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Nv WSj'i bf*;v< ' ' :c •< - ' \ ipo , :»i mtia ' » ‘»0* - # iMap^^.,...... i^- >"*'« • '^, »,-.s*i I. <^*7^ , ,,-vSr I,- A a ' I ;• E/-,f ' ' " "49^ S' ,.' .=', ; .Mfil * . ,:-„uUtiM- ,ft\. -V „ "' 'St .'/'ry. "r;;r -', ,-^ -»- ^ - , ,ssr % . •’'A i;!- nr "- !•’'' .!;'.'*'''ii' , ‘i j, *•*•;:. ''ll . J U-j;;.: Copyright by Lawrence Jack Cohen 1985 : COPING WITH TRAUMATIC EVENTS: A THEORETICAL MODEL AND A STUDY OF RECOVERY FROM RAPE by Lawrence J. Cohen Department of Psychology Duke University ~ Date: 'I. Approv ed Susan Roth, Supervisor j£. /a/ r/ Dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the Department of Psychology in the Graduate School of Duke University 1985 : ABSTRACT (Psychology-Clinical) COPING WITH TRAUMATIC EVENTS: A THEORETICAL MODEL AND A STUDY OF RECOVERY FROM RAPE by Lav^rence J. Cohen Department of Psychology Duke University Date ; 7 Approved ^ Susan Roth, Supervisor An abstract of a dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the Department of Psychology in the Graduate School of Duke University 1985 ABSTRACT COPING WITH TRAUMATIC EVENTS: A THEORETICAL MODEL AND A STUDY OF RECOVERY FROM RAPE t>y Lawrence J. Cohen The study of coping with stress has been disjointed, lacking a coherent model. The present work proposes a theoretical framework for understanding coping based on approach and avoidance. Approach and avoidance are discussed in terms of the psychoanalytic concepts of defense and working through and other historical precursors as well as recent research on coping with traumatic events. Two experiments are presented. The first consists of a scale-construction study of the Cohen Roth Approach Avoidance Scale, a self- report measure of coping strategies. A revised version of this scale is proposed based on factor- analytic data frcxn a mixed-stress sample. Experiment 2 is a study of the long-term impact of rape. Seventy three women, who were victims of rape an average of eight years ago, were given questionnaires covering the following areas: demographics, nature of the assault, coping styles, and current level of functioning. Most of the sample was found to still be in moderate to severe distress. The relationships between outcome and demographics, situational variables, and behavior after the assault are discussed in the context of prior research in this area. Approach and avoidance strategies, measured by the revised Cohen Roth Approach Avoidance Scale, had a complex relationship with outcome. This relationship is discussed in the context of the theoretical model of coping presented in the Introduction, focusing on the difficulty women have in resolving the trauna of rape. iii "''Af y:§^m 'M /fiji 1 1' / ^ • V #* 5 L f , iv> 'friiot-l»4,p':- " '' • ".-^j ' (.#1 • . '...jf »c, t>w if3|jRiit4r '4ia .'1 >».<*.. 'Mi^ j'.t^'u, ' ' ., ;,. /..; '.r’-VrW^ • t: «;*r. .o,\ : '^i -)IM w «r otsMn 'ipihfiiqXlA' pf(i M 'H* a ipo'tT a4«b ^'5tf* *f,t, .w -.‘ .-x^k'. 1 1' irie^.(Ti) ^'- ' ' ' ^' ' . IT'. ,r'.^ 1^' r'*- rtc -y ctHbI;'' ii\ nt ihtii J6 ' 'fj4^,TjH!b •jeiS's -.a '’4?P U’is .v'/uaoi * • r "I*'*) -j, ., 'tTaVfk^n > ;!«•' . II -» M 4t^ >^.t 3ia#n "t{.> i/1i^ Tt.iV ^ 'ifl , 4 4^^^^ .1 I >t . Jg'jf ' '• i ' . '>‘^4 * »% -v- Has-' ’!*Si,' » f *«R.v^4,a j t J tvi '"' " ' ^‘ *«« U ACKNOWLEDGMENTS First and foremost, I want to thank my advisor, Susan Roth, She taught me both how to do research and how to enjoy it, I am grateful to her for allowing me to be a collaborator rather than a pupil; that opportunity has been the highlight of my work at Duke, I would also like to thank the members of my committee; Philip Costanzo, who always helped me get the big picture; Maxine Atkinson, who taught me more statistics than I thought I would ever want to know; Lise Wallach, who knew how to teach by challenging and how to inspire by encouraging; and Martha Putallaz, who appreciated the importance and value of this area of research. The love, encouragement, and generosity of Anne and my family made everything possible, Fially, I owe an enormous debt of gratitude to the women who participated in the study of recovery from rape. Their courage, combined with an eagerness to help others, was truly remarkable. This work is respectfully dedicated to them. iv " 'f^r i, ^ ' ^'^V ‘t*^ ' Bl: ^^J Sit r .ft>.^ V .. «?>e|f4#’»€’'i 1. ‘ HHliifcr ,. ‘ ' -1 V d (4 fjiftt I ‘oit V<^ W #^v. f'rtv ati7.‘s’^;ii45^ ' '' ^ ' ' "I'i '4^' -t, jj MT'^' !''.s*ffi *? ’'’f w ftai« «'i«r 'vn^ ;’><»' • f.» i-i vi«ii jj,t4»ia t'®' >»|M' •' " ""' "; , "M ''fi a>fw eliff Y f W'i/i zSTj : «!si \'S' CONTENTS ABSTRACT iii ACKNOWLEDGMENTS iv LIST OF TABLES vii INTRODUCTION 1 The Approach-Avoidance Dimension 3 Theories of Coping 11 Consistency 15 Coping Effectiveness 17 A Model of Coping 22 The Psychological Response to Rape 31 Response to Rape and Post-Traunatic Stress Disorder 34 Predictors of Individual Differences in Recovery from Traisnatic Events 39 Validation of the Cohen-Roth Approach Avoidance Scale Ml The Long-Term Response to Rape M3 EXPERIMENT 1 M? Methods M7 Results and Discussion M8 EXPERIMENT 2 5M Methods 5M Results and Discussion 55 Description of the Sample 56 The Range of Outcomes 67 V ft H i Ar Factors Predicting Outcome, I; Demographic, situational. and behavioral variables 69 Factors Predicting Outcome, II: Coping variables 74 Effects of approach and avoidance 75 Interaction effects 79 Quadratic effects 81 REFERENCES 90 APPENDICES APPENDIX A: Rape Study Questionnaire 101 APPENDIX B: Final Version of Cohen Roth Approach Avoidance Scale 117 APPENDIX C: Advertisements for Rape Study 118 APPENDIX D: Raw Data from Experiments 1 and 2 with Legend 119 Hi ,\jfh * t f 4IJ"' , i^i0 m. ^4$M ' • ,• ..i;v w.' . ..Y*C.\ ..r" .. r* MM i .-n/iO « ,, ^^hyM: -/' ' •:' : .f*^, ' T ( ,-•?; '^ o-/,' -'r <*111^11/11' i(:Trv;fj i*v».'«VH;3' tO • ^ 'H4,i ^'f i(F';V €.'f ' i*....» ...,v' V--;. # tjutn. f ?3; irr>tH LIST OF TABLES Table Page 1. Summary of Approach-Avoidance Coping Formulations 12 2. A Schanatic Diagram of Intrusion, Denial, Avoidance, and Approach 25 3. Symptoms Following Rape and other Traumatic Events 37 Demographics, Nature of Assault, and Post-Rape Behavior in Two Samples 57 5. Comparison of Rape Sample with Nonvictims and Immediate Victims 61 6. Comparison of Long-term Rape Sample with other Stressed Populations 65 7. Sumnary of Significant Regression Results 76 vii ; "4^-5 >n 1 ‘ , . 1 ' . T 'i- MV m’ ^ vr i>:©-'.t \t •'«*'*.’• • ' ' , , ! ' ’* ‘ ' I ;*•)' .. 4 V,M>. Jffc^ A f< 't-tCf i^l^, ‘'tjf « ^; , I •> k i»i '‘ii(,t-».£'', c»'^ •*^’ tr tMh ' :'' ' ' ' ' '; ::, ^ . 5 . / ; I 'M I-” *; '* !i;l|t'.;. , . Mfi/;" .... ww INTRODUCTION The study of stress and coping has become quite popular in recent years, but the field remains disjointed, lacking a comprehensive and coherent model. The present work does not pretend to integrate the entire field, but does present a model of coping with traunatic life events. In order to put the model in perspective, this presentation will begin with an overview of the major themes in the area, followed by an account of the historical precursors of the model, and a detailed look at some recent research. Following a presentation of the general model, the question of testing the model will be addressed both in general terms and in the context of a scale-construction experiment and a study of recovery from rape. Some of the difficulties in developing a model of coping arise from a lack of consensus about very basic issues. For example, what types of stressors require coping strategies? Seme researchers have focused on coping with major uncontrollable events, such as accidents, rape, or illness. Others have researched coping with ongoing stressors such as economic or familial pressures, while still others have studied the response to everyday problems. In terms of coping, there are fundamental controversies over the difference (if any) between coping and defending, as well as over the nature and meaning of "good” coping. The measur«nent of both coping and coping effectiveness has also been a problematic issue. Finally, several prevailing issues in contemporary psychology, such as trait vs. situational consistency, have been raised in connection with stress and coping. The study of anticipation of future stressful events has been kept distinct from the study of recovery from tranna. However, anticipation and recovery are often necessarily related. Not only is the anticipation of a 1 ‘ ' ' ' i'... I riph - •* j tvui «' t r.rt>»i«9i!:Jfliji9cj:;i^^^ • '» .> I ( ' f'f •;-i -u ! V(d . 'T jtf- ’fiitoi iMiii • I j'ti-i- r*. , •:pi':. *: I' ,ti-) , •"^!^'^#t r.^c’X’ . *> **'v ./'A'r..J, ,. ”uw. . $o '1. .'i'TC-?* Vfla, at.-,, *f.. ’Ifrf ' - 'i . j . .‘.r;.-U>» .•/‘H' ..y. i •:v^, 0 ‘2 "’, ' > ,. * f' v.t, TW' Tl -t ^1!?' J ' <.' V: .. . • ,Vi Ms 14* .. 2 serious threat a trauna in its own right, but there are a mmber of stressful life events that include both an anticipatory and a recovery period. Also, dealing with traunas involves caning to terms with the event itself as well as with the threat of recurrence in the future. Finally, anticipation and recovery, thoi^h maintained as separate fields, have identified the sane processes as central to coping. Similarly, some researchers have considered only unexpected events, such as rape or accident, to be traunas. While the existence of an anticipatory period certainly has a great effect on recovery from an expectable trauna such as major surgery, the anticipation does not make the recovery any less important in the life of the person. In spite of the fact that not all stressors include both an anticipatory and a recovery stage, it makes sense to outline a temporal dimension of the impact of stressors. In many cases a stressor first becomes relevant as a remote possibility. Other events provide only limited warning, as when a physician recommends immediate surgery. If the threat actually becomes a reality, the next temporal phase is during the event. If there is no anticipatory phase, the process begins with the event itself. Immediately after a stressful event there is often either shock or relief, and then a recovery period that might last for the rest of the person's life. There is currently a great deal of attention being paid to the delayed stress response, in which the impact of the trauna remains dormant for months, years, or even decades. Also, there is evidence for chronic stress reactions that are not delayed (Burgess and Holmstrom, 1979 ). Both the types of stressors and the wide range of the tanporal dimension seem to introduce an overwhelming complexity to the area of stress and coping. In the present model, however, the understanding of coping rests on I ' » ' 41f Mni il9^ V^ma i^kS" i-¥iii ^Tl fx;-" i 3 flwi -ik»jr- IKf rf „,|S;. '' “i3^ tfrmt f .t *'»* .;.' HH^S * { 'I®' »giyri>4wliw, ^jfta t >.' *' 'Ifro / «4 C 9 , 4 ,1 .•J. v-.,^.ov,T ,<.t WBfa f-»cj«{VJ '.* rt.'fp<3 »,i^t»a','i'ii^' ' :"• ''/' '. .|•• . -i^'' »/<» iw Zfl't£c;u».i a »hiX^^«;,p4 ^ t M '4 f • ft;. . Vt r L- i (ij^ V 'J I 00 , j#--.. '.-r , H', ^’ •-I ’,-a® ' I t ,, .1 _ • jt, 'f^ '.i^V ' M>ir ' ,. • *MU ;#*¥«^ftto »r(fl ‘ kl' " . ' " .' . V^Vv^'-sT*' '®'v S^''" '^*' '-1 ,,r ' ’ •vaUvtt#* i.#.ifi --Uvi-nfa' ,.<^w 4^^P’«4 ' ' ' „ 'm ySKi • CP t!f»f ' , # ' ' ' • - : -ju .8 ^ u I 'i ‘ <4 t ,I «< ’. i ? :* liftw»(t! ri ,:, iff ‘‘'‘W' ICIiiii 'latn-/ ’»« a'M't-i • 1 -TJjiffVO IK 1 m tJ* !»S- \ ^* 3 two central concepts: approach and avoidance. In its most simple form, this pair of concepts refers to two basic orientations towards stressful information, or two basic modes of coping with stress. Approach and avoidance are simply metaphors for cognitive and enotional activity that is oriented either towards or away from threat. Approach strategies include seeking relevant information, choosing to talk about and think about the stressor and its implications, and actively dealing with feelings related to the stressor. Avoidance strategies include trying not to talk or think about it, avoiding reminders of it, and seeking distractions. A more detailed account of approach and avoidance will be presented below in the context of the historical development of these concepts and in a review of their widespread influence on the study of coping. The Approach-Avoidance Dimension There are three major lines of thinking that have converged in the present understanding of the concepts of approach and avoidance. The first includes the psychoanalytic theories of defense and of "working through," The second two cone from animal psychology, but have been applied to hunan behavior. These are the fight- flight fear responses that emerged from ethology and the approach- avoidance conflict that was an important element of the attempts to integrate learning theory and drive theory. In Freud’s model (1915/1957; A. Freud, 1966), defenses are aimed against internal id contents and related affects. Coping, on the other hand, is aimed at external information, e.g., the fact that someone close to you has died or that you will undergo surgery. While psychoanalytic theory has focused on defending rather than coping, there are nunerous parallels between the two processes. At the heart of the notion of defense is the idea that the id strives for gratification while defenses both inhibit complete .,Pr S^^J.r I* iKJv4_v i s^'Uk*vii9‘ :m htM ' l^- * ^ MIW «S®5A II)'- #fii iijoa« jtnihfU ,^;a ^ % v*rf'4 .' f M‘ ' ‘•'^^' *'^ .'• ' ' Hi'',® »* itWm lit? «4 J »4,;.1scti» »?% 1i«J V -t ti ' lit * .rl^.#l5^,^?n^f >(5n3i,|;il,t' ' - limll LmTi •Oi|!tf'^p vjii. brtu cts ' ' ' ', IM *f .'ll'.i • ’ . - ,<^P’'’v W-' , ' : »l ’ '?/-l. •I'J . -fi: 4 gratification and allow for partial gratification. Complete gratification must be prevented because it would overwhelm or endanger the ego. Rather than dananding gratification, threatening information demands to be integrated into the self-structure . In Horowitz’ (1976) terms, the mind has an active memory which has an "intrinsic tendency towards repetition of representations of contents until .. .completion of cognitive processing" (p*93. italicized in original). In other words, information which is "unacceptable," such as the death of a loved one, is prevented from completing processing, but ranains in active manory, exerting a constant pressure towards processing. As with defenses, coping strategies both prevent complete integration and allow for partial integration of the threatening material. Again, complete integration would result in an overwhelming of the ego, as with emotional flooding (Horowitz, 1976; Shontz, 1975). Since Freud’ s model is based on a hydraulic metaphor, there cannot be complete inhibition of libido; the dam would eventually burst. Similarly, complete avoidance in coping is impossible because of the constant demands of the active menory. The tension between gratification and inhibition of libido leads in Freud’s model to compromises between ego and id. At times, this compromise can be quite unfair, with either a rigid defensive structure or an id running amok. The parallel to these aspects of defense in the coping model is the oscillation between approach and avoidance. Shontz (1975), for example, presents a model of coping with physical disabilities and severe illnesses. In this model there is a cyclical alternation between retreat and encounter, where retreat is the avoidance of thinking about the tranna and its consequences and encounter is a cognitive and emotional approach to the stressor. Shontz describes a pattern of response to disability in which i 6 > ; >1 4!*C^'.-,JT<,r:*'l| *^0S^l^frcf ^,i!# %«f 8 , »v if 96^' • •mm .' • '*•< • i < .01 . < f i’i'lf n^v4 -*; .vt'tjaail:' i* ii n«h.>*'nl f»tih!lbik: rt ^,^•f> f’*»j r- vt/ nff ;j| , bi '" ' ' .'Si f #c- ’ • I' -Ti* > f 5 .* W'^' I ' i ^ ii4 V ~ni Ki Of! ' >* : : '':<;•> ' n it , r I'l ; tv "Ho.' * » . ^ftfii'^ii 11 , i#,i 0 ort.; 1 'V 5 ' ' • ;• , j",/" : ..^, • -.*.•«» •; t.*»v» ^(d\9f ?(V'Ti,'M'‘*' -f ' ' m ''? . ; 'r.!<»iiSJ;'' . : /M' ' .:' ,: • .. '>3 . ' ts" . i j»x i< 'i.vvr, I :a(rr 3' -'1 ., y 9 V. ;.4 rhiu; f to '(tqfi^.l; etai pi;a' ! y/ «i 'lb - Tln^ #Vt#.i*|¥U v«i „_. ., „, -i" • . ''“T .,*.'*c:c.' Iii TO . l(X<>y tiOKlb ,.‘'3|)cbin)(.i »(<« :(tlN&^ ' . ... :, .p,;^, J,.;;|; « ''• • I ij. {• % i , • .xA. •J r„ 5 intense periods of encounter (marked by shock, emotional flooding, and despair) and retreat (a reaction against the consequences of encounter) are gradually replaced by a more or less stable equilibriun. The ideal resolution of this pattern is acknowledgment, in which the threat is safely incorporated into an "integrated self structure" (Shontz, 1975, p. 115). However, if acknowledgement does not occur, the self can either be overwhelmed by the threat (parallel to the unrestrained id) or the person can become fragmented, splitting himself off from his illness (parallel to an overly rigid defense structure) Horowitz (1979) proposes a similar model, in which oscillating periods of denial and intrusions become less intense over time, with an eventual working through of the stressful material. To explain working through, Horowitz makes use of Piaget’s concepts of assimilation and accomodation. That is, the processing of stressful information involves the assimilation of incoming information into existing cognitive structures and the modification of these structures to accomodate to this information. There are basically two motivating principles in Horowitz' model. Denial (characterized by nunbness, removal of material from consciousness, and avoidance of reminders of the stressor) is motivated by the need to protect the ego from the overvhelming power of the stressor. The need to ultimately accomodate to the reality of the stressor motivates the working throi^h process. Why can't denial simply be complete, obviating the need for working through? The answer lies in two negative consequences of denial. The first consequence is the detrimental effect of denial, such as failing to perceive or take advantage of opportunities to escape fron the stressful situation. As noted above, the models of coping and defending are hydraulic models; thus, the second negative consequence of denial is a build-up of / ' ' ^ i I •»’»'* • ?' tin ^ "‘U,’ , Mi-i ;,»iJ mt- v|f,- .4ir ..vm.. a lejil W ibf||4*: I \ii J It li'lH ihik dJl M . "to;vo. ;' , ; A tkrm '^<5 :S *-4 ‘jrwt.-j^ ,ii •Ai!tf.|ti^i^:i^ ' ‘-V M r, ^;fli rs^pT^te i; £/*»« fifr c' M , 1 ' i ' ' _^^ :: Ju lirt %•*/!» ^ €fil}i4iif^^4 4/ f.v,! a <»1 V4 ‘"' ' ’.;&. 'I \ lA/’ s'l?:; I* «'. 8 i" 6 pressure. This build-up becomes a stressor in its own right, because when the pressure becomes too great, the results are intrusions (e.g., nightmares, waves of feelings, and being reninded of the stressor by almost any stimulus) , Intrusions overvhelm the person in much the same way that an unrestrained id overwhelms the ego. This danger of being overwhelmed by complete gratification (of id) or integration (of information) can be further elaborated. Anna Freud (1966) points out three reasons why the ego acts to prevent gratification. Each of these has a parallel in coping with stress. The most primitive reason Freud calls "instinctual anxiety." This type of anxiety refers to the organism’s natural dread of the strength of the instincts. The parallel for coping is that a threat or trauna may simply be too much for a person to handle, a state of affairs easily seen in the "shock" phase of recovery from stressful events. Freud refers to the next reason for controlling the id as "objective anxiety." This type of anxiety occurs when the pleasures of gratification are not worth the external consequences. The classic example of this type of anxiety is fear of castration, in which the young boy feels that if he gratifies his id’s wish to be sole possessor of his mother, he will receive harsh punishment from his father. The stifling of the urge to steal because of the fear of punishment is another example of objective anxiety. In coping, objective anxiety arises fr The final reason for not gratifying the id is the existence of superego 1; ‘ ' 9 ' ' V - '— '— , ; , -i »m. —wr ‘T ' ''' ' ,' , ' » tti,. ' Jf.;W?Bf4 jni^} ' V'w • ' ' ' .-yi- ‘^.» ^ ;'«W'5??4 14;fj:r, 1 t*m\n r*»i- ,*.tl4^': i#'r4t*Ufc;y «. i^4#F "' ' "'' '' f i ‘ r v.t*i f .4Wr* fftfr. * mi Hi:/,'*’ %Z^»f.r!!i .|M^»S^,' ^ ii* r*/4|- » fft.t »'Wap^#^’J I'/ nw'et^-y M, • '• ttrjf '*^^ . ' t* ^<1 i/f" ^-T'tr-¥" > j» « < < -w 9m ^ %i u. i'.t r,» >j-iv ;!.•!» ' # I '.' iS<.i 4 ^ ^ ^ )MHj0 ^ J? VS)^ ••• .