy being no exception, should grant the survivor freedom of choice and freedom from imposition, thereby allowing her to regain an empowering sense of control over her life (Ullman & Townsend, 2008). Similarly, creating the most holding, and obviously caring environment also necessitates flexing the therapeutic boundaries at times, deviating to a degree from more traditional therapy guidelines, while simultaneously taking care not to undo them entirely. There can be a fine line between breaking the boundaries of the therapeutic relationship and adapting them to the survivor's needs. The goal is to extend boundaries without shattering them. Therapists, like all other support providers, must also be able to contain the traumatic narrative, so as to allow the survivor to tell her story in detail (Olio & Cornell, 1993).
It is worthwhile to note the similarities between the present recommendations for a curative therapeutic relationship within sexual assault therapy and survivors’ expectations from other support providers (e.g., Kirkner et al., 2017; Munro-Kramer et al., 2017; Starzynski et al., 2017; Ullman, 2014; Ullman & Townsend, 2008). Simply stated, the clear implication is that all agents to whom survivors turn for help, from mental health providers and rape crisis center counselors, to legal and law enforcement personnel, should provide the most empathic, validating, respectful, caring, and supportive alliance possible (Ahrens et al., 2009; Campbell, 2005; Dworkin et al., 2019). This will ease their recovery and prevent re-traumatization (Campbell et al., 1999; Gagnon et al., 2018).
At the same time, there are noteworthy differences between the interventions recommended here for sexual assault therapy and those expected of other support providers (e.g., Kirkner et al., 2017; Munro-Kramer et al., 2017; Starzynski et al., 2017; Ullman, 2014; Ullman & Townsend, 2008). These pertain to the centrality of trauma processing in effective sexual assault treatment, which is generally not part of other support encounters. Beyond the curative features of the relationship between survivor and therapist (or other support providers), comprehensive processing of the traumatic memories is essential for the reconstruction and integration of these recollections (Edmond et al., 1999; Foa & Rothbaum, 1998; Jaycox et al., 2002; Power et al., 2002; Tarquinio et al., 2012).
Both survivors and therapists agreed on the necessity of trauma processing concurrent with the identified aspects of the healing relationship. Both expressed that successful processing can replace collapsed concepts with others and create new perspectives. Through telling and retelling the story of the assault, the survivor can reconnect to cut-off aspects of the traumatic experience and merge its fragmented representations into a coherent narrative. Consequently, she can achieve a reduction in symptoms and a lessening of the trauma's dominance over her life. In this manner, psychotherapy is distinct from other supportive relationships, with the possible exception of rape crisis counseling (Ullman & Townsend, 2008).
From both perspectives, and in accordance with similar recommendations (e.g., Cloitre et al., 2004; Gold, 2001), great importance was also placed on the development of emotion regulation capacities to facilitate the processing of the traumatic memories. The facing of distressing and potentially flooding memories must be bolstered by acquisition of adaptive tools designed to help the survivor regulate herself. Such tools also assist with containing and coping with the emotions that arise from the difficult content. Self-regulation additionally increases the ability to withstand some of the most debilitating posttraumatic symptoms, such as dissociation and flashbacks, thereby enhancing the processing and subsequent integration of the traumatic memories.
By demonstrating the importance of integrating both the curative relationship and trauma processing to the healing from sexual assault trauma (see Figure 1), the present findings essentially merge findings that previously stood apart. In fact, nearly all previous treatment research focused on of these two central components of therapy in isolation, hence the important contribution of this integration to the treatment literature, particularly given that both survivors and therapists shared its tenets. Moreover, the fact that therapy shares some features with other supportive relationships yet is distinct in its combination of the myriad of treatment components specified in this study, demonstrates its significance for recovery of sexual assault survivors.
Recommended treatment components.
These and other meaningful recommendations resulting from this study notwithstanding, several of its limitations must be considered. The convenience sample of survivors comprised only women who underwent a successful course of therapy. Future studies seeking to understand why certain survivors do not seek therapy or experience it as unsuccessful would provide additional information regarding treatment recommendations. Moreover, that the current sample consisted of women only, almost all heterosexual, may limit the relevance of the conclusions to other groups of survivors. While many of the experiences and recommendations shared in this study may plausibly generalize to men, LGBTQ (lesbian, gay, bisexual, trans, and queer), or gender-nonconforming survivors of sexual assault, there may also be different patterns of experiences across diverse groups of survivors that should be investigated. Likewise, the fact that only female therapists participated in this study certainly warrants a future examination of the perspectives of male therapists as well.
While there was some variation in the types of assaults experienced by the survivors, not all possible types were included. Consequently, links between the type of assaults and preferred treatment interventions were not examined. Similarly, although there was some variation in age at the time of assault, this variable was not a focus in determining treatment effectiveness, seemingly implying a certain uniformity in required interventions irrespective of this factor. Nonetheless, future investigations should examine this aspect, studying at least two separate groups, one of women abused as children and the other of adult sexual assault victims, some of whom might have actually experienced both types of abuse.
Although this study did not examine specific therapeutic protocols that might be employed when treating this population, it offers a broad and comprehensive examination of shared aspects of treatment that should be used across treatment modalities. In this way, it shows the crucial importance to recovery of both the relationship factors and the processing of the trauma. Still, future research can examine the specific components of particular methods of treatment for more method-specific guidelines.
These limitations notwithstanding, the present study extends both existing qualitative research of survivors’ reactions to support providers to the realm of psychotherapy (e.g., Gagnon et al., 2018; Kirkner et al., 2017; Munro-Kramer et al., 2017; Starzynski et al., 2017; Ullman, 2014; Ullman & Townsend, 2008), as well as quantitative reports of evidence-based sexual trauma treatment modalities (e.g., Ironson et al., 2002; Vickerman & Margolin, 2017). The study presents a comprehensive set of treatment requirements, jointly endorsed by both survivors and therapists, that were previously presented separately from one perspective or the other. In doing so, it expands the practice of voicing survivors’ own articulation of their treatment needs following trauma (Campbell, 2005; Gagnon et al., 2018).
In sum, the comparison between survivors’ reported needs and those described by expert therapists sheds light on what actually happens in the field between therapists and clients that furthers healing from sexual assaults. The degree to which survivors confirmed what therapists propose to be key recovery-promoting interventions can enable clinicians to assess their own beliefs about what is helpful to survivors and, at the same time, reassure potential clients as to what they might expect in therapy. Additionally, the resultant comprehensive picture can serve to refine training programs for therapists, and indeed for all support providers (Campbell & Raja, 1999; Starzynski et al., 2017), thereby increasing the likelihood that survivors will receive the most optimal treatment in the wake of the devastating trauma that they experienced.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.