* : <^1 #4yN?lvafri...ifft' ;«:i titi% /• fN . '*1^5 .a., ,.A. However, there is an internal set of principles which inhibits integration of threatening material. This set of principles includes such basic concepts as; I do not do bad things; I am intact and invulnerable; the world is a just place; my world has meaning and coherence; and I am in control of my life. If someone kills civilians in Viet Nam, has a severe accident, is raped, has a child with leukemia, or has a psychotic episode, then one or more of these concepts is threatened. To maintain these sel f- statements as accurate, the conflicting information must be prevented fran being incorporated. Another area in which psychoanalytic theory can provide a useful model for the understanding of coping is in the distinction between repression and suppression. While both involve the keeping of libidinal material out of consciousness, repression is out of the awareness of the person, while suppression is an active, conscious process. In coping this distinction can be referred to as denial vs. active avoidance. Though this is a crucially important distinction, it has rarely been made in the literature on coping. As will be seen in the review of the research on the differential effectiveness of approach and avoidant strategies, the failure to make this distinction makes it difficult to understand the relationship between coping and outcome. While both denial and active avoidance are forms of avoidance, in that both are aimed at preventing integration of threatening material, they are quite different. In simplest terms, the difference can be formulated as follows. Denial is characterized by a failure to think about, talk about. ' : 4.13 |»» ft ':'vl 1 •'r'tii t *• IS ^'T.' ,# 4,. -'-IP .!«*•, 1* f IM M-<'’^’ «J ."••tq liui|.-« *1 tJJOK tjSi. ' .' '^' f ] 4 ».»«“• i'l , tfU 1 ' 4 f5" ;j^ iV !'.-> mid 6m} 'i«i Mm i'i-# Mt.’ 'y 2'' ‘‘•' (' . (i'll J " '::^it^iW>li fvamn^i, >t,rna L.T>.*r 4 «i '^'"' '; '7/ , .",:.i;... >' > I*. < *-• * ot'Cyr.; 40t^;u I- i. j.;--'»n (.|)i,Milit in' ,mi •w^. , •,»,o(i*<-'.7 ..iV «^' it* r* %fcltofe .' .-‘S m*/‘, ttif.fb *» >{<'V ••^ ('f ~ '' .1 ' i'- ' ^ «; < 4- ih^j'un :«ir ’ * .'(I* ihU' mi t ^.'H • -1 * •• ^ » ' . -*iw’i!imit .w«44- , /*! .-fig's*-. ’..Ilf,* fm Vi i 'J •!,/ ' ^ *, (irf^»3o 'f • « t *. *' k' • ,» t< C^'ft '41*1 , 8 remember, have feelings about, or seek out more information about the stressor. If asked about not engaging in these behaviors, someone who is denying might say that there is no need to, that the threat or trauna is not really threatening or traumatic. In the most extreme case, the fact of the event itself may be denied. Active avoidance is characterized by trying not to think about, talk about, remember, or be reminded of the stressor. Thus, people using these strategies would acknowledge engaging in active behaviors to keep the information out of awareness, while the efforts in denial are unac kno wl edg ed In general, the primary difference between defending and coping is that the former is aimed at inner material and the latter at outer material. It is important to note, however, that other theorists have made different assunptions about the difference between coping and defending. Haan (1977), for example, tends to see coping as active, positive, and healthy and defending as negative, maladaptive, and pathological. In addition to the direct relationship between psychoanalytic theory and the approach- avoidance dimension, there is an indirect connection as well. In the 1940 's, a field of research that was inspired by psychoanalysis and pioneered by Bruner and Postman becane quite popular. Known as the New Look in perceptual research, its major premise was that perception is an active process, mediated by nunerous personality factors. One of the major findings of this area of research became known as perceptual defense (Bruner & Postman, 1947), in which words with a long reaction time on a word- association task were not recognized as readily as those with a brief delay. The authors assuned that the perceptual deficit was due to the anxiety- arousing nature of the words with delayed reaction times. Some subjects display perceptual vigilance in this paradigm, showing a readiness rather , . iml, .,'«"» as *,1» ' ' ••',. Ml •. :“-iL ry^jSa ".. !Ls:>^_j ' Brmu;y^t..,.fck. -^il«-' fe.iJ- '-vi ' “ JHh.' 'J* 7i^' ‘ ' ‘' .' ' ' ' KE.. - , , ,1 M »»*Tjht ».1:# t(j', ’hf'^i<3^ln^lr^ 'iiTOii, «^vi ; ' ' " w ’ ' jv».. ^y[j|’-'' I ‘'i'' V # - f •V* |3 -1,»0 1 1 < V K ’’’" '' ^'- Jffi .Au-rt:’ Jri ..j>/v.j,;« i«oLo- j« 7M. ^ < .'.•v»i*'Tlii3 *ijn«, >'Vi.4 '^4 ^ ' tV n '1»4iK' „ 4iUlWi©'».i0!b !^'>li5/^'|*i'(3(iC>%;';f:(.®^ t> n\ii. * " • ’ ; ,.'Y i ,. ' - v'ii*... :'y/r) :.-.-j ^ fhjr.iit i ' ‘V iSHHdiirf'/hq * . L* -m At* rJt* . ;»»» i»fr 'i j r 7 j ; 1 ; .-juj ^-3. ' ,*v tVluwloy, • -vcf '/'4»nlqnii)jtr.. n«w - t //j’fJi *1,. *'jf i«j' ' Uriy '»‘w sy ' ’ -i 'i. .UM, -ti.f »•.. •li-j, > . -> u iw b- fWiw «:i .•’...'‘D •. ,iJ . Mijw -sen1.l.vt.^ i> * iw itui' '. «U' ,' ": .:. ''.JE \ n«IK«Y , rtf'. ‘•‘1.. •• M 'I .'.'?r^ !'a vft 9 than a reluctance to perceive threatening stimuli (Erdelyi, 1974). As will be seen below, the perceptual defense/ perceptual vigilance distinction was the first in a long series of formulations of the approach-avoidance dimension. The other major historical sources of the approach-avoidance concept come from quite different schools than psychoanalysis. The fight- flight response has more of a metaphorical relationship to approach-avoidance than a direct theoretical one. When faced with an external danger, many animals have the choice of either fighting or fleeing. Which response is used frequently depends upon the distance of the organism fran the threat. That is, if the threat is far enough away, it is most adaptive to attempt to flee; if the danger is near, it is most adaptive to fight. These motor activities are directly analagous to the cognitive/ emotional processes of approach and avoidance. In fact, people commonly use motoric language to describe approach and avoidance styles of coping. Some examples are: By drinking you are just running away from the problem; I'm not going to let this illness get me, I'm going to fight back; and It's always better to face problems squarely. The motor aspect of hunan approach-avoidance is not always merely metaphorical. For example, going to the doctor when one has a symptom requires a literal approach to a potential source of stressful information. Similarly, crossing the street to avoid seeing someone is a literal flight from a stressful situation. While avoidance and flight are quite similar, approach and fighting are more distantly related. For hunans, in dealing with stressful information, aggression is typically not a viable response (though it is not unknown, as seen by the ancient custom of kings killing the bearers of bad news). Consider the following pair of situations. In one, someone comes after you with a knife. In the other, a surgeon tells you that i * 'i? . : -f»t J,M iMin' * *i|*i‘ ' f li^nti - 'ar'j . -^a^inith i04 i * .. «rra: u-1-i) )l: ' .*4» »v*f( .1 , r cJ ,,, * .' I ’ f j , |ji/r4 - j;(' ' ' '" ^ :' '€'' ' V, . ., '• P* / ;. , , s’lALOi 3til’4oi “^fc- vti. 'M ^ IV ii m:\j-5 Uf aj;(H 4^i x^j jffi .•/ I. 'toPJi/'t'] .>J' W :S(»r^d a , .*'f 'ifsfo, ./rsip ..«»*.; *,• « Ui'^.if- P 0 X 6, .tufa ’If. »> Jt\. 1 ' • .•?lw«» snr» % ‘ ' *^'J ', lu H* t^it.SU MU.'i ‘’t'Oi , lvi.li>,i(S:'4:ii'l' ,, , ’ lA t^r i 4' to «Wh#^;a . ?^T4fW -l.iflP-U J»i^' i‘tt\ 10 you need an operation, VHiile avoidance is a possible alternative in both cases, aggression is only appropriate in the assault. In both cases, however, non-aggressive approach is an appropriate response. In the surgical situation, for example, going through with the surgery in spite of its being frightening could have tremendous survival value. In each example there are reasons for approaching and reasons for avoiding, resulting in a conflict, Neal Miller (1959) has made an extensive study of the approach-avoidance conflict in animals, Hiis type of conflict occurs when the same goal both attracts and repels the organism. The paradigm for studying this conflict is to combine a desirable outcome (e.g., being fed) with an undesirable outcome (e.g., being shocked). The animals respond with an oscillating movenent, alternating between approach and avoidance of the goal. Miller explained this phenomenon by postulating two intersecting gradients, with the slope of the avoidance gradient steeper than that of approach. That is, the tendency to avoid is very strong near the goal, and very weak away fr«n the goal, while the tendency to approach is fairly strong near the goal and only slightly weaker at a distance. The result is that at a distance, approach is stronger and the animal approaches the goal; near the goal, avoidance is stronger and the animal retreats. The overall movement is thus an oscillation around a midpoint. As with the fight- flight model, the application of the approach- avoidance conflict to hunan coping behavior is sometimes motoric, but more often cognitive and onotional . In Horowitz' (1976, 1979) model, for example, the goal could be seen as processing the threatening or unacceptable information. The negative outcome is CTiotional flooding; the positive outcome is working- thro ugh and a release of the tension exerted by the active monory. The denial- intrusion oscillations are thus the mental parallels to ^ j ’ ,f‘ '^-1 ' fil *Jj t*>l j'^ '' •TJf tfi r: .^u^i<>ra^.•i^4.^i(lU%•^^'« ‘'s»W >c- v lnj3ifi , , i’ • -wf ru« » { i)', ntt. { 6 fQm': j' .r :• t .f.1 I'l. c lYy , V* iig Pi# If-.. t/<«' -*nj ,il J^nT ,'flb«(iriq4«:.4^ • '.'. ' • “'.• ' r" •'•A. I .• V ' \ ^'-'K' 11 e'li. , Uny nrii '};• - ',% '^" , r.'im •Mt?C UlC !'-">, -I f' ,J, «#• 4J*JrtA.t«/b - st»- ^ertj. i:;54;ffl *_,," Wv .1 **,»«,•) »•,; .30 ‘Kf # « ii.‘3 , f.4»ii)y^* .•' ,;,, .S3'4ii> ^'^ «k.* •' i /W»v*4f 11 the rat’ 3 original motor oscillations. To press the parallel further, the more processing is done, the greater the motivation to deny. When processing is inhibited, the need to deny decreases and processing rescmes. Meanwhile, the motivation to process the material remains fairly constant. Thus, the avoidant gradient is steeper than the approach gradient, as in Miller’s work. Both the approach- avoidance conflict and the fight- flight response are seen as universal responses to certain situations. The psychoanalytic theory of defenses, however, places an emphasis on individual differences. Which model does coping follow? While not mutually exclusive, various recent formulations of coping have taken various stands on the issue of individual differences vs. a general response syndrome. Before a discussion of this issue of traits vs. situational consistency, the contemporary theoretical approaches to coping will be briefly reviewed. Theories of Coping Many formulations of coping suggest an approach-avoidance model. This dimension, which has appeared under a variety of names, clearly emerges as the central theme in the field. The specific formulations which have been presented using this dimension have been reviewed by Mullen and Suls (1982) and Cohen and Roth (1984). Table 1 (pp. 12-13) displays in outline form several of these formulations and briefly describes how the general ideas of approach and avoidance were formulated and measured. The material in the table helps convey how much overlap there has been among various theoretical approaches to coping, and also the wide scope of the approach-avoidance dimension. There are, of course, models of coping which do not «nphasize the approach- avoidance dimension. In some models, for example, either control or perceived control is seen as leading to better adjustment and outccmie than ;r»' t '^1 •if . « Jfti'- ' ? 'i' 'X ’^( ' 4% ' ' . *^'1 Iffw rwi .. Ti.»MSiLlt^ i..irfli>*fn 'r f . Jf| #• W'l '' ‘ ' ' ' ' , , 4 9 *y . vnf 0Umf m o , ' ' , •'« 3i ' '.•’ ! ,!- t'- . t >» .» I wr, f H i i'lt, , j-^ *• 4# ^ ifi i g ;>, :'((f ^|:Tei_:y 7 •••ii>‘» '. .’lAv ,.4VAfl**, »; vn^M»5ii?v\kkr • iri ^,I •. «,. ft 4 *t. . >'iU • .. • -V.1 ' ? V* vft.'V . hsuwfd'tv^if '' ’ . « * . • Iff;* r.m !}^, ..loVD -4:<;?k?o fi^qrf '.la' ' ' ' v'', ' f * ’'•^• “:. ** V .. !»,». »C. ,»» 'Hv |< a"*j| l4 V ••Itaj.liift.. '.'It ' * ; . , ’ 0 C‘: '* ;?,^,l ‘ :'0 %> -, ', ... • . .^. Jmm pMf:f V •ir>v4 TJ»v tfivf'U' tffjf! * ' -rfH' -tfSi>ui;.*u|ri(i|k »d;> . : iji f;^;,, 5 ^ ^ ^ *• * 12 Table Simnary 1 of Approach-Avoi dance Cc/ping rr M > o 2 :? e-.ILS* g'S*!’ eg’ 5 qa «i?« B-S?8i"S?S'grirtB'io a 3 R, rrrt 0«(pB'^* rrn iac.an 3 E* 2} 2 5 •irrQ (inco. (-••CDCDa 9QH a rr a.” ~c ^ rrrt^g^ bh*-rt jaao adD* rri--f--3 (^coMn^Ba § Foniiilationfl 3 a ^‘ < g(#fBfl)BH-r» n g a o a rt tf. 3 U a ‘Q S-S " 3 B a H« a a fT II S § sfa a as* a »-* a [T fS •—aa I n a a 5’^ § rr rr 90 rr a a g ai-^a:C >->aBO {? 5^ rr arr PT 3. 5’ p i m0 »— 1 rr S' rr s I— I •s- rr • 13 rs \n O 5 {L Sunnary Soto !? 2 *^3 3 I 9 of f a S 5- S rr «<« r Approach-Avoidance Si- I »-* S ft e» i.5 CO3 VO rr 0^ •• r-* N s Coping to rr t> " c-’-g* § ?8 f »— S-g-Sf • I—* 2 S a. IS I 2 . tt 3 E to ®0 totorhH«H »5 i CD Cl. < n 0^ S S- O 3 ^ S' R* 0 3 to rr ' S B d-qS M. 5 -S- 4 1 2 hs Forrailationa ri o n c to o D \ rr to to to • •i to ' 3 rr Cl. * 5 cr »-*• -• o Q D to R.0 i 3 rr rr> rr to to rr 300 _ »i rr to to C d rr to D ^ S rr to n to to • n illl*— ° 0- rTl t-> '^C'S-'S r.' g- s-^r B. n * o S-"« g rr H^ i-h ^ to a I d f6 Q < H; -3 r-| M. rt . CB- to H«r| o S£| onto rh >-•- to to 8 S' o “ c. 8 2 6 to to fT Q 3 D to K E" nll^ •o 0-0 m‘ B 2’8 to M O < 5 g'sa ? 5-8 2 P *n JL^ s H-OQ g.'^ is 8 S. S 3 S 8 5. C--0 -^ 8 2 O II 5 * S-g a a rr O < 3 m i->. (1. u il:i.'3 rt V to o* «! ^ •— H • IV * ®‘g c g i )»• O O CB n f- o" ® 5 Hi l-h Hi *3 o o " »-n rt iS 3 15 •o -o 00 2K r*‘ K* rr 2 ^ ig^|l § 8 g' rr o QO I tj- rh to ^ O O t;- --li 3 . B rr rti e * n rr IV S .2 B-Q ff si T 5-B- C to STB S 8 §1 1— to 1— 8 m fi- to IV < ^ s « S ^ t* pr is i'S r-r* r~*k^. I' 3.* 2 r^» Q to CO 5 ^ i wrt to I-h n 8 G. 1; rr r*» rtr to •B ?c “•8 H* rn O r- ra rr a R- c* •B I to to 14 lack of control (Wortman & Brehm, 1975; Miller, 1979; Silver & Wortman, 1980; Seligman, Maier, & Solcmon, 1971). This control can result from a sense of personal efficacy and mastery (Bandura, 1982) or religious resignation (Friedman, Chodoff, Mason, & Hamburg, 1977; Chodoff, Friedman, & Hamburg, 1964) . Though not explicitly related to approach and avoidance, the concept of control has often been seen as a mediating variable in the effect of approach and avoidant strategies on outccwne. For instance. Miller (1980) argues that blunting (avoidance) is better than monitoring (approach) if the situation is uncontrollable, while monitoring is better if there is potential control. The implication here is that approach allows one to take advantage of opportunities for control. Cohen and Lazarus (1973) t however, point out a potential hazard of approach in relation to control. In their study of a surgery population, vigilant subjects had a more complicated recovery than avoiders. They theorized that the approachers sufferred because they knew too much; they started out with a high level of perceived control, but then learned that the situation was out of their control. This hypothesis must remain highly speculative, however, since the researchers did not directly measure perceived control. Furthermore, other researchers have stated that surgery is a stressor that is not inherently uncontrollable. Langer, Janis, and Wolfer (1975), for example, found that patients taught to avoid (by being taught to look on the bright side) recovered better than those forced to approach (by being given large quantities of information about the surgery) . They concluded that the avoidance instructions increased the patients’ control over their situation, because it gave them a concrete method of mastering their anxiety. The vigilance manipulation was thought to decrease control because it offered no means of dealing with the incoming information. T9. .s*P‘ "1 't»tM , ut'0^S’»y 4 ie.tix.mu-n ' m> *i, “ ','t ^1 ‘ '' '' .'t"#' - ^ ,io->4.rr> fi. i*',Tii/'|^::'ii" f^.r^i|4'''-i'ii: 1o rwiS<^m>.'v, (>d yt'iW'.^ifftiflW, • . . .» '.. M i«c -i>3 : K- -y-.f-.l >• e»uiav*rjr.i!»i^''^j(i.t>_ i \( r,^t/ Ti,« , t6 (*ci*' 4 jy^t »vM • «*<[“• -tArt rf» . j sNtx, '*i *adJ be>4«. .MMrt j #* • • 1 i ->>»' J . 1|« 1 leij y;. |;.fifff . KM *l} oif » t..1 ' ' u. ” Dll -Id maUh* rtmrt'f 1 ' m • k u»|A Tim o 1 « t '"'Uf 'd4,i itx:, li *1.0 3&, lortio* #/u-Tn4oO:# in...,.* .' ^ I »l> .w Jiiu ' wrf * 'O. . ; itteonl |l.,#ivif 1 TH 10 ^ . 15 Two important categories cut across all formulations of coping. These are consistency of coping strategies over time and relative effectiveness of different coping strategies. The following two sections address these issues Consistency The issue of consistency can be formulated in various ways. It is important to note that while many researchers assjne that coping strategies are either consistent over time (Byrne, 1964; Janis, 1982) or situationally specific (Lazarus, 1980), there have been very few attonpts to docunent either position. The most extreme trait view of consistency is that people are either approachers or avoiders. Several research instr uiients , such as the repression-sensitization scale (Byrne, 1964; Bell & Byrne, 1978), have been developed to tap this supposed individual difference. Unfortunately, such instrunents simply assume that they are measuring traits, and rarely test this hypothesis. In fact, the repression- sensitization scale was found to have a correlation with manifest anxiety as high as its test-retest reliability (Bell & Byrne, 1978). In two recent studies from our laboratory, a high degree of consistency over time was found in subjects’ response to abortion (Cohen & Roth, 1984) and cancer (Manuel & Roth, 1984). However, while scores on both the approach measures and the avoidance measures were highly consistent, they were not mutually exclusive. That is, people could not simply be characterized as either approachers or avoiders, because nearly all subjects used sane strat^ies from each category. Further support for the idea of consistent individual differences between people on the approach-avoidance dimension comes from work by Averill and Rosenn (1972). These authors found a sharp difference between groups in ; ; 'I a it ;.S-. W'. • lo 'tf •' ()'- i' ‘-I . J * §VJ Im • ., / -'z I '..•b’>i V' AU . ' i'>' pi > 0 , ' ' -to'V : . 1 *1 ijti . y#'* HJ»g » ' r. ^ •. *.i,., 1,t:ik <^4»9' J8*lt V' i *rfi , ® ' /51' ' .’4 ; »t< ’: a 10 ' I . I ^ "Mf}!-^ ' ' '.. A ' XK , '' * -'''’ V V; ' 4v'^,. , ' ’’ ' • '^'* ^ . . . -V , & mma *v.,i ,«vi>V/ 'iniy^l 4 - , "’ ' . • ‘ -. V^^v« ;f\t V i»’ :tft • ~ I • •• '•^•.4 ' •> , Ai V. \ I i--' . j.. . -^.^AE3iti. ,» . n i B.» Biwvl iM< ^XdOfc- '%r.ia-5t t ; 1 Mi;'*! fftl I ii , .-• rt.'-’j'i .j^-r-ou » V iilw * a®''” IV i*itj *^ 'vx;|ii.ly, n-,;-v l.JU.'OO I. ". .1 rtf ' ,.«?' »90 fy^ i u 14 y'fi'fen * ' ^ d/„ 16 an anticipation of shock experiment. Subjects were allowed to listen for a warning signal or listen to music during the interval between shocks. In one condition, the subjects could easily escape shock after hearing the signal; in the other condition there was no escape. In both conditions there were vigilant subjects, who primarily listened for the warning, and nonvigilant subjects, who primarily listened to music. Thus even in situations which might be seen to clearly demand one strategy, some people continued to use another. Though there has been no direct evidence, it seems likely that at least some people have strong preferences for specific styles of coping, independent of the situation. In other words, as Bern and Allen (197M) have pointed out in relation to other personality variables, consistency does not have to be identical across all people; a variable can be more consistent in some people than in others. Even the most internally consistent individuals, however, respond to situational demands when these are extreme. The formulation of consistency in terms of a universal pattern of response to stress has been based on such extreme situations. This type of pattern has been proposed for specific stressors, such as the various stages of facing death (Kubler-Ross, 1970), or stages of rape recovery (Burgess & Kolmstrom, 197^» 1979). The idea of a universal pattern of response has also been presented in the form of a general response syndrome. For example, Horowitz (1976, 1979) proposes a universal sequence of stages including shock, oscillations of intrusions and denial, and working through. His model, which has been discussed in detail above, has been studied using a mixed-stress group (Horowitz, Wilner, & Alvarez, 1979), bereaved psychotherapy patients, and bereaved nonpatients (Zilberg, Weiss, & Horowitz, 1982). Further, a study of abortion patients using Horowitz’ scale found a very strong similarity in pattern of response f ' -i^";td#|(S’ ^.T fi r-,iL^'^'^ - m ” '. • , "AS 1 /- V' ,# ' [9 ^irf,i»yigwBr r-:,. - ' ••.•'. - -a ‘JilW"-.. -,.' * .*^ SaSr • -Ti» . 'i V r 4 tii >fi^' %ttt b tl^rnl^ ;.-jA;iito fir: iri^':|d.-;!» .. ., \‘^M! v«tr'- i>,iv ">' rr.§. Fi-W mi .. .' ' . ;^yj0"' ;\ ; m§: • !»'£iimi3 IW ..Po»t#ilit .'3 .. v jftii'fe .‘ .i 1-0- a'0£t s iw tk*i4i‘. -,ii^t: * , ,:VV,^: . .^ m a.^,f tfj9i^.ti 1I>1 yi T ., ilweoqb'ii'i' XW’'” b jftSi.vVj'— ' " ' ' " ' . .. 1 ^‘,' ' I t'*-. So' ^ L'i 'tiX t » w tsV " t Tij flnioS’ ‘mil nt «»3'J ;OeXo «s ' f • r ,1 ''>T^ . ,'V7^i>. .u. swa,£j! «iftit Ia#^Onji 5^5^..* m V I -itM tu , r. I « X'^'% 1 f r«» , ,brt« \ ‘ ' ,i • f > ‘ c j '. j rtxii >^.u I'ii I ^'&ti.4fot..*i* 'i -1“ i * -1!^ «^Jj[ • nS: ;-i.v»MKit.'i '®^J' vA'S . 17 across the populations of abortion subjects and bereaved patients and non- patients (Cohen & Roth, 1984). Cancer patients, however, were found to report far less intrusions than either abortion subjects or bereaved subjects (Manuel & Roth, 1984). The existence of a general stress response does not rule out individual differences. Descriptions of ’’universal" responses always refer to the average or prototypic case, rather than to every person. For example, in the stage formulations described above there can be tremendous individual variation in intensity, duration, and relative importance of the various stages The idea of situational specificity in coping has not been adequately researched. That is, there have been no studies of coping in the same people across different situations. On a theoretical level, it has been argued that controllable situations should trigger approach strategies, while uncontrollable situations should trigger avoidance strategies (Miller, 1980). Averill and Rosenn’ s (1972) dichotic listening experiment, however, suggests that not all people respond with the most theoretically predictable response. One explanation of the failure of controllability of the situation to predict response is that people may be differentially attentive to cues in the enviroranent related to controllability. While a salient factor to sane, to others it may be secondary to internal affective cues or some other factor. In general, the question of consistency of coping must remain an open one, though it is clear that both individi^l differences and situational variables have an impact on copir*g response. Coping Effectiveness Whether or not specific situations result in different coping strategies, there is evidence that certain strategies are more effective in tm ?5^' '= B' +i;iTil m l-.^J i^lu > ’Q't m 13.i 'Jff’Jwn Mf w ^ ' ' >'i. ' T%' v". ;: "', ' 'V'fr,. ,, ^;'*';.r .''i.;'' ,.^ >» y u ,»k-«i«ii »ti -!0'j Vj|^ 'UiA'S!®''!'*' t r PfviV^h.i^.n^^^it; fkd ^ ifll'llfe^fe'* «- •'. •*« . u.-*d i. t .1#*0 d«W ^yl' ' '' ' ' - '''J^"'. C’%, vi! <*'iTSs i-e.- • ‘ih'i nt si^u,qno >0^r.'•^A,kJ^> "ort in'd4:’^M J-^I ’j»tov-^ ackvti ran il, .•?••: , < fjilr r ii?4 ymf 5»«»;ii»"i,te *r. »- *yr* , *»%%^C5H •'> I ~"^^y '*'1' ‘ i^; V • 1. “ *Nr •C..ji5r; i>*Ms3 ^1A^u^/'^m^ m ,: r. •‘^ ^ '^ •" -r;;-' i i --I •- ' /rte • iS.,lC-; * .? ,M ^ ,\ w >«'; .,(> ;•’>*•'•. V ^-l VA, ’*:' .. ksi®'. ' i i * ;>1 ««tll '"d\4k 18 certain situations. For example, one relevant factor is the time dimension. Mullen & Suls (1982) fotcid a consistent pattern across a large nixnber of studies, namely that rejection (avoidant) strategies were found to be effective when outcome measures were immediate or short-term, while attention (approach) strategies were found to be more effective when the outcone measures were long term. Unfortunately, none of the studies reviewed measured short-term and long-term effects with the same subjects. Psychoanalytic theory provides a developmental analogue to the short-term effectiveness of denial and the long-term effectiveness of approach. Anna Freud (1966) notes that while denial is pathological in adults, in children it is both conmon and healthy. Thus, in both a developmental and a recovery time scale, denial gives way to approach as the effective mechanism of coping. Another relevant factor in effectiveness is control. That is, while controllability may not always result in approach, those people who do respond with approach in controllable situations will be more likely to take effective action. For example, Katz, Weiner, Gallagher, and Heilman (1977) foizid that avoiders delayed seeking diagnostic evaluations for breast cancer, and thus reduced their chances of effective intervention if they did indeed have cancer. These authors proceeded to make an argunent which is unfortunately quite valid, namely that ”an effective defense is not necessarily a healthy, reality-oriented one" (p.240). In a similar situation, Staudenmeyer , Kinsman, Dirks, Spector, and Wangaard (1979) foiJid that asthmatics who approached at the onset of an attack had fewer serious attacks than those who avoided. Lazarus (1983) concludes from these and related studies that coping effectiveness depends on the controllability of the situation. Illnesses such as asthma, diabetes. ; m ..f ,,'r^ ' 0^ -*11®' < -y-f * wB% ;Mfc4 »it'l |i. i' I« -.'f'-W ,«Ml3r* *'t-j4ft, '<•.?' " -:?4ihi -.1 >' J«|' > »w H'4* <.14 (i> ^oJ>« P-i“.; ,*„« » * (« i J <( t -^pr >U /, ,: " Jjc.'i;! ® (A *5 K*» < U>» .' '.i| f--' *V«t» O' '(tf •i^ » .- • - tr.> •? ; # ia:4Pi.'' '<• r a ^L ,m ,t* ,T<*^ . rsv- * “• *w *fct<'-K] -»r '<1? •i,.|ij»jiw*ii«f^i*j .: - '* ' * '»,* iiW '.' Hw*' wi-'‘ /''"' ' •• ' ^ 'M • . i •»•». . t,*-f ia©-r#|flt»..^5*r% '«>: • ', -'U; I. ' % f :• *: V’i .'X.T V.(( t Ar.iH5» ferlilT., l.yl ^V> r II .-ir I M -irr If r ,, 19 and cancer require vigilance for proper diagnosis or treatment. With other illnesses, such as paralysis, there is no advantage of approach, while avoidance serves to reduce anxiety and depression. The differential effectiveness of denial fits well with Lazarus’ (1983, 1980) distinction between problem- focused and emotion- foe used coping. For Lazarus, problem- focused denial is maladaptive (unless there is nothing to be done anyway). Emotion- foe used denial, on the other hand, serves to keep morale up and distress down. The fit between coping style and certain demands of the situation is also a relevant factor in effectiveness. This fit can be seen as an interaction between individual preferences and situational variables. An experiment by Miller and Mangan (1983) underscores this interaction. They compared surgery patients who preferred to avoid stressful information with those who tended to seek it out, using two treatment conditions: a high amount of pre- surgical information and a low amount. Subjects whose treatment condition was consistent with their preferred strategy had less distress than those with a discrepancy between the two. Like pre-surgical information, the counseling that people receive before and after stressful events can have a direct impact on coping. For example, Cohen and Roth (1984) found that abortion patients who used approach strategies decreased in anxiety over the time from five hours pre-surgery to immediately post-surgery. Those patients #io did not use approach strategies did not decrease significantly in anxiety. One possible reason for this finding is that the counseling at the abortion clinic where the study was conducted was strongly geared towards approach. That is, the counselors made sure that the patients had made a careful decision about terminating their pregnancy and educated th«n about pregnancy, abortion, and birth control. ft ’ ' ,.Vf44M»'v** J i K' ‘t«‘‘ , ,,1«4j3aJU* -;;,f.J|'^r::, , . ' '•' '- ' _ ' ' ' t- ’Ss'ii/ itW'tWHJ tof;. '' #?• ' ' ’m tlUV f)W >'I©’H >4B 'j f-!rtf'' V-' t " ^ > 1 i >w. 4il',,5 •t.'t / . i'„t . 1 g -ft V ' : ' Hv, ' Z .i J • i U «£lf J • = ti ) "tt ' )' ',' •» * ’i.-.ji t •«©»< . '»/ » Hs'j ' rx. (IC -J »«'i w| J £| ,,"£i I - no'Tnii;'' r fj,- rj T'(V p ' Wt'-.*' j-i.tn ^•r.*iTi}<3© “tu 4 ^)iiT' ,‘VV ' 'ivj «(/j; •,, jf^, r4lf.f , y i“»f' f «jh<> 4 1 .;t #- .: 1 tiwtt t - . fi.'" twftf 1^14 ; J ^ 20 Thu3 , the approachers’ decrease in anxiety may have been due to a consistency between their preferred style and the counseling methods of the clinic. This hypothesis renains untested, however, because of the difficulty of finding abortion clinics which operate on an avoidant philosophy. Another finding of the abortion study was that avoid ers were more and depressed anxious than non- avoid er s , both prior to the abortion procedure and in the recovery room. This pattern fails to fit with Mullen and Sul s' (1982) finding that avoidant strategies are effective in the short run. One explanation for this discrepancy may simply be that the "short-term" for abortion patients is immediately after discovering that they are pregnant, rather than inmediately after they enter the clinic or inmediately after the procedure. Another possible explanation lies in the difference in formulating coping styles. While Mullen and Suls' review reflected the trend in the literature to dichotomize subjects into either approachers or avoiders, it was clear from the abortion study data that many subjects used both types of strategies. Instead of one dimension, therefore, Cohen and Roth (1984) formulated approach and avoidance as two separate dimensions. When independent measures of approach and avoidance were used, subjects were found to score high on both, high on one and low on the other, or low on both. In short, a level of analysis is available with this formulation that is not available with a simple uni-dimensional model. The separation of approach and avoidance into two dimensions promises to provide the basis for a clearer understanding of the impact of coping style on outcome. For example, Manuel and Roth (1984), in a study of coping with cancer, found that both approach and avoidance strategies were effective in reducing distress. These findings would have been overlooked if approachers were simply canpared with avoiders. In another cancer study, Greer, Morris, i 4 A ^A * ? t ^ ^'TTiT' ' ‘ ' 0^*1 i‘9 ^u. 5*«ta"S '^0j '«! ifh -H : * 'tt'm • A'tW -..-if' i> f. WMi'v Mfii^-J^'M' ' '". . - li •flt 8*4»rKf- t*' rt.^ r- '• •^v * u^Ujm ti4 *#^ ^ _ ’' ' ' ' " " ' ' .' . /® 'ji 'li. H/t> ..; ; »'f«.-te »/li fli, j-' t , j'm« ^ , '..A ,rt Wv«%r”ijii virt^,; rt|/,,iijijll^;n. '. %'i ''I visit ' '" T' ' ^'T^i*A*,' ' tl*''f' ‘t g.|jj ' «» &•»&»• • » t -.,f)^ J ttti fc-.-Jiifb , V ,<5(U • »f.MVi .. . •!& r 4 o^'y !ft-i£i-, )» 0» W# ;t>^ :mmJtm, f rf;^)»:f> » Ti-w fcs*t<*w« »‘W.: ._ , ' ' ' ••' iM’”^'-'- '' crS -V <5<» »»*& 10/- (it| jf»iti y«of iif4|uwi'!>'^' 'feif(.;f' ‘^. - ', ' m- : .. ,ig,.,~ R/™^' v.-fl --i *ir*'nT 7»4 4«<''lt»,tt<»A.l>. ' ’ 1 iS*'. '-.i.] ; iWikik. rriJ* ll^J« V' '»©' ..' . j ™'*rm ->• . liT»c|l' , f'M' '#1» bsyiT^' . . 21 and Pettingale (1979) found that both denial and a fighting spirit were associated with fewer recurrences and longer survival. Greer et al contrasted both of these effective responses with stoic acceptance, helplessness, and hopelessness. These latter responses, reflecting the failure to use either approach or avoidance, predicted a very poor pattern of recovery. In research on cancer in which avoidance is pitted against approach, approach is consistently discovered to be associated with better outccrne (Achte & Vaukhonen, 1971; Achterberg, Matthews, & Simonton, 1977; Blimberg, West, & Ellis, 1954; Derogatis, Abeloff, & Milesartos, 1979; Rogentine, et al., 1979). As implied above, these studies leave unanswered the questions of whether approach is better than non-approach or avoidance is better than non- avoid ance The work of Pennebaker and his colleagues (Pennebaker & O'Heeron, 1984; Pennebaker & Hoover, in press) adds an interesting twist to the question of coping effectiveness. Pennebaker has found that confiding in others after a traunatic event lowers the rate of occurence of a wide range of health problems. This finding is consistent across different traunatic populations, including bereaved spouses and incest victims. Confiding, which is clearly an aspect of approach, was also fouid to be inversely correlated with runinating. Runinating, as opposed to fruitful thinking through of a trauna, is thus not an aspect of approach, and is associated with more health problems rather than less. There is obviously no clear-cut answer to the question of the differential effectiveness of coping styles. Although the research findirgs are complex, it seems clear that both approach and avoidance have costs and benefits. The potential benefits of approach are being able to notice and f ^ '1»l f ,'ie ' .Im ’i#'*iaj( ,iii( vav’‘uit' -t**^ ' ' ' ' 1^4" 1*. 0 ^ y uW 'Si"*: '''v5l • » .-i *.'^|.t4ra '1^)*i# «4\ ;’“!•; r .vfM*iua- .,, , i4 ty " V ' .' V'..J A'Jq’Iii; ’» . ... 5i.T'.>t^ ,.' ' ' .' "• «' • •••“j ' . ;- >%-s- •: tji'lfl*##'-, .nii ' ' • '.^'' '1‘, :, m '• 1*1 ;:f«-3 III ^iA4bMvi» 'i<3 Wr>fl«'T<|s5'fl-irt,'p«: ) ,*,“» ,^>''->&H''i (IttrtijVs .j. A 8 <1 .%i • IM •* jv .’ I . .lo: r-.*“« .i<4 .: ',4St? ri:^ia4U 4 xrvfc'if.-tt f '. 1 i/ p t- ' iSftAtS :‘S'i It*-' i '' ,, Ji*’) . hi'IAf^;:) Ai.f ) “' ' - t ?«* •'ff'*., «ff.f. al /loiwBfjaj' K ••;’ , f'vif Ci'r. »f;>.,,<5fc,j^ia'«y i.'fe, f i ‘» i JOfl > ! take advantage of opportunities for appropriate action, ventilation of affect, and assimilation and integration of the stressful information. The potential costs of approach are high anxiety and the physical and emotional drain of chronic hyperv igilance . The potential benefits of avoidance are lowered anxiety and increased hope and courage. The potential costs of avoidance are missing opportunities to act appropriately; failing to notice relevant changes in the situation; a build-up of tension, possibly resulting in intrusions; a great expenditure of psychic energy to keep the material out of awareness; emotional nimbness; and disruptive behaviors designed to keep away from reminders of the stressor (such as phobias). Whether or not these potential benefits and costs are realized depends on the characteristics of the stressor and the characteristics of the person. For example, in uncontrollable situations there may not be such a clear benefit of approaching. An example of the importance of individual difference is that an effective denier might not pay any severe costs for denying. Though it seems from the list above that the costs are mostly on the avoidance side while the benefits are with approach, it is clear that in extremely stressful situations it is impossible to just approach; the incoming information is too overwhelming. Thus it seons that both approach and avoidance are necessary for effective coping. A Model of Coping The merging of approach and avoidance into one dimension, mentioned above, has been one source of confusion in the coping literature. Another source of confusion has been the failure to distinguish between denial and avoidance. Basically, denial is an unconscious walling off of the material; avoidance is a conscious attempt to keep the material out of consciousness. In stylized form, avoidance can be characterized as trying not to talk about. ' !• , % mm .'lo#»l '*' Mk'h i^l to' «M£ 44liiy*iv' i: (pn'w^ Wj'jSa yl*; fsa.4, 1 '*A^<:^ * ' II if'-Tr'lJtvy^-'il «U ,;?<^‘JCwUij##'^ vMfl I jWIX’iUJWifc '«Sk ^,. „ ^'<5d4iW 'Vit •• ’ ' ,- V r j'i;’' ' ' IS'W Ul..‘0»4ni a^^.r '^cin ^Q;‘if •mM tr r^’l»^*'>ilt^<'tmt^f'nmi.i^3 I'MI $ 'S», '' : ':'^'i5 ? V /w»!^' 'lol' >;« 9fi; 1^'^ I!i, 4.1 riP 'tlSA<3%.pl$ '^li'C^ ht ^t'a'**t3J c.:f ii •^.1 it "‘Afh S?. ' - ' ' 6#V«Il ^ ’» i -t^aiL ' t I*iii»i? -''.iwU;* ^'i'i.v^Si'feJi |i^Sl ,;5^^ VI,* , r'sy 23 think about, remember, or find out more about the stressor. Denial can be characterized as not thinking about, talking about, remembering, or finding out more about the stressor. Referring back to Table 1 (page 12), it is clear that some formulations of avoidance have combined elements of denial and elements of active avoidance; others have focused on one or the other. The problem with confoinding these two types of avoidant behavior is that they might have very different implications for outcome. Because denial is more radical than avoidance, it might be expected to be associated with poorer outcome. Also, avoidance can be seen to give the person a sense of control and mastery (e.g., Danger et al., 1975), while denial does not provide this sense of control. This hypothesis renains speculative, however, since there has not been a study measuring both denial and avoidance with different instrunents on the same subjects. The distinction in the present model between denial and active avoidance is paralleled by a distinction between active approach and intrusions. While most of the approach formulations listed in Table 1 refer to active approach (characterized in a stylized way by trying to think about, talk about, remoTiber, deal with feelings about, and find out more about the stressor), Horowitz’ (1976, 1979) model gives an important place to intrusions. Such phenomena as nightmares, waves of feelings, and images that pop into one’s head are a form of processing threatening information and being oriented towards the threat. However, with intrusions the processing is not at the bidding or under the control of the person. Furthermore, Horowitz theorizes that intrusions, though they enter consciousness, are not processed in a useful way (i.e., they do not lead to successful integration of the experience or the information) . With active approach, on the contrary, the information is allowed to be processed by conscious decision. Thus, while ' Ta P'.y:'i' iH' , (tr w^V r Kl. V - - -A '. taifj'Jrt ''M < • •«'. o» ;- -Jx- fv« "' " ' '^' ’’ 4^® ^ «i I t f 4N »o»i P'wfl Iv. ' • ' • i>i '' U imMi> . *n:c^vti^" +.*«' it^iv !iin> oj! >M '" .::v iS ,ui ^ '’ JO'/fr lMl*?i >'t'i(i:Wfc< dit'kJ'' r;% -;, /^ov, , cfetcJ:i|4 . - .. iiiw t'liK U ’t lillrt’* . f t- 4 ffl • I‘t«c 31 Ai'. vt.lC'l Oj ‘tar.n .' 3 fl" Mk ii-,1 Mk;ta -fj ' -r. ’•ii.r ' . i/;«ifr»-, .fyodtj uTOm' it5^ ,,, ;« i »(•' '¥ a® j'-v** 3 . r.t^^nu'W.il •n':>'4,i&^'-T1’fQ '_‘ 4iti' *-«.'0 * t.-fi '!« f!}i>s f.A rji0h)i I ,••,'' ' ( ' ' .' ' ifta --i.: 9flf 1 ^ 'tfi..jf4 ..' < m , £»,9 „r? cm p# 24 approach, avoidance, and denial are all coping processes, intrusions are symptoms of poor coping. More specifically, intrusions are the result of incomplete processing; threatening material , denied access to conscious processing, forces its way into consciousness. Table 2 presents a diagram which schematically represents the four processes described above; intrusion, denial, avoidance, and approach. How do these processes work in response to stress? The following section presents a dynamic model of coping. When anticipating or recovering from a traima, approach is the a priori preferable response. That is, all other things being equal, it makes more sense to integrate the material into a coherent, consistent self- system than to fail to make such an integration. Of course, other things (such as anxiety level) are never equal. There are therefore three possibilities. First, approach may not even begin, because the initial shock and flooding is too overviielming or because the imagined danger of such flooding is too great. Second, approach may begin, but stop because it leads to an overwhelming of the ego by the tracmatic nature of the material. Finally, approach may proceed in an uncomplicated fashion until the material is successfully integrated. This last scenario is likely to occur only in less severe stressful life events, or in a person with a very strong ability to face stressful information. Since pure approach is often impossible, it must be tempered by avoidance and/or denial. These processes of retreat from the material may last indefinitely, as seen in delayed stress responses or in people who are never able to integrate a traunatic experience. However, continued avoidance and denial over time is problematic, because of a hydraulic build-up. This build-up can be seen in two ways. First, there is a build-up of affect which • ' ^ K C M ,|S -'W tr .4. '’ -: ' , "U ,, ';iT i'i ^ "', -...-' <» ^'' iT»i 'V-'V' W •P'Wfl''V iLoTL- #•*,.) ' ' ' 11*^ . ,' , .f*4 .' jr . w 6. ,r 't ' SM^ - W;''*V.v'r • ;^T- - >v t .. fi( ';;'v-7 ,( , ^'<'i>U' '^p^f^^'' '' f- . ' *»i .t .»« J,»^-’iyji..in . , H- ^0 ^ , -;,,i "J. , V). ,, 1 i 4^4'cffvi ^ 'ta ^ - I ' •' . '.'• '. \ Yt I ;• .'»*y : M mpl f»’Y;Vf*t\ , '•''> " -'-^V '., '.'''r — I' . .'( >»<'r J'v ‘ / r • - 5 ;; . tiiu .. i'T .,i.|; ./ f^;!i|,3^: ^ ' ' • /''-*^ .' , -'t -, ' f ‘/ •: i‘.. ‘li i\V' 4 '<.4‘'.f 4-' •' ^•»OT.rj v'’.‘ ; >^u 1 . . - >*• u v*v> . ' ’ * -* * - .4ltl*‘lJ«^ #. * It I ' '’fe. 25 Table 2: Schematic Diagram of Intrusion, Denial, Avoidance, and Approach INTRUSION The information intrudes 4 on consciousness consciousness threatening information DENIAL The information is sealed off conscio usness threatening in formation 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 > 1 1 1 information is 1 The AVOIDANCE 1 1 7 1 actively avoided 1 1 1 1 1 1 1 and pushed back by 1 1 1 1 1 1 1 1 conscious effort » 1 1 1 consciousness threatening in formation APPROACH The information is actively brought I into consciousness consciousness threatening information 26 is not allowed adequate ventilation through approach. Second, the information which is avoided or denied exerts pressure to be processed. In other words, to quote an old saying: truth will out. It is important to note at this point that while approach and avoidance seem incompatible in that they serve opposite purposes, they are in fact not mutually exclusive. There are three ways that these apparently opposing processes can co-exist. First, there can be a rapid alternation between the two orientations. Second, certain aspects of the material can be avoided while other aspects are approached. Third, a person can approach in one mode and avoid in another. For example, someone might choose to think about a stressor (approach), but choose not to talk about it (avoidance). While both approach and avoidance have costs and benefits, the consequences of not using either strategy are predicted to be uniformly negative. That is, failure to avoid will lead to the person's being overwhelmed by the traixna; failure to approach will result in a continued lack of resolution and integration of the experience. The negative consequences of denial and avoidance are intrusions, a shut-down of emotional functioning, an inability to perceive or take advantage of appropriate action, and increasingly extensive and maladaptive behaviors to keep reminders of the stressor out of awareness. It is hypothesized that all of these consequences are more severe with denial than with avoidance. The positive consequence of denial and avoidance is a reduction in anxiety. Ideally, this reduction in distress allows for more approach, and the strategies continue until resolution is complete. One of the problems with denial as ccrapared with avoidance is that if denial causes a reduction in anxiety, the person is unlikely to follow this reduction with approach, because that would entail giving up the premises of the denial. jj. « m VW^ .. -,!®: 1. !?< ps^t , ^O iwl*" 'K^p VXvO»i^'q-' ^‘f t4ni mtii em*!^-' *'^d Itti ,£«.. £m 4!i ^ao' li5il»#ip:;'«)f':^ .' ' ' A_ .,.is»J^c ,5it. , "W . til y'lap^ » ' ' if?! JIta. ^ V : "1 i^na' 3d 4if. s'&, ^»(ynl9,floa ,i^. /fJt IP ;0/' fc ti{» « *1? I r ir44 j Xt w t>»ia vX -I’igiif' ;»;< P*jU rf.»,t< dnf%»C;r4^ ' ' ' ' ' *'.'=*' ': r j X -|ol o • .i#r ,,4=^ “ f‘’ *p r»i (^4hf itr^^ciibiiT ^ 4 *t| ‘ wKei, !.: ? Aq . -'-I 27 namely that the event did not occur or was not stressful. In general, the symptoms of stress (intrusions, flooding, and shock) can be brought under control by the coping processes of approach or denial/ avoid ance , As suggested above, excessive denial results in symptoms of its own (emotional nunbing, phobias). As the person works towards resolution, there is an unstable equilibriijn between approach and avoidance. Temporary resolutions can be upset by anniversaries or other reminders of the stressor, re-starting the coping process. Eventually, the equilibrium becomes more stable as working through is achieved, Ihe working- thro ugh process has many aspects. First, there is an incorporation of the new information into a stable and coherent self-system. Second, there is often an acceptance of what has happened or what will happen, together with an understanding of the meaning of the stressor in the life of the person, Ihere is often a re-fY'aming of the situation, as when people realize they are not really responsible for someone’s death. Finally, there is sometimes a channelling of energy into social causes, such as helping others who have had the same experience. The concept of working through is not always applicable to anticipation of threat. In anticipatory situations the desired end result of the coping process is adequate preparation for the upcoming event. The model presented above provides a framework for urider standing stress- related pathology, forms of treatment of stress disorders, and situational and individual differences, There are various types of stress- related pathologies. If the person renains overwhelmed by the material, unable to either actively approach or effectively avoid, then the result is shock, emotional flooding, panic, and disorganization. If the person must resort to overly rigid forms of denial or avoidance behaviors to ward off this flooding 4 ^ ' '»il ', ' *' .. :,^«!K (fSS, . J , ' , w»' 't .1 Mfm,k %aw t« tfijli* ^7© iSj|1^«' tml ' isL>! it>pt>’' aH# j\'.i'Xf^‘iti'--:'»M istc ' :i* <«# t; a'lairt.t, ,i9.iii:^ \"M*k£iv ~i.v*> 'rf* -\^' f i tw , l'Hi(;if>h;«|iirt Vis? ', M fii 4»!*r eo ,f[0 »/B.ulR.*fW to jnjiteJiiS'f^skiiSf^^ ! ." .til . fti aaffe' » **»‘f?o?»fft)iaf -tel: 'M • ft ?!- 4 ' a os. ^ . ?e V no Xs'l e • "V^ H'A.^7? ' 3t»: ‘.'r* itt Jtjao«ov ,0’filT: a . •j.t,(iiip^fca 1 1 ct 't'ociJiiiia ' -<: • '. f 1 ' ,4,^ y: PiK».ta -^»|WV iCkl- 'i ,0. ii' *» ft n(li' ' :;' : - ": ’. ^ " . ''lEfc. ^ 'fern. ftof ':«.--oi'i » ,t.t|, :• ' ft'O ^Tjuv.a^ . . 28 and panic, the result can be phobias, depression, psychoscmatic disorders, alcohol or other substance abuse, and obsessive- compulsive phenomena. Of course, prolonged denial and avoidance is not inevitably pathogenic; it is possible that a traijna can be effectively denied without any severe consequences, especially if the person is not bombarded with reminders or other threats to the denial Another problem with failure to approach, while not technically pathological, can have severe consequences. This problem is the failure to take appropriate action, as when people delay seeking medical help, or fail to take birth control because ”it can’t happen to me." Excessive denial, when it stops working, can lead to the pathology that has become associated with Viet Nam veterans, namely flashbacks, intrusions, and reliving the trannatic experience. Finally, a less severe but more common type of stress- related pathology is the result of continued oscillation between approach and avoidance, with no adequate resolution. This failure to resolve the tranna can manifest itself in a variety of ways, such as depression, anxiety, physical symptoms, problems in all areas of furictioning , and poor social adjustment In addition to pathology, the model provides a framework for examining strategies for treating traunatic stress reactions. The most obvious strategy is uncovering. This technique, rooted in psychoanalysis, assanes that traunas must be approached. The danger of this technique is of course the possibility of leading the person to approach information that they are not prepared for, resulting in an overwhelming flooding reaction and perhaps an even stronger denial. This danger can be averted if the therapist follows the natural flow of the model: gradual approach to the material with strategic retreats as necessary. ' „, ,, Bt ^ ; to y - ,:in.>4 W '’"' '. S''*'?'? . W* ..-.ilaf^J V i ^JCW^!;' „«;1;^ ^\/ ,^'i * » 4. SjH” ti J,w^..f ' < i J ,'i itfvf k; * ' - ‘'.V I.H.’ r .V . :^rf f-»» a>^%' 'Hf^r ) ^'^'i ^ ' ' ""„ 'V^' ' ’ ” : ^^' i-Ji ‘'-"Ki»-i *• u ,|U - f)l^’5i'J'' »d*l AimW V0j ^nif^ *’t'iy^^i£-^i':‘4M§'^ fife *'“ ‘' * '"'“ '. 1 ' ' n - I '-‘jT •'- "j ** ““ !<. i’ n •i»j (/,< .t: .Tc '«-*. 'M *4'irp»04 ie : .'> f ,, 29 Another type of treatment is re- framing. Pierre Janet (1925) developed a fascinating technique in which he used hypnosis to actually change the person’s memory of a traunatic event. In a way this technique involves siding with the denial, since it takes away the pressure towards integration of threatening material by removing the material itself. In more recent times, a similar therapeutic intervention is used whenever the meaning of an event is changed, as when a person relinquishes a sense of responsibility for some tragedy. A less dramatic treatment is relaxation training. Such training has two possible goals. One is the teaching of avoidance strategies, such as how to distract oneself in order to relieve distress. The other is to minimize distress in the service of facilitating approach, in order to hasten integration. Systematic desensitization can be seen as a model for this type of intervention; the threatening material is approached in a gradual, step-wise fashion, with overwhelming anxiety warded off by relaxation, rather than by denial. Much of the intervention in traunatic populations is performed by self- help groups, or other non- professional support. The group processes of vicarious catharsis, removal of stigma, re-fY-aming of the problem, gentle pressure towards self-disclosure and affective expression, shared experience, and an accepting environment all facilitate integration and resolution of the material. In addition, effective coping strategies are shared, and hope and courage are instilled without having to deny the existence of the problem. There are important modifications to the general model based on situational and individual differences. For example, there are traunas that are so devastating as to render extremely difficult the task of resolution. How easy is it, for example, to integrate the experience of having killed an innocent child while in combat? Or the experience of being the victim of a m'-. - .1» %A -^i ^;tilBte ^.’fi'i: rf4 «'i- fo'#«rt,i?8 '. ^ - s, 4 VI 1 f^'V « tv Ji.+sv> ir , 4M ^ M 4 , ^ fJn/:' * wr.:]t^‘"'i. p.t''‘Tif-Y. ..j* ' ' 't'J l,*v 'JCiJf -f'* > t fJl'ailT to t S[o>t' y»| Vtf> i^i-^ " ' ' '" " ' "' jrf ' ,'fi^' : -1 ht Y'l • fif •-/;,tf R“.'Rrt .' ^ ! '* « ^ i.9 n« nr o n.! 1 1,> 'i| g , Ma m04 t'' .v.-i f, ; iHa 'fin44cAJ • •k!i wjS 1 irt* i' f-.it;:'>] < u; gi*#®?-* / ^hi is, Off: ,iit, -i# .-SiiSIliA'iiDi l-i ¥»«,> • '"'•'^'tfei 5T' i! i‘> ar ^flii ' T/r. ''1 Iff . 30 senseless and brutal crime? If assimilation and resolution of trauna are inhibited, then the relative costs and benefits of approach and avoidance look quite different from those described in the general model above. Non- productive worry and distress becane more likely consequences of approach, while the continued non- re solution of the event makes effective avoidance impossible The difficulty of resolution depends on individual as well as situational factors. Thus, while a particular trauna, such as rape, might not be devastating for everyone, for some its meaning so violates certain opeating assunptions about male and female roles, or about the relationship between the sexes, as to make integration impossible. Finally, resolution may be impossible due to a person’s limited resources, such as low tolerance for anxiety and inadequate sources of support in the environment. The costs of avoidance may outweigh the benefits when there are frequent unavoidable reminders of the event, when the event is charged with a high degree of personal significance, and when there is already related material being kept out of awareness. Ihe implication of these qualifications to the general model of coiping is that it is difficult to make specific predictions about the relationship between coping and outcome without knowing the limitations on resolution of the trauna or on the ease of putting it to rest by avoidance. Thus investigation of effective coping strategies must proceed in the context of knowledge of critical characteristics of stressful events. The model of coping which has been outlined above has as its central focus the processing of threatening information. The symptoms comnonly experienced in response to stress are seen as consequences of various modes of coping (or failing to cope). Before directly addressing the issue of « '4 I Sw V ” ^ „ '' ‘ ' ; # ; V: •KS :.' •.'• tr mi’f OV0 t ^1 J ,; , AM" f?'v. e»6 i?*»W «* ‘X«’Al| acjj 4/riilfr , 3 CA <10^ HI** > » i» J-riVo * ft rik i’ol y > i.i,l_.»tc-l >hij ' -itcK' ;s toT ., 'W^' is; )'-{ V /|CJ Io« » 1 ,V XXvjii , 5X£f/'tf'j)jj?iq^ ,il‘l -* !‘ •C.T.? rn.T wof' »if fidi . 4 < '> If .1 a J M' tc MrfUia,. 4^, . rfV 4i Xii'i.ftJ' • I' •» iw J u y b(AS‘"f ‘et: E£ . 'ai ' ''^xl ' ' :’ *J;-' 't ..: .£ A •j I fi r>.!»T >(fO ')W ,1'iJt*; < X!!a/to'^“!r' V, ? :t«>X.n. 1 -:;^1 •'t-.s Ms- •Y. (tM,i ifoX'loi'a, ,.f a-,. ' ' •' '4*. • M ' .. 4 ;w .io'l p " ' ^'’ ;''i '"# I i . flWAir 'M . ;b , t , ,-,nf . ^ . 31 testing this model, I will briefly review the literature on the response to the trauma of rape. The sheer mmber of rapes each year, as well as the magnitude of the crime, make this an important population to study. In addition, little is known about why some women seem to recover adequately while others do not. A coping perspective can be expected to shed seme light on this clinical question. The Psychological Response to Rape In a recent comprehensive review of the rape literature, Fraenkel (1984) noted that the psychological study of rape victims has a very short history, though much has been done in the last several years. While the political ramifications of rape and research on rape are beyond the scope of this paper, it is necessary to point out that the women’s movement, especially the shift from seeing the weman as cause of rape to seeing her as victim of rape, has been largely responsible for motivating the recent research interest in rape Since only a small fraction of rapes are reported, several studies have been conducted to attenpt to describe non-reporters and discover the reasons for reluctance to report (Binder, 1981; Dukes & Mattley, 1977; Feldman- Suitmers & Ashworth, 1981; Norris and Feldman-Sunmers , 1981). The main bulk of the research on rape, however, has been aimed at describing its psychological sequelae. Much of the early work on response to rape was psychoanal ytically oriented. Symonds, (1976) for example, noted that rape leads to a regression to self- preservative and innate patterns from early childhhod, because the act constitutes a threat to the won an’ s very survival. Unfortunately, much of the psychoanalytic work on the response to rape followed Helene Deutsch ( 19 H4 ) in focusing on the role of women’s rape fantasies and masochistic ... '•* <1 i»'|. (*o ' ' 0'' " ';. V.' I0ir4f * ' '' ' ’ \ ’j_ ^'jy .V-o;i'S ftl' ymv ^ >! 4» Jc Kjon^s jniiJf' iS^'Ci^iod^ rijf 'ft ' * dv,,-..': . t * i>l ?r. - :.Jl:l ilo-WW-Vl »1 f iii v,Ti)5 , J an ul bv ' v: ,, . V' a^lttd ‘Ukfff •Iflf . ff8« f, • 8i PJ'J rfl <]f,«. ' ’ ’ ' ’^j '( .V ^ -y .10.' t V » tlli'Tf S «'t?ii!Ki»|' ’’milf’' .Ii}'4^''’ a /%wrtii.i .‘" '(W'' '^" *4"*'*"'* ^ 4« ?-f ii!! . 32 tendencies Eurgess and Holmstrom (1974, 1979) began a trend away from the psychoanalytic model and towards a stress-oriented view of rape response. This trend is exemplified by the term they coined to describe women's reactions to rape: "rape trauma syndrome." This syndrome consists of two phases: an scute phase, lasting several weeks, in v/hich there is great disorganization and often physical symptoms; and a long-term re-organization phase, in which women often m.ove or change their phone number, get support from their social network or community resources, and experience intrusions and phobias. Follow-up studies conducted as long as six years after the rape have found that this re-organization was still in process in many women (Eurgess & Holmstrom, 1979). The presence of serious long-term sequelae to a rape experience has been found by other researchers as well (Nadelson, Notman, Zackson, & Gornick, 1982; Notmian & Nadelson, 1976; and Sutherland & Scherl, 1970). The negative consequences of rape that have been well documiented are fear, depresion, self-blame, poor social adjustment, and disruptions in sexual satisfaction and functioning. Several studies have shown persistently higher fear in rape victims than controls, both in terms of rape-specific fears and overall level of fear (Kilpatrick, Veronen, & Resick, 1979a; Ellis, Atkeson, & Calhoun, 1981; Calhoun, Atkeson, and Resick, 1982). The research on depression after rape is equivocal. While some- researchers have found that post-rape depression lifts within a few months (Kilpatrick, Veronen, and Resick, 1979b; Kilpatrick, Resick, & Veronen, 1981; Atkeson & Calhoun, 1982), Ellis et al. (1981) found that depression lasted up to three years. Part of this comiplexity may be due to differences between 'I n ..-V »-» &:®S^ J®'W,»W4*''‘ 4 8-K1* 'iU binvftvi tV>^t:»f : I £'’•'' -^a,..’'!: t * 'V».|‘M fh, U . ' t ba,u44 , *• .„* j U' ,.,>• %yn •*!« timi » sTfHI ‘ 11 '•/ f}i- f’|;x^s i'fiX • » i . 'OfTvt’i'i/. ‘ s^ifl •1 0 fiX'«’up-i53' sTl. M irt'i't:"' 1 , n/‘>q'’ii.'»!3't ,fts-m,iiail ' ..-' ' V ^ M :t tyH,aC *.at' aor . 4 i*" .. IS r?:4|2 I#'’ , ‘?®ka' : ^,J-, y, “3fW-- *..M :.iV,:;.-»# -,m 1 111 id. 3 i ^ n*'i ^0 i^vil K:o>vo' ill-?; :;n,»l ;r-.-?f ,v*HtS !> .IIMS/IJ^, ,iin.} -Mm^i 4 .I 5 W. ±L 'n-{h;i 4^.-1 .• . VI , ,ta u M< Ww.« » ^'.taivii 4-^! . 4 ,’': ' !nT ^ > 4aVH: /imm -fc# . , 33 subsamples of wctnen. For example, Atkeson and Calhoun (1982) found that old and poor victims had longer persistence of depression, as did those victims with a pre-rape history of depression or other psychiatric problems, Ellis et al . (1981) found that women raped by strangers reported depression of twice the severity of that reported by wcmen raped by acquaintances. Though self-blame is theoretically related to depression, as well as to guilt and shame (Notaan & Nadelson, 1976), its relationship to outcone in rape is not clear. While some have argued that this common response to rape is something that should be treated and corrected (Abarbanel, 1976; Schuker 1979 )f others have suggested that there might be benefits to self- blame (Bulman, 1979; Libow & Doty, 1979; Burgess & Holmstrom, 1979). Social adjustment is another area in which rape victims have been found to have problems, sometimes lasting several years (Ellis, et al,, 1981; Resick, Calhoun, Atkeson, & Ellis, 1981), Finally, disturbances in sexual functioning and satisfaction are frequently found in studies of rape victims (Feldman-Summers, Gorden, & Meagher, 1979; Norris & Feldman-Summers, 1981; King & Webb, 1981) Though most of the studies of victim response to rape focus on the differences between victim and nonvictim samples, it is clear that there is a wide range of individual differences in response within the victim group. While great progress has been made in only a few years in describing the common psychological response following rape, little has been done in the way of evaluating coping responses or explaining individual differences in outcOTie, CSie study (Burgess & Holmstrom, 1979), found that those women who used one or more coping strategy (e,g,, self-blame, suppression, rationalization, over- dramatization) recovered sooner than those who did not. However, statistical tests are not reported on these data, and thus they : te ' ' ' , . :Sr #V ^ iS ^.ttH »9 ,r.>Oj:Q^;:-»‘*frip)> rt|" <5t '<3«rt«way«-*,^ *«i£».Wff .**• v'i- ifc?*; |tS|:i| r I ’ .. 9 r p ?v ' < A>*W ... ' , ,/' ; .^'f^'"'^>'''v: >jp>ti avini^ pr^ij^jp "' " "' sr“ ' •' jfKC r 'i? >*»-i(t}'l»1 „Jl -f #4 • ’ i»«f i*lii>Ayi ;1o^ ^ * *J -r > art^ 74»t* ^ / ..fi '«':»; i™r*-k^ - . ;:^ ' ' ' ' {^ ’ . . - i ' , t , . .f* 1 f, f<|, r '>j|,j ,-siy :¥|»,,^|^ 'if* ' ' ' .‘ ^ , , >f^ " ilvi ._ '«^ .'I J|:;l . Ijf , ' ' ’ - ' ,'!£ T' ^r' 't»K -^. a 4«(n.rwii'*,j», ' :' ' . f' ? -;U • , . . : k.'j ''. Jil Jsm maiU W l•t-^/, UJtii i,,# «^’i^' f)«>t tWi 3 ^ remain speculative. Some of the research on the long-term response to rape vras discussed above in the context of specific symptons. In general, this "long-term” is usually quite short, covering only a few months or years post-rape. Furthermore, studies which obtained their long-term data from follow-ups (e.g,, Kilpatrick, 1984) suffer from the problems of nonrandom attrition and repeated assessments. Burgess and Holmstrom (1979) found that after four to six years 26% of the women still had not recovered. Becker and Skinner (1982) found that three or more years post-rape as many as 39% of the wcmen continued to have sexual problems, including fear of sex, arousal dysfunction, and desire dysfunction. Response to Rape and Post- traumatic Stress Disorder What is the relationship between the response to rape described in the section above and the diagnostic category of post- traumatic stress disorder (PTSD)? Kilpatrick (1984) notes that many rape victims could be diagnosed as having PTSD. This formulation, however, does not provide a complete understanding of the response to rape. To fully understand women's reactions, it is necessary to do more than simply janp on the PTSD bandwagon. This section will compare what is known about rape with the PTSD model, without ignoring individual difference variables or situationally specific aspects of rape. PTSD has primarily been studied in cOTibat veterans, and its history is largely the history of combat psychopathology. Goodwin (1980) provides a historical context for the diagnosis of PTSD in soldiers. Prior to World War I, psycholc^ical combat casualties were considered to be due to cowardice and poor discipline. With the advent of artillery and trench warfare in World War I, casualties were at first attributed to the effect of exploding shells : , ' •*: -i-v. ' -!li, # •% -. '^ :’ ir' ••• . . , * ttf4» ;v> Yi • r '. , "/rt j w, I . f- • •'I'jSi? ft-'M fe.?«SgEi^E3, « •> tj hjjt . •»»• •«. rt';''{.(p.!?-i ii'» i. ' ' ‘ r '•^'(ni ,;' ‘.' flM'A 1 ^^;i^_:if v.^^. >^«l^Syf^^i{'?^.•^:4^«!f - ••.•' ;‘*4 •i *< ^ u 4 0,t1 76 , Ji '• " i l i Xi''lt :T m nu V , *.-* -1 'i i •" ittVi i i<|.'»u«s x *' r • n' '. r (•.?:,. •••1,1. t L*> . *1 » r-..»f- .rtRif rv»^' v. : .' V : .•^(».-« I t {^ ... ' ,$i.: r*» .1 >}^ 1 n& >c.»V'»;i^.. < A 1.^' ' ' ' '' " ' . • '-* '••'•" -'• •• '^-M I >\r _ "'• i ' . 0 (•'>’ viPI jK-A’ ibi'^..' . ,>r .' ;- -i c.. i V # 35 (hence the term "shell shock"). The shell shock hypothesis was soon replaced in mainstream psychiatric thinking by the idea of war neurosis advocated by Freud and his followers. In war neurosis, the stress of combat was assuned to trigger a neurosis, but only in those predisposed to neurosis because of constitutional or early childhood factors. Combat psychopathology was studied extensively during and after World War II, most notably by Grinker and Spiegel (1945). "Battle fatigue" replaced war neurosis as the fashionable term; more importantly, there was a shift in thinking on etiology. Battle fatigue was seen to be a function of combat exposure, rather than a result of an underlying predisposition simply triggered by combat. Another difference after World War II was the observation of delayed stress reactions, in which veterans exhibited anxiety, nightmares, depression, and explosive aggressive behavior years after the war ended. Though fairly common in World War II veterans, this delayed syndr In the civilian realm, the 1950’s saw the first edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1952). This manual included the category of "gross stress reaction," defined as a transient personality disturbance caused by the necessity of dealing with overwhelming fear. In the 1960's and 1970’s, at the same time as Vietnam veterans were making headlines with violent symptcras of delayed stress reaction, there were many studies of victims of non-combat traumas. Some notable examples are a marine disaster studied by Leopold and Dillon (1963) » the Buffalo Creek flood (Titchener & Kapp, 1976), and survivors of concentration camps and the atomic bombing of Hiroshima (Kinston & Rosser, 1974). Many similarities were found " ' '• ' * *• V-. “!•!»' '- '-'S^ »XM Uta^tmm «Im 4#U«fl.C lo yoJ ;, ^w'uil', sMSIk '' a ^'’V • :M }c «»ua.-«0 5)fo-w*« r.i ixM^^ - •' ' ‘™^ * a rtn tri^ «;U TL/ i.' V l! a v I flai x^'". ’•* J ••.•>» iiJUil" . {^r/ t»!^/ ’ ' ' I ;; ;.4b;' ^ C\% -• . •T V -4 1 it£yi(ia ':.K • ] i •jf' c>* na<9i ,iw 6 3 'T.sflvfi^ , '*r 30^<^|^Va ;'j^^ U,>'(iu Jt»*r| 4' it 4 .fie. ''iff .,ii-^‘ ' .. : ,rt:. -rhi"!*’, '••>.< •-MJ i; -laW. l«Xl04 ) ::: .Vi -< '%• -« • t ... H - lol '4fii^yj j 'rtggfi ^. -iVJe.of* 2 SS jSca^ a: '!<••) t *i > : . Mjfe “^ it‘-’’'i^:^X'«f^' sT^' ir(4i;'' r.MOi -.^v r, t- » ,> U, 4 -r ; S' V ui.4 uJ r ^;. 4^5 ‘Bt-fe, .-{< ' 4.- ..OJ*.'m '' J ' 1 w f iwf if •-•*•: ’: . : . ••'•r. «r-<- i 1%. ) ifi/ie‘»M T0 : isunall i^f r>. r*'ij£ t. t \})^‘ ;^;3 ‘Ti^f ‘ ^ •• - ;.^.^ ' , 4 >i TU Jf« A ' ^ tA (t4ij; .i > ^^ - K..*^V Jl,.u.Tf/V. a'-.ftii 4;fl ; / Si!' ‘C -jli... • v'* . vj*.'i ;-«ni , ,, >3 ? W« hi 4 t L'" •51 mm 04 yjviM Cif^r ^ :!:^0 36 across situations in response to traunatic events. In I960, with the publication of the third edition of the Diagnostic and Statistical Manual (American Psychiatric Association), these similarities across situations were consolidated into the post- traumatic stress disorder diagnosis. The criteria for inclusion in this category are included in Table 3, together with descriptions of symptoms experienced by various post- traunatic populations. As Kilpatrick (1984) states, most rape victims fit the definition of PTSD. Rather than stopping there, however, I would like to consider three levels of post- traunatic symptomatology: the universal, the situational, and the individLsl. The universal level consists of those symptoms shared by virtually all victims of any major stressor, such as depression, anxiety, intrusions, guilt, and fear, Ihe situational level consists of symptoms shared by many victims of a particular stressor, but not necessarily conmon in other stressed populations, such as rape-related phobias in rape victims, violence and exaggerated startle reaction in Vietnam veterans, a sense of loss in the bereaved, etc. Also, universal symptoms may have different meanings in different situations. For example, intrusive images may arouse anger and violence in vets, but arouse feelings of shame and dirtiness in rape victims. Along these lines, in a study comparing bereavement with personal injury as stressors, Krupnick and Horowitz (1981) found situational differences in the content of intrusions. Further, a symptOTi might theoretically belong in the universal category, but only be manifested in certain situations. For example, if rage is a typical response to trauna, then the fact that women are culturally constrained to inhibit rage might mask this symptom in rape victims; the suppression of rage might in turn exacerbate symptoms such as fear and depression , Mi m #»! ^.Su-.i'^, .- ' NBSI4< i...r ?V: '*>(• M-i - • S' , I \^; >««4il> •IM>’1I^ w ; ;,!»H’iiifc»/< *v-f-45r-( *•-'«! 4t PisMBuJa**' 'it'.'. ,#>1 -tk i’i ••-'t*si‘V ' ' '^yj. ' ' '’' : . . ._ , mi . 1 , 11' ' ;. *ftf I , ' '>'' '^ ^.; ,*!;*'*>, , , ; , - ^ ’(H.f , a. -V' %fU»l it \> %d bp>‘TtjH«i ‘ ^ ' ' ' ' . ' 1 *U4k~‘ r%:t nt , V JwJf'Hj?**. fi(Oi:i!e-^o;;i^'^fc ^-0%r4 , ^ym'^ ^ ^ '.-’I l.via,u nwoiiqtiHt t'4!| tei^ LSiP . »r..'.'o n V .eri';»'?iv sen A" ,ri j-i: Iv .» V\.i ' ' «)»•' I . ' . -‘ftone ^Aaj W' ‘ I-' f Utm A'.’ ^ ,ji t> *te'' boLtm'' M ' ''• ‘s • mmii II* ' ' . 4 %i&»i.n 37 Table 3: Symptoms1 Following Rape and other Traumatic Events Rapel Vietnam Vets^ DSH-III PTSdI Buffalo Creek Floodii Anxiety Anxiety Re-experience Anxiety Depression Depression of event Depression Fear Fear Numbing Disorganization Helplessness Helplessness Helplessness Intrusions Intrusions Two of these: Intrusions Sexual Dys- Sexual Dys- Sleep problems Numbness function function Survivor guilt Outbursts Social mal- Social mal- Hyperalertness Rage adjustment adjustment Cognitive impair- Sleep problems Sel f-blame Sel f-blame ment Survivor guilt Guilt Guilt VJorse when Isolation reminded Hypervigilance Avoid reminders Startle response Rage/violence Numbness Suicidal ideation Substance abuse ^ Eurgess and Kolmstrom (197^* 1979); Kilpatrick (1984) ^ Goodwin (1980) ^ American Psychiatric Association (1980) ^ Titchener and Kapp (1976) Table 3 continues i iC-’i ^ ’' ' ' ‘ la^ 'JF" , , W a''''’.;'*X — *i*«^ ii^ -- ^i— .!*»»»» w r'y*. j.-? 1 .y , v*^(A£xJ»A . , • 'ij-'. ; ..rcv.^ .^!j t»t)J^.'V'»'V7fU aigii^ffl))i>H CjDft-F.tiUoO ;!i;OV:i::V%43, ' fi453Al''F'&'I:'t^Y:H' -li «4T5i' V 10:^4:? jJii^g v.vxv/Mu-. ' KOflW 'll*- ' baortifflw"! iM»,u’i.'.-,-so l'»kM 38 Table 3 continued Three Mile Island^ Coconut Grove Fire^ Concentration Campl. Anxiety Anxiety Anxiety Alienation Depression Depression Chronic sympathetic Disruptive behavior Cognitive impairment arousal Helplessness Fear Cognitive impairment Hostility Guilt De pression Intrusions Intrusions Sonatic conplaints Regression Sleep problQTis Somatic complaints Somatic complaints Startle reflex Marine Disaster^ Hiroshimai- ^ Baun, Gatchel, and Schaeffer (1983) ^ Liitdemann (1944) Affective disturbance Anxiety ^ Kinston and Rosser (1974) Depression Depression ® Leopold and Dillon (1963) Fear Fear ^ Kinston and Rosser (1974) Intrusions Guilt Paranoia Sonatic complaints Restlessness Resentment Sleep problons Nunbness Somatic complaints Preoccupation vdth death ^ i>'\ f I mtiJats. truv •' n-•Adi:''^#r5 39 There are sub- situational levels, such as date-rape and stranger-rape, which share certain features with the broader situational level but may each have a unique pattern of symptonatology. Similarly, there are meta- situational levels, such as single events versus prolonged exposure to a stressor, which have an impact on symptomatology (in this case, a single event would be more likely to cause an anniversary reaction). Finally, the individual level must be recognized because every person who experiences a trannatic event will have some responses not shared by others in the same situation. This variation is due to idiosyncratic associations a person might make to the stressor, or to idiosyncratic generalizations of the fear response. Variation might also be due to differences along any of the dimensions that might influence outcome, such as level of functioning prior to the stressor or coping mechanisns used in response to the stress. It should be clear that rather than either forcing rape response into the PTSD category or defining rape trauna syndrome as a unique disorder, the present formulation makes it possible to consider both the unique aspects of response to rape and the overlap with other post- traumatic populations. Predictors of Individual Differences in Recovery from Traumatic Events One of the most crucial aspects of the individual level of post- traumatic symptomatology is the class of individual difference variables that might predict recovery. What are these variables? In general, possible relevant categories of variables are pre- traumatic adjustment, prior history of traumas, demographic variables (especially socioeconomic status indicators), social support networks, and coping differences. Ihe research literature on predictors of recovery is inconclusive; in the case of response to rape, the results are often contradictory. t e ^ , tt tMijf b’ '« ^:ri 4 L w “/* ' p M ' ' is> ! i ^hii(in4m • «kj u'vutHfU.Ms (•lo ,v vilwS' Y r’^v^ «f,f' J %«! :• -*ni' »ftn .aVeif'S’pWr'’'^^^^^ ' ' ' i ivJ'%,l'il't!."'L^ i '.K.A 1 .'. .s c >J a nv f..„ i I f. ’ f#u b: « 'tf^i;,•;'a|^^l2^. V « ' 66' • i > , c v' / \'\ 6? *to * n '.v^? T^a; lOi'l'Iiltiit:, ’2 'iS®,® '“ -i^ & . ; oj vj. i»4 Pf •V.* , >«bi.:ijo ^ ;•«», Cl -M#'n 4s:l:r ‘ wjfw f'B.i'-'iie *( ,dqti-7 gut-i' .I’ot, ' ^'•’ " »' - '.^\ , . .; .1^" ^%3 .'»l)'ju««it> .‘yp’oi. a I'.ij 1<. =-*• 'i';f , G K':il''L .rsAiftimOr oi:^'".l' - *, i i* l'i..j oq , r Jfto ‘^yft ^|*§l'VO 'A * :>ju4 1? MW’.umn.'i .'tioi'i v1wliwciJ<^i elidi K' > •' *,--Y i> ’'-ii i«i,6|.rvf*;iirtij[; Yb •». -« f >.M9 v<-iib Xai^vi'W }<» '• o • ;.- • r ;>) . '*a Y r '?p.9idn <^ray *;?.«»?< y .i/»q , rotted no/iiJt 3.3 wm>a$i0i 'Q$ y .i; •0'i4 j s frao.itv 1 . ,.*r . '^-b 'fe'v'i,r,. I l'i,,«4^ li'k^ . . ^ irw* ‘ 1 '>>» * 00 » f 40 In the psychological literature on Vietnam veterans, there has been an ongoing controversy over the relative importance of pre-ccmbat adjustment and combat exposure in predicting the occurrence or severity of PTSD. This controversy has become quite polemicized because of its social and political ramifications (such as compensation for veterans with PTSD). Research on this topic is hampered by the difficulty of assessing pre-combat adjustment. In general, however, recent studies have found that pre-combat adjustment is not a reliable predictor, while extent of combat exposure predicts PTSD fairly well (Foy, Rueger, Sipprelle, & Carroll, 1984). In other samples there has been no consistency to the findings on predictors of recovery. Coping variables have seldom been measured. Victor Frankl (1959) noted that concentration camp inmates who found some meaning in their lives adjusted better than those who found no meaning. Eurgess and Holm Strom (1979) found suggestive evidence that women who used at least one of the coping mechanisms they studied had a better recovery than those who used none of these. In terms of demographic variables, various studies of rape victims have found worse adjustment post-rape in unmarried women, adolescents, and employed women, others found worse adjustment in married white women, and still others found no differences due to race (reviewed by McCahill, Meyer, & Fischman, 1979). The confusion grows even more when it comes to pre-rape adjustment variables. Some studies have found that good pre-rape adjustment predicts' better outcome (Frank, Turner, Stewart, Jacob, & Vjest, 1981) end that prior history of psychiatric illness or treatment predicts worse outcome (McCahill et al., 1979; Frank et al., 1981; Atkeson et al., 1982). However, Kilpatrick, Veronen, and Best (in press) found no differences in outcome based on psychiatric history. " * *••• ' -r^ft 0 <1^ ••'liivie tiitwo'i o4w ,.®‘aijs;0n'ii4fii« tma 'r.s. myitis' -4in.ijii»#W''b» i^bfl(fTO‘T;^ ii? '^: fv.H»< imldot'v, i)4a>, lo, iMlbu.’i^V,*?.’^ PWa ,^;tn»«a.!9jfof.>fi. ..na’inpw bf»« few i>Xl.iw bis)i;t'i4'iB'^ttX;4iSb'iti'‘i^i2!^^ ' id!* ' ’ '" ' • ’ ? •«"' Cl -ijKI ;' ' ''• ' . , , J'''. Px''"' 'P^.. i , r^^t^''r bii^^ivP’i) '»pM' '' ' ' ' "' " (' ' '. "' . i^'.^ ^''' .tna^JWitba b6<>SiiXs4#: bit'tfpjf' ' :"' ^ :' ,1 f..' • • ,'.v;-’9^''. :-, Wi 41 There is more agreement in studies on the predictive value of the nature of the rape itself (i.e., the level of force involved). McCahill et al. (1979)f Frank et al. (1981), Kilpatrick, Veronen, and Best (in press) and Atkeson et al. (1982) all foetid no effect of the nature of the assault on outcome, with the exception that especially brutal rapes led to worse recovery in one study (McCahill et al., 1979). The present study provides an opportunity to assess the effects of demc^raphic and rape-description variables on outcome. In addition, the study provides for the first time a systematic basis for assessing individual differences in coping as a variable predicting recovery. Adjustment prior to the rape is not a variable in this study, because of the questionable accuracy of such retrospective assessments and because of the desire not to be additionally invasive. The following two sections describe two experiments designed to test the model of coping described above, and to advance the understanding of response to rape. The first involves a validation study of the Cohen-Roth Approach Avoidance Scale, a tool for measuring approach, avoidance, denial and intrusion p-ocesses. The second involves a study of the long-term response to rape. Validation of the Cohen-Roth Approach Avoidance Scale To be tested properly, the model presented above must obviously be studied in a variety of stressed populations and at a variety of times relative to the time of the stressor. The goal to keep in mind during such research is the application to treatment and prevention of traumatic stress reactions. Before conducting a series of studies in a variety of situations, however, it is necessary to first establish a technique for measuring coping style V A 1 re ^ 1 »’V ft y ' o £^^i4)Q ih M 'viqp ti t# . 4» rii;t ' iM ^ ^ ’ r . a. E-, ' ' Wty., ' ^'' ,.; '-'-'•^'l^', .»v ""^la^ .r, 3, %z. i >ffii 1^ -T*«rr ^;iiv' 3 > ./'itl#;oitr ’^j ijW > -’tdi ofiKiu j yi^a*. » 4 ^ f ia .;«j»;,: iMliW'- o,v \(lNy. iti.f yr4,,, ^'^ns^s 'i* 4 ' '-'' ' ''' 4 - : '"'iJ ; "« ' : : . .. ' , ,. ..._. _ u. ' ' .' . * I^f’ ; .' mU '7V/ nt .vO ' r«ij , '-. i-tj .V 'Kifyootf’f -3 S' ' V ’ ' ’if," »WaiVQf r.i^.'.{> i, ( t To 'i3 - ' "' ''V ' . 1)^ ' • -I .< ' > OOq[%'»T 1 $/!i ^-'!^ .t" 1ft b. »n't 7 '.fefi *:*c j ^ It.ic 1 -.;»«1Ci / >»1J 7 ial.r^h . -- ''ixtov.^ . -rol :,i: ' ~ .• Si ^ V *n,f''- v'1 & io ,.^)fla'.V, (I ^g. t%' <*?•<«#» V'. 'yifc hrj« tij; ?i>"if(i^' ijf 7 •" ', .' . . 'J -’’w: , ^ ertrH nlii. * 'to f»^ft,ji-i^ v-'-* - *'„ 1 ''S’’ rs- t.| The author, together with Susan Roth and Jack Smith, has developed a scale designed to measure approach, avoidance, denial, and intrusions. Consisting of four non- overlapping sub scales, the Cohen Roth Approach- Avoidance Scale ( CRAAS) contains 64 items in all. The items are rated in terms of how true they are in describing the subject’s reactions to the stressful event experienced. The CRAAS includes all fifteen items of the Impact of Events Scale (lES) developed by Horowitz and his colleagues (Horowitz, et al., 1979 ; Zilberg et al., 1982). The intrusion subscale of the lES has been included in the new scale, with the addition of 10 other intrusion items. Horowitz and his colleagues, however, combine denial and avoidance items in their denial sub scale. Thus, sane of the lES denial items are included in the denial subscale of the CMAS, while most are included in the avoidance group. Examples of the denial group are: My feelings about it are kind of numb, and I felt as if it hadn't happened or wasn’t real. Examples of lES denial items placed in the avoidance subscale are: I tried to remove it from my memory, and I tried not to talk about it. In addition to the lES denial items, the avoidance and denial subscales of the CRAAS include a number of items derived from clinical experience and from an interview study of coping with cancer (Manuel & Roth, 1984). The approach subscale of the CRAAS is an elaboration of the active approach scale used by Cohen and Roth (1984) in a study of abortion patients. Examples of approach items are: I tried to deal with my feelings about it, and I wanted to talk about it with people who would understand. The entire CRAAS scale is included in Appendix A (pp. 103-104), with the proposed sub scale memberships labelled. Using an undergraduate sample. Experiment 1 consisted of a confirmatory ' '> "'’' , , '.r'""’ ifj^fcB("V- . $t$ tMw.ri «^tr '.#li •' *.; : : * imi W ' m f »U -.i 1 . 7 IOV, “io' is^iR'l ;Ye^ i'W^ ^ « . n,t' fi-mr / .. . ^ M «'iM :d'f: ^d)oHe ) cH ,nm^dt. 'd t wiBoi.ln^fiQ'i B pi.f n -Yslij ' n# '•*«i nl,?irti;sJi U4 V4 i'bl '’?i5fii^.ttl; ^'’' •••’*'».•.•' 54 .c.*ns '*» i-fd ni i^'bpvtot »%'' 4w Cm 9 .daija lo ••'tft duf}di •* 4.yiJ.' tr, ( ic :',ictj>stfi3. . Wfi •>> 4'u.»>, ii/f.'j n'UQDc r'/JXJe w[,sii T^, v..;;^ 4.i./ to .W.>jA10(itsIir i>..^ '2/j ® '‘W 'W.- 'V .55 .J * • ».t 3 « . '<» d. 1*,#) v«r .u,iw il>»Jf^4 ’*-•" ' ^'^‘''' 'f’ 4 - 5 A""'— !^p5^ 5.,#1 --^^'''^'W'?' ''V -iii£. ^'-' •« • ‘- *'l ,T r-?iw»7«twju 'U^il.fyf: (JifJ^J' ^.f- ;tsr ^^, ., »«iiw .^:‘cr.r*'jsw 1(>0 a 43 factor analysis of the CRAAS, with the purpose of testing the theoretical dimensions of coping outlined above and the ability of the CRAAS to capture these dimensions. It was predicted that the a priori assignment of items to the subscales of denial, avoidance, and approach would be confirmed. The intrusion scale was not included in the factor analysis, as it does not attempt to measure a coping process. Rather, the intrusion subscale of the CRAAS was compared with Horowitz’ measure of intrusion from the Impact of Event scale (Horowitz, et al., 1979). Experiment 1 is described in more detail below. The Long-Term Response to Rape There are two main categories of questions addressed by Experiment 2. The first category involves the long-term reaction to rape. Is it basically the same as the immediate reaction, only less intense? Is the population bi- modal, with seme wcxnen recovered and some in severe distress? What is the effect of the length of time since the rape on current functioning? What are the effects of the situational and individual difference variables, such as nature of the assault, age, socioeconomic status, marital status, etc., on outcome? The description of the long-term sample in the present study includes both symptom and coping variables. An additional interest is the comparison of this sample with other traumatic populations in terms of both symptoms and coping. The second category of questions concerns the relationship between coping and outcome. It is difficult to predict the effect of various coping strategies on outcome in any simple way. While active approach is expected to be associated with good outcome, active avoidance might have a different outcome depending on whether or not the person also approaches. Denial was lpp/> “MT' its ^11. *i, liilKi li »ft' f§'i 5 © S'# .-'«•' ' .' • Vi »!©«• f: bo-ji*” . ,« 4 ;r, 4M'M .rr,-f..,'t^ #‘v' r 1 '*1 Tff mft'i? ' ‘ ' (!• ''Ml' • " ' ‘ • ' . V 'V '^'V %U*^i»sa Tit Cl ,*^;B,n ^1' . „, . .nifi";' - r fln|j»iiKqi^ ti. t. < m'j '7».iKitjliii' $X ft' .c -Sk 'Y Wt7 «i . 4 *f('W •mi 0 fa iad '4 r-^ii^'t'f‘9t%i.f tf.\ <'V^. t -t V V <«4«* , t^-'lvf b , VA-Cii ' ' •' • ' . ‘.{J' ' . - , '•‘^t'-i :m |«v,,t;i:-i’&.T}-,jV.it;,t<»'^:'' sij '' ' ‘'‘ ' , I ir% .*'• ' »t» tfiftH . ir^;,, i:»a. of)^ V. (»r|^ ilCX(l( 4C ^ft’'lfl(^,,^'^2 ^ / ''iV. ® > ill m 'i^M .... »an • f«;tr^Kir« Itr f '. . . S®. f ;i^j '- .*»#v 4,^ 1 ,^y< 1 t ^ m mM > * . 1 X.v" .iJ .'i,I*I'*-iTO )';-:^.‘Xii 44 predicted to be associated with poor outcome. In terms of the overall relationship between coping and outcome, there is a possible sampling confound. Approachers, whether or not they are in distress, can be expected to volinteer for the study. The potential confound arises in the avoiders: while avoiders who are having problems may enlist in the study as a way of learning how to cope more effectively, women who are successfully avoiding (that is, having no symptoms) may stay away from the study, not wishing to remind themselves of the incident. The result of such a sampling bias would be that avoidance would erroneously appear to be a maladaptive mode of coping. Results relevant to this possible bias will be discussed in the Results section. In addition to the data on long-term consequences of rape and the effects of different styles of coping on outcome. Experiment 2 also provides further standardization and reliability data on the approach- avoidance scale. While the CRAAS is designed to measure coping strategies in response to any stressful experience, the measurement of outcome must be situationally specific to be meaniningful. For instance, change in birth control use is an important variable in an abortion population, but not in an injury population. While general measures of distress and adjustment are applicable to any stressful experience, specific populations require specific outcome measures as well. As seen above in the context of a review of the literature on recovery from rape, the following variables are important to assess in a sample of rape victims; fear, depression, social adjustment, and sexual satisfaction. Hie specific measures used are described below. Modified Fear Survey (MFS). The original fear survey schedule was developed by Wolpe and Lang (1964) for use in behavior therapy and research. Veronen and Kilpatrick (1980) modified the original survey by adding 42 items i. ,: ;Mv tk.. 'i^' »«A>W ' * ', , ^ - ", ,." . fi? ''^•.i,>*',TRia»’»..,i; , T. A.. '" ', . , jir ' sg’.' r*ri'- li f jitr s<' •’iifii'fWl vmM 'St I «» <: .jv.; \ .'ft iC«»\iC® “to rp 1 •; f>.^ m ,..;<|e( : : !H r.'i < ^».ifliMil, OfJ ''ill'f of r\ iV » * ^ ' > . *, ‘T i."!t>,»*i' , H UK jW' ,^'7 .1 t -tyd '* h / .0l i^ S;’»'4vivp ; W: lid, ' ' ^ 1^, . »-»*? Si ^9 A'^YitUi imi specifically relevant to rape, such as fear of being in a car alone or of going out with new people. The MFS consists of several subscales, including rape, classical phobias, social situations, and illness and death. Subjects report how much they are disturbed by each of the 119 total items. This instrument was found to have high internal consistency (Cronbach alpha = .98) and high test-retest reliability (r = .73 after 2.5 months). Norms are available for rape victims and nonvictims. Kilpatrick et al. (1981) and Kilpatrick and Veronen (1983) found that scores on the rape subscale and the overall total of the MFS were significantly higher for rape victims than nonvictims at 1 month, 6 months, 1 year, and 3 years post- rape. SCL-90 R. The revised symptom checklist is a self-report clinical rating scale based on the well- validated Hopkins symptom checklist (Derogatis, Lipman, & Covi, 1973; Derogatis, 1983). Norms are available for the SCL-90R on various patient and non-patient populations, including rape victims (Kilpatrick et al., 1979a» 1981). Internal consistency, test-retest reliability, and construct validity are all quite high for this instrument (Derogatis, 1983). The SCL consists of 90 items which reflect empirically validated primary symptom dimensions: somatization, obsessive- compulsiveness, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. While the depression subscale is the most directly relevant dimension, the other dimensions provide a well-rounded clinical picture of potential areas of distress. The SCL-90 also includes global indices of severity and extensity of distress. Finally, Derogatis (1983) has developed criteria for "caseness” based on T- scores of the various subscales; caseness is a useful index for categorical distinctions of subjects into recovered and non-recovered subsamples. Kilpatrick (1984) found that rape victims scored higher on all areas of the ' , * 'IV* f T8I 0 f K !i . » fjmt ' ' ‘ ^ .f? ^r' >\w A-iiBra , #»*.,• iHM?n •tii I Jt» ', 'no KO'I ' lf-'« m>if *«i ' ’’ '' j,'' ,. ; -.ui ,'^ ’>'’SS fli«)r<\ri^ 0 «»?i i3- ,8 t j* ..(nj c^(i;! ''; ^OC •-’''• i IC'l i^xdw n» ' 5?.v -,j..i. 1 ^ :iij V ^4.»:^a«f .'->'vXt»i K'S'<»4 .«i - •rf.J i'> ‘ «! . • iil-l 0 *f < « 0' t qf»l "r;! " ' I '{-S ''• *• I > ; #'% . * '»X iff'M * " ' "7 . if' 'rf:^: ._ _ ' ! “ fft .f*iit-JKi,r I.J '€ ' -7 il0 3($. nw ' > ^ K!'-;- B.: 0 ’^ : (aiJitte,* •) i*% iff 46 SCL-90 than nonvictims. Social Adjustment Scale-Self Report (SAS-SR) . The SAS-SR is based on an earlier interview scale of social adjustment (Weissman & Paykel, 1974; Weissman & Bothwell, 1976), Both the interview and the self-report forms are well validated, and norms are available for nonpatient controls, depressed patients, and other clinical populations (Weissman, Prusoff, Thompson, Harding, & Myers, 1978). Also, the SAS-SR is sensitive to changes due to treatment in depressed women (Weissman & Bothwell, 1976). Both the self- report and the interview versions have been used in research on rape victims (Ellis et al., 1981; Resick et al., 1981; Burgess & Holmstrom, 1974). The SAS-SR covers seven role areas: work (including work in the home or as a student); social and leisure; extended family; marital; parental; family unit; and economic functioning. In addition there is an average or overall measure of adjustment. In Ellis et al.’s study (1981), problems with extended family members were the most persistent problems for rape victims. Derogatis Sexual Functioning Inventory (DSFI) . The DSFI is a multi- dimensional scale of sexual functioning developed by Derogatis (1978, 1980). The only subscales that will be used in the present study are two ratings of sexual satisfaction. One contains ten specific areas of potential satisfaction or dissatisfaction, such as frequency of intercourse and performance anxiety. The other is a global rating of satisfaction. Norms are available for the DSFI on nonpatient controls and on a variety of sexually dysfunctional populations (Derogatis, 1978; Derc^atis & Meyer, 1979). While there are no norms available for rape victims, Derogatis and Meyer found that sexually dysfunctional women scored significantly lower on sexual satisfaction than controls. No reliability data on this instrument have been reported in the literature. » ^ ^0 : "'4.. : 1 . ,u k‘ .^4 ' to.; -V ' * 1^' ' *' T I ', : jiil ' si 'iffi» I ,* ..:,w •' ,;•" ’. v':j. •* '"di^'^!^''"v'''i^ ''^. A • •"'V • •O’# • •r: >-'r 7 f /, '' ' ' ^ - . . ' . 'r r ^ ''if., y::o: ; x ^ i ;-*ri. i mi^, ' i f»'tl ' 4>- ' -•6 . . -•- .IVv'V'i -- ' nistJt'' iti' -''" ' '''^ ' ' ' ' . u ji r^,Ai vert «n-j ^, .1, 'hmM*-~- -‘-inyrriaK p; '>' 1 - *' HU.i’A » fU>4 > *« V I 'ft;" J'''1i'flt'';t<|'^ v! J/* : '^r tf ; '. n .| I t |i»«4'tii; ,: '(^Wif; Riri'j , H'i .>.,* «i">y ‘ Ur . A#, : am ’W j\rr- 4 , - . .‘V (»:') ' ' tH'» S' I i. * |j« : , .iifjJ*»t^ <>| “Vi;^ ;vi. ';' ' ‘I .!?¥ nt «\i«'U n; " '... ' 0^; ' (''' irti ;,'’!?aS iS'' .1 iM Additional Sexual Functioning Questions . In addition to the sub scales of the DSFI mentioned above, two measures of sexual adjustment were included in the questionnaire. The first was a global rating of partner’s sexual satisfaction, using the same scale as the self-report scale of global satisfaction. The second was a question about the amount of time that elapsed between the rape and resuming intercourse. Demographic and Descriptive Measures . In addition to the outcome measures listed above and the CRAAS, the present study includes the following demographic and descriptive measures: age, race, marital status, occupation and educational level (combined to measure socioeconomic status using the Hollingshead two- factor index (Myers & Bean, 1968)), date the rape occurred, type of assault, level of force used, place of the assault, nature of the victim’s acquaintance with the rapist, whether the rape was reported to police, whether medical or psychological assistance was sought, and whether there had been any prior assaults in childhood or adulthood. Experiment 1 Method Subjects. The subjects in the sc ale- construction study were 332 undergraduates enrolled in Introductory Psychology, who participated in the study as part of a research requirement. Procedures. The subjects filled out the Cohen Roth Approach Avoidance Scale (CRAAS), described in detail in the Introduction. For the purpose of this study the following instructions were added: This questionnaire concerns people’s responses to stressful life events, such as death of a loved one, serious accident or illness, assault, abortion, loss of a relationship, failure in school, etc. 5 ^ ^•&n 'lif* ' ',,?> > , I % w^»lj » 1 ,i t i ^/ J ' \q ^ '^fji|il9i ' •- ’V t'T rvj ' SW .JS '*' ' ' ' ; '.•'*?^y' '^ irt.' - 4a'-, . *':? jU'T^i/'o viT.* i>.»(ll)’' vt^yo,V't' * 1 / V? ,vyfUAOt£'# /li nj »Ra»- » k r*w '’’H 4t>''.''Ot+?.ft'ttt' ''IC k? St^4 .’ i • ''. . .y, V'. _ ,-,.: . ' ' " ’ w . * * 9»Ai^* .'A r\, ; :?-^>'1 ^r^fH//lMC-J.^:,l!(l^l^^(l': '- •» „..; -i.f r'r,} ..-^ '• " -. . .'f M ( •* , t ‘ V Wv i» rUf i1pj» fti’r ^3?;l?3|'i H ' ,*t#^’L; : ' •, 'J -'*)' sif •'r^iUv/f '/.f ' .' ••'' '.. It •>'... 48 Please write below a serious stressful event that you experienced, and the date it occurred. Results and Discussion The stressors experienced by the undergraduate sample included bereavement, loss of a relationship, illness, parents’ divorce, moving, failure in school, and the death of a pet. Since the range of apparent severity was so large, an attempt was made to distinguish between major and minor stressors. However, when this discrimination was made, those with minor stressors endorsed the same level of intrusive symptoms as those with major stressors. Thus, the decision was made to include all subjects in the scale construction study. As noted in the introduction, intrusion items were included in the CRAAS because the format of the questions is the same, not because intrusions are seen as a mode of coping. In the undergraduate sample, the intrusion subscale of the CRAAS was found to be correlated very strongly with the intrusion subscale of the Impact of Event Scale (r = .93, P < .001). In the rape sample these two measures of intrusion were also highly correlated (r = ,95, p < ,001). Therefore, it was decided to continue to use Horowitz’ (1979) intrusion sub scale, since that scale already has considerable data accumulated on it. Thus the intrusion subscale of the Impact of Event Scale, rather than the intrusion scale of the CRAAS, was used as the outcome measure of intrusion in Experiment 2. Confirmatory factor analysis (CFA) was used to analyze the data on the approach, avoidance, and denial subscales from the undergraduate sample. CFA was used rather than the more traditional exploratory factor analysis (EFA) for several reasons. First, CFA builds theory and known information into the data, rather than simply fishing for relationships. Second, in EFA every « ' ^ mf *^'i*. iiW“<5t3ff» To ifryi ^ ijtvs .- ‘tfrui , ' ' '*'-- ' K. :' / v^’ - IjH , MC \ ,'. H/yti »it- nl b^tiU r“ ''ti ..d'l^W .*1'^ * U .tl'i t •.Ijrtl a(Ku *JC»k(j-': , #.)tt,9J|, »'f irrtJ »trw *f jjnoTr^n V'^ V j'V ; *'’•'». a >-‘4 >'1 ) 9X^:!2‘' ; y"., ...r -s: ' 4 : » ' ,tOf. ' 0*» 4 4 W ''Ml 5ti- 0 f aa.rt 1,4 **» Ii(ni*>i5tl , » ia«a j Oii «*1 f 6 .' Oi'iStail .''it . x.«'’*w - Its •f*J .,‘0 #^*D »('i. «?Yi».s\to C4 IT3 .-I»i a-i't U iA> t Ifcv ^ -* SQ^CJtl y '< t>vr iu y'V»v5< 49 variable (or item) is affected by every factor. CFA, on the other hand, allows the researcher to specify the exact model to be tested. In the present case, items on the various sub scales of the Cohen Roth Approach Avoidance Scale were theorized to belong to only one factor each, violating the assumptions of EFA. Finally, CFA allows for correlating errors of raeasuremeit of different items. Error of measurement refers to ariy variance not accounted for by the hypothetical factor. For example, if one approach item addresses talking to experts about the trauma and another addresses talking to others who have gone through the same experience, these two items might be supposed to share variance independent of the items’ participation in the approach factor. The possibility of correlated error is not accounted for in EFA. If the error of any pair of items is indeed correlated in the population, then exploratory factor analysis will result in scales that are invalid. The specific CFA program used was LISREL, Joreskog and Sorbom’s program for linear structural equations (Joreskog & Sorbom, 1984; Bollen, 1984; Long, 1983). The LISREL program provides the experimenter with several indices of the overall fit of the model specified. It also provides indices of the amount of variance of each particular item accounted for by the model, and suggests modifications that might improve the overall fit. These modifications might involve dropping an item, loading an item on a different factor or on an additional factor, or correlating the error of two items. Modifications must of course be theoretically as well as mathematically meaningful. After each modification the adjusted model is tested again for goodness of fit, until a satisfactory fit is found. The initial model consisted of all 47 approach, avoidance, and denial items of the original Cohen Roth Approach Avoidance Scale (CRAAS). As | 3 f}.T rJ("«44l ’ 1 ‘‘j I J ' I im ' 1» V V 'sv /-.J ' : '''w.f 1^1 ‘ I.V i / j J ra JN' ?,ll M i . fcJWWfl, I »>. » »c(.j i 4Nf«i>Tioo »<* .»'«•! Its OC '1.1' J'.Ci.lp&^'.;' 1. .. :.j t *.4Li i*v'.T» V .tf ' :' at'l r • s'6t» Bm, •/ \ C . tt.^ mi **y o f.K t.j i» fi I it Ijb (9 ‘ . % n 4* at r « I Jl» i'c'' ' ,# * ... . . ,r- .. . '.;-b'v- 1 fS* 'VtMhiH'M » ' {• # » V A 4 j.A't ': - «' luWii'^. .W' -SH'lii t,.f.'V'll /W'.,®.i .. Jfj® , .jS 'piS^^FL '.'l ... -fl,'; 50 mentioned above, intrusion items were not included because they measure a symptom rather than a type of coping. Using all items the fit was inadequate for a proper run of the LISREL program. Ten items were deleted on the basis of an examination of the correlation matrix for all items. Those items that were not significantly correlated with several other items in the same factor were excluded. Following this, the procedure ran, but the fit was still poor. There was evidence from the modification indices that the problem lay in the denial subscale. Items were deleted if R^, the measure of variance accounted for, was less than (.2). Many of the denial items had R^ of less than (.1). Items were also deleted if they had a large lambda modification index, which suggests that their factor assignment was incorrect. After several LISREL runs, only four denial items were left. Looking at these items theoretically, they did not appear to capture adequately the construct of denial. The items remaining were the following: I found that things almost never reminded me of it. I’ve almost forgotten all about it. I remember very little about it. I didn’t give it much thought. These items might measure complete recovery from a trauma as easily as they might measure denial. Thus the decision was male to drop the denial subscale from the CRAAS. That is, though empirically confirmed as assessing a single factor, it was not clear that this factor was the same as the originally hypothesized factor of denial. With denial dropped, the LISREL assessment of the goodness of fit of a two-factor (approach and avoidance) model required the re- insertion of the approach and avoidance items deleted earlier. These items had to be replaced because it was possible that they had been deleted on the basis of an overlap ' • ( A''u «*,• ,• IB*- ^‘',^'*-'*1 ' «.#w .’ r -Mj # * i 'fS^^OidM^O' ^ ' ***jfl. ‘ 'V 'jK iB /•dJ »ift^ ^i .frii-Jj> ir-- * ‘ : • «r<.t >W. v.l^'sifi i4Ji« «..if ill yt\3 .V(i '-'^il Y*i *.- -; vw U.f^ e i'-v j Uiihb Sti0'l 0 ii. /fcrfmaf -»-’'* '‘4' /- s^oa .4r/i 7 19.4 -t fivff :•-•,» yls’wvaU ^!Tt'J;»'* :>s'a(|'i't£ J'Og^“Mfc%VM3H':-.,=y|pty7^i:4^v^ .. *i 1'o 9(n- fi|ifc(Tj;>t'4t,i ' ' ' ..:.w4-.^. .tfi V t»a tUtc^ ttitiyuni.e- oiora .:'7 &: •»i<.«? xii hyiryb 4 rinlt .s jtjJfcrrftfci- ta i3*an|l'iei »c m "’<« ', ,- V i« !'.«> >.X4 4i« . 51 with "denial," a consideration that was no longer relevant. Again an value of less than ,2 was used as the criteria for exclusion. Furthermore, if correlating the error of two items was predicted by the program to increase goodness of fit significantly, and if this correlation was seen to be theoretically appropriate, then the model was adjusted to correlate the error. Following these decision rules, a model with eight approach items, seven avoidance items, and five pairs of items with correlated error was found to have a good fit with the data. That is, using the LISREL goodness of fit indicators, the model was confirmed. There are four such fit indicators. The first is the value of chi- squared. Confusingly, the exact fit of the model is the null hypothesis in this program, so a small chi- squared with a non- significant probability value is desired. In the final run of the present model, the chi-squared value was 87.28 (p = .382). Since chi-squared is affected by degrees of freedom, a second fit index of LISREL is chi-squared divided by degrees of freedom. In this case, chi-squared/df = (1.0M). A chi-squared/df value of less than 2.0 is considered a good fit. There are two other indices of fit in LISREL, both of which vary from 0 to 1.0, with 1.0 signifying a perfect fit. The goodness of fit index (GFI) in the present model was .967; the adjusted goodness of fit (AGFI), which accomts for degrees of freedom, was .953. Finally, none of the modification indices in the final run predicted that a change in the model would improve the fit. Therefore, by all of the appropriate measures, the assignment of the remaining approach and avoidance items to their respective subscales was confirmed Further data for the internal validity of the approach and avoidance subscales comes from calculation of Cronbach’s alpha coefficient of reliability on these scales. For this mixed- stress sample, Cronbach’s alpha 1 i It '* 1* «a > '• » „ n V *r . , T^‘ ^ ^ ,.,! .!»• *..V 3,t n«i •-tew' *ru, cJ 4 cu sav* ' ' ' ' ^ ' '’:^^' :• . 4 «' m^n n-'vfirv -f 4U« > '^^1v i«K^i (it/ 4':; * ' ''• . ' t 'II.J ,y l -wl) ft! :jj»'n/r :*r 1 ({»« '" ' ' '.' '/ i»:- .'•* J'^‘» vd i-(c I fli b«op«8- 'Tf* &>' *: 'U 'a ' ^ if ' f- . * . 't ‘ " '' '• ' ‘ - * * f -. "'.',»|j (/ , , i J J I ^>t>0l^4 s >, „ ; o t f ., S 4„ , , 4 >. • > . Ciiv^ Ms 52 for approach was ,80; deletion of any item would lower that value. The alpha coeffecient for the avoidance scale was ,86; again, deletion of any item would lower alpha. Unlike the denial subscale, the approach and avoidance items are clearly related to the hypothetical constructs of approach and avoidance. The revised two-factor, fifteen item CRAAS is included as Appendix E (p. 117). Before leaving a discussion of the factor analysis, it is necessary to justify the correlation of error variance in the five instances in which this was done; a suggestion by the computer is hardly theoretical justification. Recall that a theoretical reason for correlating errror involves an assumption that two items are measuring the same thing (to some extent) independent of the factors of the scale. The five pairs are 1) changing the subject when someone brings it up and avoiding reminders; 2) keeping it out of mind and trying not to think about it; 3) looking for people who might understand and wanting to talk to such people; ^1) wanting to forget and wanting to remove it from memory; and 5) (a negative correlation) thinking about it in spite of being upset and removing it from memory. These correlated errors do not modify the way in which the subscales are calculated, but they make the internal validity of the CRAAS much stronger than it would have been using an exploratory factor analysis model that did not allow for such correlations. The final consideration in the discussion of the scale construction is the decision to develop a new avoidance measure, rather than use Horowitz* denial subscale of the Impact of Event Scale (lES-D). In the initial attempt in the present study to factor analyze the CRAAS data, several items from the lES-D were placed on the avoidance sub sc ale and several on the denial subscale. This arrangement was based on the view that Horowitz’ scale ‘ . ' . ' .‘'-•‘'jfiri'''' ' - t :y«.. T';;V\i,qn .v '•w4»',*\4. w'-'m 'I'.-- • * *i - -. «ftV' 14'M' ^ tVi;i;;Vl4 m mmlli . • • 'I ••/•' ? 7III.X ' rtfc- 5^ Jt ;j;ndd . Wi '^‘SWm ' » t .nrv I '%.ia ' . ' '• ' " V V.. .< < t ;./t^ '. 4^ tf” tK; ’>^i| " " '5 •• r , . • '* <"••!•• ^yy' A»u.i I ! ^^^ * "M’*' J .r'' 0 r i< Ju '-•‘ri’. ' V ^ ' •". ' . . ,‘MlJ.i.i: I , mf/'l ’ *‘ •"< •:• • -i " i V tisi i^4- . 1 1 f -!f ^ - Vit>i 4*».l j,. ,• ', i'i4/'.'*v4)r.e:;-' >4!2^ ‘‘ ' ' ' >•' . ‘-LT^'Si - • Uw itJ' . -I) W.«i>vk -.iv^: gj (VI*:** ,.’ 'Wr:'' 53 combined the concepts of denial and avoidance into his single subscale. In the final LISREL analysis, the denial items were of course dropped, and three items from the lES-D remained on the CRAAS avoidance scale. Even thoigh the lES-D and the CRAAS- avoidance correlate highly (r = .87; p < .001); the decision was made to use the new scale rather than the established lES-D. Ihis decision was based on the theoretical coherence of the CRAAS sub scale as compared to the lES-D. The latter, which consists of items such as feeling numb and feeling as though the event never happened, was conceived by Horowitz as a symptom measure, not a coping measure. The CRAAS- avoidance subscale, on the other hand, is a straightforward measure of the range of avoidance coping strategies. Additional data on internal reliability of the CRAAS using data from the rape sample will be discussed below. In the model of coping presented in the Introduction, a distinction was made between denial and active avoidance. Ihe inability in the present study to obtain a theoretically meaningful and internally valid measure of denial does not undermine the existence or importance of this distinction. Not surprisingly, denial is a concept which is elusive and not easily amenable to measurement. This difficulty is exacerbated when the research is limited to self-report data. Unconscious processes have never been measured simply, and even complex techniques have fundamental problems with reliability and validity. Perhaps denial must be measured indirectly, for example by memory for material in the appropriate area. Alternatively, perhaps physiological measures, such as Gudjonsson's (1981) method of measuring the discrepancy between arousal and reported distress, are the only pathways to measuring denial t , ' . ' In" '^'1 .',•^^*(1 )l f|. SiiiiSB u ' ' «?' - »• ?' • < tl# H ' 4 , *"r ' ‘'V4^ # ^ ^1? « -r *> Vtt #nt‘h > ' IF." 'Mi j„ •t ’ !• “•*•* c -Aii^ J f ,.i ' r ^' '<> ' • ' f - %jf '»,i:Kj *>' Tv' 'S(N ;5i: •. ' "» r -::.^ A;n c - . m ' , »f ‘ ' ^ , n | ‘•.» 1 • ^ iv •:"^jr,'-.. ,i:c ! :» » ' -'. • " '5 "I - , . 'r-i" :».. j.. , ; v;/i ! tffi *' 5®, '^:.? :'.:';i*'" ,. V « '1* V ' -f -i./'^5. «, f. I's^ tr.'/.' ’M ,.t. ' i"< 'Vrtf to * ' ' ' ' '" ' fi' . ‘r -v , .JV' .- .' -• »»:)' * It <«., \ j i ,»w 1 h(T»» •yi'Ht, j', • ’ ' '- V • 'V ,:. > M >; »••*,•:.'; ; r»; •»<) i 'vi : ^ . ,.««||^4l liJk t> ki. '"ski .n '4js!? » ; Ai\ 54 Experiment 2 Method Measures . The measures used in the rape-recover y study were the Cohen Roth Approach Avoidance Scale (revised as described in Experiment 1); the Modified Fear Survey; the SCL-90; the Social Adjustment Scale-self Report; the sexual satisfaction subscales of the Derogatis Sexual Functioning Inventory; two additional sexual functioning scales (partner satisfaction and time between rape and resuming sexual relations); demographic variables including age, race, marital status, and socioeconomic status; and a brief set of questions related to the assault itself. The coping and symptom scales are described in detail in the Introduction. The entire questionnaire, including the cover letter mailed to subjects, is included as Appendix A(pp. 101-116). Subjects . The subjects were 94 women who responded to an advertisement requesting participants for a study of rape victims. The advertisements offered free educational sessions or participation in a free therapy group for any subjects who were interested in these services. A sample advertisement is included as Appendix C (p. 118). Of the 94 women who responded, 73 returned their questionnaires. There is no evidence as to why the others did not follow through with the study. Following Kilpatrick et al. (1981), all female respondents who described themselves as rape victims were included in the study. Six of the subjects had been raped as children by family members. Three male rape victims who responded to the advertisement were excluded from the study and referred to the Durham County Rape Crisis Center for services. All subjects in the study completed their questionnaires before participating in any of the educational or treatment services provided. ^ , .‘IIS' ' ^ j-i«» t is^ ^..JiA:>f Mi '’ '. ! * t:^• V' 5l 1 ,» ' ;!; ',i' -'.li T . ,f p ii,d «Wif " ;'JM;;J ' ' ' " 'J' uj® ''^; " #; 4 “• V Vr WIF' ,'• 'J v.ye'Tftk-ia, *.' .*»'? i : . ' ^ • .*: »«.'| C-| Krt *.»vit'ilf’ HJfiWl# Ktito I fs tmim V <1#^. ' 'fcAjf >K\-i '®' ’-t}4J > liji TviTVv,/ . II ,, svm^ ... • ,'''',‘--i ®.-''iC,iV «i ' ' '' '-‘'^ '' ' ' - . M . ‘ t i'm r-* , *: it -lo :i u •! si",'' 4 55 Results and Discussion As mentioned above, the internal consistency of the CRAAS, established on the undergraduate sample, was corroborated with the rape victim sample. In the latter sample Cronbach’s alpha coefficient was ,78 for the approach subscale and .82 for the avoidance subscale. In addition to internal consistency, the present study provides data on the construct validity of the CRAAS. Several questions were asked in the rape-outcome study about behavior following the rape. As expected, women who reported the rape to the police were significantly more likely to approach than those who did not report (t = 3.8, p < .001) and significantly less likely to avoid than those who did not report (t = 2.14, p < .05). Similarly, approach was negatively correlated with time taken before telling someone about the rape (r = -.35); avoidance was positively correlated with time before telling someone (r = ,28, both correlations significant at p < .05). Finally, women who sought help after the rape from medical, psychological, or rape-crisis resources were significantly more likely to approach than those who did not seek help (t = 2.99 1 P < .01), although they were not less likely to avoid than those who did not seek help. Thus the cognitive and emotional aspects of approach and avoidance measured by the CRAAS were consistent with situationally relevant behaviors. The implications of the construct validity data presented above are not straightforward. If reporting to police, confiding in others, and seeking help were considered to be beneficial behaviors in and of themselves, then there would be clear indications for counseling rape victims to approach and not avoid, at least to the degree necessary for accomplishing these behaviors. However, friends, family, police and judicial personnel, and even medical and psycological practitioners are often non- supportive to the degree ' "m ' "j «4|bM0' Wa •'1^^. . : M iv ,-.J 1 «vif I cl 5t -*• • ••V' 'fi -w, . 'iwrtf ^4 ' ' ' ' ',"?; ' .T ' ' '' . ; .-/ t ... , -i •''ftw ft ‘..'i^J4 #p i’s/r'<*^R^'' p®4 t ^ m t.i w ‘ y ' .. wffi ? '•' ' '‘3)‘'| t‘*.» /..ur 'Ti^j,!.. h'flii . , •, I'R’-V q ’»|jp;)^.'> ^ TiV :'%k •' -’<' -M ( 4 <11 i' iu f, lx !: ^ / l^„,-;^J.' ^riv;* J’J r.,i5|i» ,T'i45''i ,^.SS, st >1.) ' ' ' ' “ .i. .{•• ,.,' . 5*5^ Wr,''' ’.- '«* << I , 'ly-ns i^.vi ,-.i4 ' ' .. ^ . T i" W'H ' " ' ' ^ : V Ji • IV'I<( V / I'l <1 ’.| M'j ’ '.''.•’’y ' .' 4' '(!'« . '~' '< >1 .Ovl a n n ’4^:^r'‘ ' , A ^ ' ••••I7 i-.*'» >J'i<*r >v jon ftJkb t'rtw Ai^rp'-. I . - tr|f» ‘i' vO *iu<’,fc ? )aj <''V.»i, 'V'' <''“5t«>ir i.qii'ii' lA' i 4 *r* .-. f 6f.u . 5"i-^-trc »», : ?-«<<*¥• ''“f t\n. ol !..J«-i'e'jf.i n '<1 : T‘ { . > t; H-t'*' ,^^.<7: /'Malypp- "i Si ^ rt/w f»M73iC'a^ to I , ' t««p :4'.; ' ' w' . .» -'ll n,^ ly ‘ ' J m . j Hsjflw* ri9^ ^>4 56 of contributing further harm to the rape victim. In fact, the reaction of society to the rape victim has been called "the second assault” (Williams & Holmes, 1981). The literature on rape victims is full of reports of the additional psychological injury caused by husbands, boyfriends, friends, parents, police officers, lawyers, judges, doctors, etc. (see, for example, Brownmiller, 1975; Russell, 1974; Silverman, 1978). Of course, other women report very positive and supportive experiences with people in these roles, as well as with rape crisis counselors. Nevertheless, it is important not to be too hasty in deciding a priori which post-rape behaviors are likely to be beneficial to the victim. Specific data on the relationship of outcome with behaviors such as reporting to police and seeking help will be discussed below. The main results of Experiment 2 consist of the description of the sample in terms of range of outcanes, and the relationship of outcane to demographic, situational, and coping variables. Description of the Sample Table 4 consists of a description of the rape victim sample in terms of demographic variables, certain aspects of the assault itself, and several post-rape behaviors. In addition, comparable data, where available, are reported for Kilpatriclds (1984) rape-victim sample (142 women tested immediately following a rape, with a subsample followed-up for several years). These data are provided for the purpose of judging whether it is appropriate to use Kilpatrick’s matched non- victim control sample as a comparison group in the present stujy. As can be seen, the samples are quite similar, except in race. While Kilpatrick’s sample has a fairly even racial distribution, the subjects in the present experiment were almost all white. There is no ready explanation for this discrepancy, given the racial ^ , W: ' S: .tP..•JI- m " niy' r '|4 *. ** 'iM 1 'f ."': ^: •'V,fi.:'. . -"fU'm f lut. w lo', ' '1 • IIS' 10% i Mv‘ Uf U i ,fi‘ ''' ' '•' ' ' '' ; ^ f rdJ «'# tiaf'U biM , iT 4 4 w t c j’ " '«' :rK* < • •• -' • r J' .^rtj a» : ^ bi'^ ^ »j j Tf tt , ; ’W) ' ' ^ " ' ' '•^^''. ' ' 'W ’flif ~U ,'t^l . ‘Afft' lo .•/!)( Jitifftct, ' ' ' . Tffiiaff ( 1 .;T''v;' - "*'< f-j vitf. 'J 'jii’#..iaf>i''l4/ 1 '"„ % .- ft »»3 .. 1 , ^' ,> *<.. ^til'i'f' 'V- 0 ! :i \f' f ls¥ ', • » .' '.««•» i' *v»iA I > u a ' i*' 'I . i\«iv ''>^ rF4 4> :r '* • 40 w <: #*' ' *^' ’ ' ' ' ' ...''* . 71 • , \.. \ ^ '*• * •• . » *i .» Ik* ‘ *10 ';. ;i* I (isr 4 , ' '• ' •'' ’" '^ :' ' '. ',, \ r . -> '.|0 - $J^4 i -ik l*t.r*>: tfilfjj', ^ •«4 *»^.sierw 57 Table Demographics, Nature of the Assault, and Post-rape Behavior in Two samples Variable Duke Kilpatrick (1984) (n = 73) (n = 142) Age 29.7 (6.9) 26.1 (5.8) Years since assault 8.2 (7.0) Age at assault 21.4 (7.3) Marital Status never married 5^% 41.4% married 31% 26.1% divorced 13% 11.3% se parated 6% 16.3% widowed 0% 2.0% co-habiting 0% 3.0% Socioeconomic Status 1 (highest) 0% 2 ^n% reported 3 64% not 4 20% 5 (lowest) 1% Race White 97% 57.8% Black 2% 40.2% Other 1% 2.0% Table 4 continues ti*,t ' Jll^i . \ I fo.*; .Vi tnt>!,i l»' •-M. 58 Table 4; continued Variable Duke Kilpatrick (1984) Relation to Assailant stranger 52 % 52.02 seen before, but not a friend 242 33.02 date/ friend 5 % 8.82 bo yfriend 3 % ex-boyfriend , ex-husband 42 husband 12 relative 102 2.52 other 4.72 Type of Assault intercourse 83% 92.02 attenpted intercourse 102 8.02 other sexual act 1 % 0.02 Level of Force Used verbal threats 42 restraint 232 violence 212 not reported displayed weapon 322 used weapon 142 other 42 Prior Sexual Assaults yes 352 not reported no 652 Table 4 continues ) 59 Table 4, continued Variable Duke Kilpatrick (1984 Age of Prior Assaults childbDod 60% adulthood 16% not reported both 24% Anyone told about rape yes 96% not reported no 4% Vfhen others were told less than 1 hr. later 43% 1 hour-1 day 20% 2-7 days 6% not reported 8-30 days 3% 1 month to 1 year 10% more than 1 year 1 9% Reported to police yes 57% 93% no 43% 7% Sought Professional Help yes 74% not reported no 26% JCit 60 distribution of Durham, and given that advertisements for the study appeared in the newspaper serving the black community. In spite of this difference between the two samples, they were considered to be similar enough to use Kilpatrick’s nonvictims as a comparison group for measuring the level of distress of the current sample. Table 5 presents the means and standard deviations for all of the outcome measures used in the present study. For comparison, the values for Kilpatriclds (198^) immediate (6-21 days post-rape) victim sample, where available, are also included in this table. In addition, various nonvictim samples were used for comparison purposes. For the SCL-90, the comparison group was Derogatis' (1983) female non patient sample. For the Modified Fear Survey (MFS), the comparison group was Kilpatrick’s (1984) nonvictim sample. For the Derogatis Sexual Functioning Inventory (DSFI) , the comparison was to women without sexual dysfunctions (Derogatis & Meyer, 1979). There was no comparison group for partner's sexual satisfaction, as that scale was developed for the current study. Finally, for the Social Adjustment Scale (SAS), the nonvictim comparison group was a female community sample (Weissman, 1978). As can be seen in Table 5, the long-term rape victims in the present sample scored higher (i.e., worse) than nonvictims on all subscales and global measures of the SCL-90, on the full scale and the rape subscale of the MFS, and on the overall scale and all subscales of the SAS. These differences were all reliable (p < .001 in all cases for two-tailed t- tests). The specific areas in which these wcxnen differed most dramatically from nonvictim controls were depression, interpersonal sensitivity, rape-related fears, extended family adjustment, and parental adjustment. On the DSFI, a lower score signifies a worse sexual satisfaction, so rape victims can be a ^ <> .-‘"t-.fi* ri’.re 'v?" w> '.**.**' /C»ft ' ‘ m-;. .,.^f''' , ( • '. 1 ' •'•l! •Jt^i' "* ' C-.’ (1 .% il-illf.- Alt' d4 'jir. cpa-'S;h J D » y > 'n>i rj|WP 3 H :j„:,. : wV, {fe- .: ;At*-a^ ikw iNi ;x^ 6H§|s 0 1 f.*«*£a.v »rt.-» ,,'0^1- -m't nl --ft.-tv ,Alq^ir%. «“»-)’••« :.-uil-i •rt¥* 'i- taal M4 r>iv .••‘Istitiitt ''is*> sq<-Oi^ *^la£0^5' .Jwirr-^ aii-^yooni fWr; '* *)iOi iJaq,u*f ssw •J Irt-W eft*- f /atj'nDti omff ^'•/•vifiavnl' ^ M ' ., ^ iOaikiMC^IM U . mil '.^>^ , TfioiaA v^iOUPiAoo .*Ji.'in: e fta*; Adslrtssiqta^^ ' ' ' ' " '' ’ - 5 -«!, • - y 4 a fiaap-Kj /Ji 'T i^tl i^;*' ", A '.. '.':", (WM ujflr i€ Jt^t r?> ’rn> inrvl* .:’V,tert '^944 ^ v:.. ^ ^ All r ..-ae. -ft «lfc « iaxa' tXVJ •*v.-r #4 .‘; Jv fs » ' • ' ««‘'' ' ' «•,"'• . '^nf'.' . 4 .«. 1 ' >•-.; :>» <-* '’J i.*-K3irJ’ lui e6&«s X4V rfeti., > ; ^ :/« mnt Jr trpf ik,' ' 5* 1^ 16 iC .-i’'. * 4!t6 , «o £^^^ "pm mf i^ffP 'TR'» ‘i»‘ iRRAti." 61 Table 5: Comparison of Rape Sample with Nonvictims and Iiiinediate Victims Measure Duke Nonvictim^ V ictims^ 6-21 days post^rape (n = 73) (n = 122) (n = 142) SCL-90 som atization .76 ( .75) .36 (.42) 1.2 (.8) obsession 1.14 ( .89) .39 (.45) 1.7 (1.0) int. sens. 1.22 ( .93) .29 (.39) 1.6 (.9) depression 1.40 ( .97) .36 (.44) 1.8 (.9) anx iety 1.05 ( .93) .30 (.37) 2.0 (1.0) hostility .76 ( .91) .30 (.40) 1.2 (.9) phobia .62 ( .88) .13 (.31) 1.8 (1.1) paranoia .99 ( .96) .34 (.44) 1.6 (1.0) psycho tic ism .67 ( .70) .14 (.25) 1.1 (.8) GSI 1.00 ( .77) .31 (.31) 1.6 (.8) PST 45.06 (22.80) 19.3 (15.5) 59. 2 (19.5) PSDI 1.81 ( .59) 1.32 (.42) 2.3 (.6) (n = 73) (n = 143) DSFI satisfaction 7.44 (2.55) 8.00^ global satisfaction 5.21 (1.87) 4.25° partner satisfaction 5.73 (1.93) — Table 5 continues , 62 Table 5, continued Measure Duke NonvictimS V ictims^ 6-21 days post-rape (n = 72) (n = 173) (n = 139) MFS all fears 27 9.65 (67.82) 2^12.1 (64.7) 309.6 (82.3) rape fears 108.07 (25.92) 88.9 (23.6) 121.0 (34.7) (n) (T) (s.d) (n) (T) (s.d) ) Work 70 1.77 (.56) 272 1.46 (.50) social 72 2.32 (.60) 277 1.83 (.53) extended fam il y 72 1.99 (.54) 274 1.34 (.35) marital 31 2.08 (.65) 191 1.77 (.49) parental 20 2.10 (.80) 175 1.43 (.43) fam ily 54 2.19 (.77) 270 1.54 (.62) econom ic 71 2.00 (1.2) not reported overall 72 2.06 ( .45) 277 1.61 (.34) Nonvictim samples i ^ Kilpatrick SCL-90 : Derogatis (1 983) DSFI: Derogatis and Meyer (1979) ° S.dS.d.'as not reported MFS: Kilpatrick (1984) SAS: Weissman et al . (1978 ) *' * ® I J^i/r t. . 63 seen to be more satisfied by one measure and less satisfied by the other. However, neither difference is significant. The absence of significant findings in the area of sexual satisfaction may be due to the fact that mariy of the subjects (31%) were not involved in a sexual relationship at the time of the study, and thus were not included in the mean sexual satisfaction scores. At least some of these women may be uninvolved sexually because of unresolved sexual problems stemming from the rape. Without an in-depth assessment of this area of functioning in the victim group and a control group, it is difficult to gauge the level of sexual dysfunction in this population. Table 5 al so reveals that the long-term rape victims were considerably less distressed than victims tested 6-21 days after the rape. Again, all of these differences are reliable (p< .001 in all cases for two-tailed t- tests). These rape victims, tested an average of 8.15 years after the assault, were significant! y less distressed than victims tested immediately following a rape, but still significantly more distressed than non-victim or non-patient controls. Kilpatrick (1984) presents follow-up data on the victims that he and his colleagues studied at several points in time post- rape. As expected, most of the symptoms display a consistent pattern of decrease in severity over time. In most symptom areas of the SCL-90 and in overall fears and rape fears, the present sample scored roughly equivalent to Kilpatrick's subjects at three-month testing. Depression and interpersonal sensitivity were slightly higher in the present sample than in Kilpatrick's three-month group, while phobias were considerably lower. The pattern of continued improvement of Kilpatrick's sample over the first several years following the rape was not found in the Duke sample. The improvement in Kilpatrick's study may have been due to a beneficial impact of repeated tUJt vhi^t Ni-a j.*»c4)ifti firV^o ->o ’'^KJ* afjt rar>.-» >!«*» ‘s.iJ 03 -ui>''3«( " ^ ' '1 . : ”# ^ t^; J» s‘tLiWficJ^^BXArf ki ;if ‘ baVlibvitl;' .^'®^'*tf?w.;^ ^i"'" ; t.» »» Lst^ »9<, . «S!>nt ':^4 ^tl]r- hj ky'p$ r , 1 !v skuftvbJ -5*e m .!.r^ I '» OiM. j i ,« JlL: Oti i iW . f»1 t>H J rnoi.’lt v*.s?v»^-«*fcf:, >'f ^ , i*Vijeo t bii/2 '4i. «/:'t ‘fi 2 j crtu'lKy b '>3 b lo X»V3 j! ii(- f-^^ili^3."c>:^ .MiJi W':S J ^fil ,'• •• 'j^-‘'m '*'0 ^(,il';roJy fniivt ais»4-Vi’bj!: &23lf4 ;isdJ?'b’iaay9ka',^>^ *' ‘ ‘ ' . _ ' ,, J' •'’fs ^3] rc_.^ lO I/s , OA ,i>JGT ‘>[i-f s j\ob rs-a 'b9v/i^.9ij : V; Lr?/'irf-.w.J •«c! **r iXtt -»t f 0(^ > g). ' .^.r; _v^J' ?.7w' -,-j';a e-iaiiY 2f,"j >10 a^in^Va y I f*'. ^iT(•siTfCu 2*0 Jr-»J e fqiJoiv uSiii' ir: .nUJ.ly-nc.T K->FiifXtztb >'y^^p, "~ '’ ,'. ,%.''!‘n)'^X 'tf ,: ; j-n-iAt* rj a.iUOii fs*s:.*w»' .;/i b:i»tW4t' ,. % 9 tjeq J,.^ mimuorr s y«l4«!ib fesa,a4qijrY8 ' *' ^ '.' ,, ;.' ' 1 '\-j!X: ofij m 4:5'^'jfcr ~M .:.;>» ^‘i Z:, ,<;• .i. ,v< ;>.in2naif 6*3^14: • • - .-. J' J i-'-?-?ngsKl .; ^ i >) A Mtiii; 9 i)4 mtfi5 4 v?- 93a_ 8 i1 i< lU ' ^.;Vit''k , ,.:!r,Uf; , ft .^}:,vi 8»Tt‘ .iti-HoX V W3-T.^s-i , tT""' ''':,;5p^;c^:.;>'?M'^?^'^''i^ '''’'" .yrl4 ovo 9 i’*" rtX 2nYi»vc‘»Q.'nX srtt 64 assessments or due to selective attrition. Alternatively, the present study may show high levels of symptoms because of a possible self- selection of a more distressed sub- population of rape victims. Tables 4 and 5 present comparisons between the long-term rape victim sample and other rape victim samples or nonvictim control samples. Table 6 presents comparisons between the long-term rape group and other stressed populations. The Impact of Event Scale (Horowitz et al., 1979) has the most cross- population data. As can be seen in Table 6-A, only immediate rape victims are comparable to the present sample in level of intrusions, and only immediate rape victims and mixed-stress psychotherapy patients are comparable in avoidance. Clearly the chronic rape victim sample as a group is still experiencing post- traumatic stress disorder. (Note; As discussed at length above, it is important not to confuse the Impact of Event Scale-Avoidance measure, a symptom index, with the CRAAS-Avoidance subscale, which is a coping measure.) In other symptom areas (Table 6-B) , the long-term rape victims can be seen to be less symptomatic, as measured by the SCL-90, than psychiatric out- patients. Similarly, the rape victims reported better adjustment on all areas of the SAS than acutely depressed women currently in out-patient psychotherapy. However, the victims scored worse in these areas than schizophrenics, who were also out-patients receiving psychotropic medication and group therapy. Finally, the rape victims (at least those with ongoing sexual relationships) reported themselves to be considerably more satisfied sexually than women seeking therapeutic help for sexual dysfunctions. These data help to place the rape victims' distress in the context of a range of psychopathology. That is, rape continues to be a serious trauma resulting in fairly high levels of symptoms across a wide range of problem areas, even ' ^ •m^ r ®- m ' ’ - ' '. '«.' ,'' " ., .m SI hm »*i* j * iijtff < 4'nyiih / Abbs :mli : XM w»4*M s“^K# b.^'fliraA vi'^» > .^1 ,' ,,''''' ' ';' VSFl , / : '.•i’*" 1 ‘Mpy I'/t, ^(i .T t^'' •>f*fui 'j A—^ - S 1 N V li . '4 (^0 . , '.‘V. -.; Mj»i' 4*' ** : • V <»| I'H ^ /v I a<<4; ' i,,ij .|, '>, ip '-iii -JVC DJ T.TS'fK i7 ' -UU ItfU , .... ' tn n Jtmv.f e.)~ t 'v^'b ».i?; Jh f -JUL n/ ' ' V ^’, .''t'is T.-’’ S*''. iTi(M ’ •**r'W , 9i'^/ sw(^\41 S'}..! r .'.tt iji >1 ,'| yen tort ‘ V '. .-• '. - '>'4 ' '»•*? •5/1.-', V*:m 'rJtO'ttt - ',-« . •->... '"•;< . 'A-' "' "Jv . , ''T'./. .. >(j^- . ,a)(i,. AA . , ^ '#ii,' Mfcs: *-h,;W X f^l!,n^)l^^lRrtC':, '''" • ' .; .V- V''c; a''" 4 ’ <'» •’ ' >*^ itr th nn I vV Mi‘ I D i I Wt 'S|.; ' >) .»' '" ' ,’ '- ' ' '.ji .’if^„' ' 'X'''- •'#’?-V -^'a'^ ''s -.« 4 a>Ii.*#i ^ IbH f4 0 ' b«' ' ' ' . . . ,* , '^'-'IV.^S^', V? ) 65 Table 6: Comparison of Long-term Rape Sample with other Stressed Populations A: Impact of Event Scale Intrusion Avoidance Duke rape-victim sample ( n = 73 26.5 (6.3) 24.1 (6.6) Mixed stress® (n = 66) 20.6 (11.0) 23.1 (9.4) Bereaved psychotherapy patients (nr 35) 21.2 (7.9) 20.8 (10.2) Bereaved nonpatients^ (nr 37 ) 13.5 (9.1) 9.4 (9.6) Victims 6-21 days post-rape^ (n r 142) 25.6 (7.2) 27.2 (10.4) Abortion patients^ (n r 55 ) 17.5 (9.1) 16.7 (9.0) Cancer patients® (r1 = 35) 6.7 (4.9) 17.1 (7.9) Adjustment Scale SCL-90; and Sexual Functioning (DSFI) B: Social (SAS);; f Duke Acute Depressives^ Schizophrenic (n) 6C) (s.d) (n) (x) (s.d.) (n) (X) (s .d .) SAS work 70 1.77 (.56) 149 2.47 (.74) 35 1.66 (.78) social 72 2.32 (.60) 155 2.83 (.65) 35 2.37 (.77) ext.fam. 72 1.99 (.54) 155 2.15 (.69) 35 1.66 (.79) marital 31 2.08 (.65) 93 2.46 (.58) 19 1.98 (.75) parental 20 2.10 (.80) 101 2.25 (.82) 18 1.61 (.67) family 5M 2.19 (.77) 140 2.86 (. 91 ) 29 1.85 ( 1 . 02 ) overall 72 2.06 (.45) 155 2.53 (.46) 35 1.95 (. 66 ) Table 6 continues >•» V' > ».“ ’‘I? i.'V ss.:;) o.e*; r-.e) \r.e) §.tt /&.U) v.^y- ''- '' ’'-a. : 4 1 r-> c> ,cT) in) ;;• . ,«'f . iKi »‘v.) V,';. t [b.^ e-?. ^ (*•:• • " ; w ,, ^.r-', / .; :-^ V , ..H- • . I *« lu f * ->3 « ' Ci* . :'t:3 vfj t-: ue.?' ••^^i i*0 ,f ’ •• • »* '. .vi :i viruii; Jnc i4rjT Table 6, continued Duke Psychiatric Outpatients (n = 73) (n = 577) SCL-90 somatization .76 (.75) .87 (.75) obsession 1.14 (.89) 1.47 (.91) int. sens. 1.22 (. 93 ) 1.41 (.89) depression 1.40 (.97) 1.79 (.94) anx iety 1.05 (.93) 1.47 (.88) hostil ity .76 (.91) 1.10 (.93) phobia .62 (.88) .74 (.80) paranoia .99 (.96) 1.16 (.92) paychoticism .67 (.70) .94 (.70) GSI 1.00 (. 77 ) 1.26 (.68) PST 45.06 (22.80) 50.17 (18.9) PSDI 1.81 (.59) 2.14 (.58) Duke Sexually Dysfunctional Women^ (n = 50) (n = 40) DSFI- global satisfaction 5.21 1.85 ® ® Horowitz et al . (1979) Manuel & Roth (1985) ^ ^ Zilberg et al . (1982) Weissraan et al . (1978) ^ Kilpatrick (1984) ® Derogatis (1983) ^ Cohen & Roth (1984) Derogatis & Meyer (1979) ^3 -h ''' '" '^' \ / (rfe ^ ni '*.5->T"W vI4S)tiJt5*S — - - — -»- N'.t — • 1 >»|1 W,< ij ^ M — »— m il— * A»^if . t ll#BW— |H||^ <(VU t .i/ . 67 after five, ten, or twenty years. Though the wide range of symptoms present at an extremely elevated level immediately after a rape drops off considerably, at least during the first few months, they remain elevated compared to nonvictim controls. In the specific area of post- traumatic stress (as measured by intrusions on the Impact of Events Scale) however, the long-term victims remain at the extreme end of the psychopathological spectrum The Range of Outcomes The previous section closed with an allusion to a subset of the subjects in the study who continued to manifest extreme levels of various symptoms even many years after the rape. As usual, the mean values described above and compared to other populations do not give a complete description of the sample. Some women scored in the extreme pathological direction on virtually every outcome measure, ethers scored better than the average nonvictim. Still others scored at some intermediate point between these two poles. Overall, the sample was skewed, with more subjects scoring at the pathological end of the continuum. Eurgess and Kolmstrom (1979) reported that 11 % of their follow-up sample felt that they had recovered within a matter of months; felt it took years to recover; and 26% felt they had not yet recovered after four to six years. In the present study, after an average of eight years, more than half of the women seemed clearly to be unrecovered. Thirty nine (53%) of the subjects, fit Derogatis* (1983) definition of "caseness" based on the SCL-90. The criteria for caseness are that two subscale scores or the global symptom index score have a T-score greater than 63. This construct of caseness was subsequently used as a global outcome measure, because it separated the sample roughly into clinical and nonclinical groups. ' M ' 'yfl'.'', ''.Sa.' » •»' - ^'. Wnr. ^ iH'iCH ..:'»i^'? fis*! c^'t pv'i^#i^‘«j 4 fine' W ''' W ^. . . "* ^_. V «»-® , l«l < l ,T<> “ ‘' ' "" ^ . SiwT#' ?: w....;- » "'i. '' 7'\': .-b«i tM'i a,ij^ I0 . ^ < .Jb; t.^: 3 '!)’., 'f%.iTyty a§'-'-toc433V..£> ' -- ' ’- -- ^ ,^0. s w,: v.Aw is^:VyVb ,*'iU it%* • ,>. , ./ ^' \ _ __ _ - '>\id*\; J'tt ^'il,*tot)C Ha«i»r qi/.^^iin-r ^iartv* ip '^1. " _ P.v>' E 1 -^'^ :’» 'ij.*..l 1 i-’^itt ,a :r^»Y' Jo W' ) ‘ ‘ ^ '•%'% r ' »?ftt," ij, e 'ni'it : ic^.r ,;'^-j!?^ u'f’ ’'O' « There did not appear to be any pattern of specific profiles of response to the rape. That is, it was not the case, for example, that some women scored high on depression and poor adjustment while others scored high on anxiety and fears. Rather, all of the symptom measures were highly intercorrelated. This pattern of results provides some suggestive evidence for a rape trauma syndrome, a set of symptoms and adjustment problems that women experience to a lesser or greater degree following the rape. That is, while women do respond to this trauma idiosyncratically, the individual differences are more in overall degree of severity than in the array of problems manifested. Careful attention was paid to the women in the least-distressed category for clues to understanding individual differences in recovery. There were 13 women who scored at or below the mean for the entire rape sample on almost every outcome measure. These women tended to be older than the whole sample (about four years older on the average, with fewer women in their twenties and more over thirty). The better-functioning group also had a higher average socioeconomic status, and a slightly longer time had passed between their rapes and the date of the study. None of the 13 women were under 16 years old when they were raped, as opposed to 15% of the entire sample. Similarly, none of the women in the subsample reported the highest level of force used during the rape (use of a weapon), as compared to 20% of the entire sample. In addition, the best-functioning women were more likely to have been raped by a stranger rather than an acquaintance. Finally, the 13 women in the subsample endorsed a lower level of approach and avoidance strategies on the CRAAS than the entire sample. As will be seen below, most of the factors distinguishing the best recovery group were good predictors overall of level of symptoms and functioning. The one exception to this ' ' , rt- iW9^y»P^ ^(p »^!S y»^ - -T J fTiitt.: vc *M'ri H»rt/' «;i i ^.“^1 "IIS' ' >'•' .• 'VjsL-'’S3 j| ' ^ • '.• S'-.' 4 H t5ii? ,^'*1? v§ 3sn tTl ', •MO.NiJ* ft/j r/'^(d*^& • i«*u -'l^ii ' «\U ni^'f^i' 'i'*»l5’ici ^iii.s':'£'t^..-;©b;ten ij;. 'rtl' ‘'^k 1 ' 5 s 9a Bt>-5 aii-'j * tiojf 'd m ‘-, ' 3 4 ._ .m~j“ .wm 'W.-’ ‘a. , .,71-W^W «’3 ,>,kqi'A f^JtJt'ifO >1 .:t , iQ iJijT' o:^ r tf-p ^-filonxl ‘ ' - 'J\'' ; A'.’ • a.;* ...wvi "yj^ -,’^.j •#7 •-J.* ,H 6 ii»« io0t »itr,^i$S»,Mi-' i*mpm *0f>9 •iSiJiM li^' i'i 'foO'^., '•“W ,f:jt^ me^'§ ' MtitS ‘bJ If'a'4 .ir;ri<9<^P>l1iil'- " '- ' ' ' ."S - figjifal 69 pattern was age at the time of the rape, which did not predict outccme in the entire sample, but did distinguish the best-recovery group. Factors Predicting Outcome I : Demographic, situational, and behavioral variables Demographic variables. As discussed above in the section on predictors of response to rape, the literature in this area is inconsistent. In the present sample, there were no effects of marital status or age at the time of the rape. Current age, however, was significantly correlated with several outcome measures. The older the women were at the time of the study, the less overall symptons they reported (GSI) , and the less intrusions they reported. In terms of specific symptom areas, older women were less likely to endorse obsession, depression, and anxiety items of the SCL-90 (correlations ranged from -.20 to -.30, all significant at p < .05). Since age at the time of the rape was not significantly related to outccme, it is clear that the current-age results were not simply an artifact of the effect of time passed since the rape. Socioeconomic status was fomd to be strongly related to outcome. Lower SES was correlated significantly with worse outcome on all measures except intrusions (correlations ranged from .21 to .38, all significant at p < .05). This pattern of results is not surprising considering that lower socioeconomic status has been found to be associated with a higher incidence of a wide range of psycho pathological disorders. The final demographic variable studied was prior history of sexual assault. Though prior psychiatric history has been a coninon variable in rape research (with contradictory findings), the presence or absence of a prior history of sexual assault has been neglected. In the long-term sample studied, the presence of a positive history of prior sexual assault was u'i-\m •m ' 'it§\j^' ' j «7 *' ' ’•"W‘* '.>*' f » o»- »Vii It.l .V *' ' •• , ‘Tif '' ' • . *4s If . !> I - t wi' .tM < 4^ * \c » :.i f '<. •». • • I •* I'-' ',* ^ i'. ' f. ;i*iCR? f ' .. .; V.,; ; ^. ; '‘:^'¥!''-j!if^ *f> ttffd >/t V -.;i ;*K#f ’ ^ ’ !* '"j* ^.1 (Trr-j .. ; < I . ii»'fo jy: itM: 3tj »m' ••: •: •. »\s’0- p M 'i!Ffl('-'‘,' • Y i • 1. 1 * f.t ri . j y i 1 j ttsKf it\ : V, ' . -’’v rsf'ci ,^ * i » f I. I : . MTft Y;i4 •?:' ‘''-‘I!!. ' ii ’ '1 ' ' ^' ’, ’ ,1 -:'»j(S^---.,^(/7 , ' r ; - -.1 ^ .1 -i), • (7, !• ,.VP" ' -.it I ts# '.flj,,, ;t»4-',j-®Y -m . if t"’ ' •' • ' '**> '<*[ 1 ••'j’te.? ' ' .rtj, 'Y' ' 'V^ r^'::',_ ‘u I lU n ’Tdi.t M (.."j. *:'(^ t%r? ' '.*- 4 x 4 4ii,9/y«»»VrSY‘^<*Y;-^ .'! •i3l 4»v - , 70 associated with worse outccme on a variety of measures, T- tests showed that women who had experienced a prior assault were significantly more symptomatic overall (t(69) = 2.51; p< .01), and particularly higher in scmatization (t(69) = 2.28; p < ,05), anxiety (t(69) = 2.45; p < .05), depression (t(69) = 2.01; p< .05), hostility (t(69) = 2.96; p< .01), paranoia ( t(69 ) = 2.35; p < .05), and psychoticism (t(69) = 2.24; p < .05). Women with a prior sexual assault also scored worse on total fears (t(70) = 3.15; p< .001), rape- related fears (t(70) = 3.40; p < .001), and non- rape- related fears (t(70) = 2.82; p < .01). There were no significant effects of when the prior assault took place (childhhod vs, adulthood). Clearly an overwhelming traima such as rape does not have an inoculating effect on future responses to the same event. On the contrary, the repetition of the event serves to exacerbate the symptans presented. Burgess and Holmstrom (1979) noted that women who sought treatment following a second rape generally spent as much time talking about the earlier event as they did about the more recent one. Situational variables. There were no significant effects of the type of assault (intercourse, attoupted, or other sexual act) or of place that the assault occurred, Though several studies have found that the level of force involved in the rape is not related to outcome (McCahill et al., 1979; Frank et al., 1981; Kilpatrick, Veronen , & Best, in press; and Atkeson et al . 1982), the present study found a consistent relationship between force and outcome. As might be expected, the more force, the more symptoms (GSI). Other outcome areas that were significantly correlated with level of force were obsession, anxiety, phobia, paranoia, psychotician , intrusions, and rape-related fears (correlations ranged from .20 to .27, all significant at p < .05). A high degree of force in a rape accentuates the threatening aspect and the generalized arousal that attends traunatic events. All of the , ' W -" B . ,;jn a; ^ . J , .< * ^^' 1 '.’ 3 ft! ’ I» *a.i*J ^» V 47 teSfifli*'" & wf - (e^H) ^»io«9 iekq . /, »'^i -%7 Lsc^x** ioi 5 f!:f*^' i^»»w . ( 5ci* ;^vq>s:fet';s'v^: isi .e ^ '» * $. i- 'j i ( (#v 1i 4 Of* fB Xi^-i -.-Jiq.tt 1 W»^ ;:fo«)|., > ,( J»^', ,,t;^^' tLu ’^tu *KW Kr Oftrtw "to ’ fe.J ' . : mst:. ^t^;:.^^jif. ^‘'i ' 'j?,^ '' 'v^*w S' 'fi ?t .JCCB te(Tt.iw If Arti '‘Uf'J**iiUfxj** 1?1?vCvO' Ttoito y I;*T»1»P'^''VI*T»U 40''''V , ft/ fir- ei*J o^ f If'*''’* '^ •*' 1 ' '5 nil- ,„'.i- ' I V./^ V'', ‘ ^ l trtsL T :jv o?«5w J»ficf f)9J04j.. (4?Vtfr) (:5c-^?e f. .'• -I ', .;. !»pji .fcifiqp' ^XXi^.rt^a '/:' "'^v , 'T?'',v,"'-"-'i'S5'l KKln -'' ' - ' '’"'"''^^p'vi' . ''i''''. \ '.,'Y‘v>-(^i ' 'i* -*oy j If ^Hjri»&T 1.5 ^i»'. r't l VU5 /sili ^.34 1o- Kc (:f';6 Jtiijx£*t ^1.'. :o Sir nl jf-i Jiirti birid! -iibti. «ei.Bti>i*- i€Hii^'f^Yt(^^i&!S^ ' #s:-#p%|; V <.u- tH rx»i;$r ,.i6 -k-*. I£irf«jc>'vl mP , : J 9 i>ns ;fti^^^, (it , -ip'^- .-^i •': 'lo'J H5» 9 H^'?:'d qirlo I'loi r«l,sn‘' -f\ ei»o>J«ff-'V« »lom ,>-S'aho| I':' iMr tool , ite5 Xui('i*>fiovB(|; ,.?Si'' »cai/’VifF Xi« 4 vs. e>4 ic'i2v'»' ' !(#.! :'! tK<'--% -''.'Aik ~Ta»a^'i ‘.•;J.''’iW,^ ,:;sv:.':*^«^ ^ '/v'V' Y 71 symptans that were found to be correlated with force share an underlying theme of fearfulness and hypervigilance, Ihis theme seems quite appropriate to the specific areas of concern of women who were raped with a high degree of violence. How can the relationship between force and recovery described above be reconciled with the consistent finding in the literature that there is no relationship? One possibility is that the other samples consisted of recent victims of rape, in which the average level of distress is extremely high and the range of distress is minimal. Such a pattern might mask differences due to situational variables such as level of force. Stated another way, the effect of a variable such as force may not begin to play a role in differentiating outcone until the process of recovery has begun. Length of time since the rape had an interesting relationship with outcome. As might be expected, longer time was correlated significantly with fewer intrusions (r = -.3^» P < .01). No other symptoms, however, were worse for more recent victims. In fact, one measure, partner’s sexual satisfaction, was worse for women who had been raped longer ago (r = -.26; p < .05). If these cross-sectional data can be taken as a general indication of the change of symptoms over time, it appears that intrusions decrease but partner’s sexual satisfaction also decreases. Perhaps the most interesting finding in the area of situational factors is that women who were raped by an acquaintance (a friend, date, co-worker, husband or ex-husband, boyfriend, or relative) had a significantly worse overall adjustment than women raped by strangers (t(69) = 2,29; P < .05). In terms of specific areas of adjustment, this finding was true in the area of extended family relationships (t(69) = 2.64; p < .01). Women raped by acquaintances also had a significantly higher level of sexual fears than t7 ' ‘ - .M'®, ' " ': . m’ ^ -r ' ~' i' f ""nW \CK> i, 9'^o-h i Sft^s !/ r*'»i V3 r<*:>J«'’ii rf :r*4| ,\*^ ' \>.pp^\.TIih I i:/ t ' ' '' ''™ '' ' :i!^‘ 71 ,-t V i b >J*v«.,in ' •• -* ^ " ' '’ .•• •.'• • • ft? . '^. '.y?. •'‘hi «/ SH.IM tt \-»-£n I ''*^6 ,. . vL> .)i-ji V 0tf V , ¥:i. »tTJV ,.l iwu"x??>r ^ :v''-.- - il f^ris 1i,MO£>.r W'MWm '' ' ' - , ' v.-‘ i '$it /A v:tjiW.rifli "'C ' -' • ’ . »• V ,'i» \’I). • T t • ..'' 1 . > . -Wi TJ' V#yi . " ^'T*, y.» ,, % '10 ol 1«3i 72 women raped by strangers (t(69) = 2.5^; p < .01). Both of these findings are quite uider stand able; friends and family are often reluctant to acknowledge the trauna or scmetiines even the reality of rape by someone known to the victim. Also, women are less likely to discuss such rapes with their families, for fear of hurting someone, getting someone in trouble, not being believed, or being retaliated against. In terms of sexual fears, the fact that a girl or woman is raped by someone she trusts or even loves makes everything related to sexuality frightening. The results described above are inconsistent with the findings of Ellis et al . (1981), who found that women raped by strangers were twice as depressed as those raped by acquaintances. The findings for stranger vs. acquaintance rape were examined further to test for the possibility that the effects in the present study were due to the six incest victims in the acquaintance- rape group. Excluding the incest victims, acquaintance rape was still worse than stranger rape in the areas of extended family adjustment (t(63) = 2.90, p< .01) and sexual fears (t(63) = 2.23, P < .05). However, the effect for overall adjustment was no longer significant, and therefore seen to be a function of the worse adjustment of the incest victims in the entire sample. Post-rape behaviors. The effect of behavior following a rape on outcome is an important area to study, because wcmen are often counseled to report the rape to the police, to talk about it with others, or to go to a therapist or rape crisis center. The assumption in this advice is that these actions are beneficial to the victim (though reporting and prosecuting are also advised on the grounds that they may help other women). In the present study, the results in this area were inconsistent. Those women who reported their rapes to the police had a significantly better overall adjustment (t(70) = 2.43; p < .05), and also scored lower on all fears (t(70) = 2.59; ^ 1! f |kti» ai(l4t.l tth.‘ ;'44 '4Hi -jjmf'i ' ft. 'jqfij ^ ^ 'k rin.l:li( MTS 'V''" '* ' ' ,' a - ’' ' ,' '-p'' -'' ' ' , !’W. I ;^ 3Ko\j pfUjfi odv#, » . •if iVi. f't.'v vboi^'!:, '«s» ' - i*wu 'Hi i^XJ, ’ ,1.1'.:, "T " w Vi. * 1 ? (rm'^no nil 'j^ 2 I f-‘ »K HOC iLO uo ^#3 :t<^'..i'»* C'. ii> f o.ti Ob M’KisW' #i ^».i'>,, 4 .» «.h n ..Q'it Vv,) 10 ' ik¥l ' ' '/.' ' 'V:'. ';# \ , ’ -•• '• •Ji3 ; ' J i. .» )I 4 / . M ^4 »i , # m, 'i'"'*i/^. /I V ' ^ Q«ft • • »,l 1 , f> bha, ' < t* (# .£> X ft ,, t << hVmfii |i . 1^ . • i.nmm -, -iji .il r r„ -uiilittffi i>iiw (ftw '.»*: iK ' 1^1 mi n"' Vf yVir',- -Vtffvi; >J5 ?:’ : r ' I?' jiR tefetSs 73 p< .01) and non-rape fears (t(70) = 2.86; p< .01). Seeking help after the rape from a therapist, rape crisis center, emergency room, clergy, or family doctor was associated with significantly fewer intrusions at the time of the study (t(69) = 2.24; p < .05). In general, seeking help can thus be seen as a positive step, especially in the light of the common finding in psychotherapy outcome research that the most distressed people are the ones that seek help. In terms of psychological treatment, the two most important types of help-provid ing are psychotherapists and rape crisis centers. It is certainly assumed (at least by practitioners) that these interventions are helpful. In the present sample, however, women who went to a psychiatrist or psychologist after the rape were not significantly less symptomatic on any measure than women who did not. Women who went to rape crisis centers actually had significantly more intrusions than those who did not (t(69) = 2.68; p < .01). They also had more phobias at a marginally significant level (t(69) = 1.88; p < .06). Of course, the causality could well be in the opposite direstion, with women who have more intrusions and phobias seeking out rape-crisis centers in greater numbers. Paradoxically, while seeking help is beneficial, seeking it from sources which might be thought to be the most helpful is not beneficial and may even be harmful. I would not use these results as an excuse for exposing mental health and rape crisis centers as fraudulent enterprises. Rather, I would make an appeal for better education of therapists and non- professional counselors in the areas of stress-response , rape, and especially stress- oriented psychotherapy (see Horowitz, 1984). Though almost all of the subjects told someone about the rape, there was a wide range in terms of length of time before telling someone. The longer that the women took before confiding in another person, the worse their . v/ :1i '.«iiii. e. w' --rtl iV 4i*^fO,»5f1(b'> J^IHStl -JCK^^t >>'<3 .’*»rij (46 mi ;./’ 1 ••i jvi to, fmi»f r/,t ',-iPci '#;'(< 34?*i'e •'‘‘I ,rf«' jt rt f m M f « fri^ c^ , Sr, '' :'.' r ;v,^, ' vif .» vtai^ ,1# rye f '• - TV aq '‘.W , oil'i^l jrrnjcw I.1W(U ikTtjtttsro * ' ' '' •-••• •.«: :• '•' '• •••Y’..- *w^'— '•IS'-;. .-,>^,>"*15, < tfii\ c-r^ vs.rfl iffl, . Ut» > w ;wa .r .TOflKx# .(,,;. «> y . (i -»YC^ Ort^ r y*Jija n-ilA/ yu ' ' ' , •<***•»•**• ' * 4 • 9-]f> ; . V, Wl.7 , '^rtl ,W^,.V ; 7»w^' »*o^vaPN?':" ^li^|fi ,7 'swr . . 74 global sexual satisfaction, parental, family, economic and overall adjustment, and non- rape- related fears (correlations ranged from .22 to .49, all significant at p < . 05 ). However, waiting longer to confide was associated with a lower level of intrusions = -. (r 22 ; p < . 05 ). This inconsistent set of results is very difficult to understand or explain. The positive benefits of confiding that were found corroborate Pennebaker* s (Pennebaker & O'Heeron, 1984 ; Pennebaker & Hoover, in press) findings on confiding and health, but the lower intrusions are an anomoly. Again, it is important to keep in mind that the present study does not provide for a method of distinguishing the direction of causality; a high level of intrusions could have pranpted early confiding in a help-provider or a confidante Factors Predicting Outcome II ; Coping V ariables With the exclusion of the denial subscale based on the confirmatory factor analysis described on pp. 48-53 » the Cohen Roth Approach Avoidance Scale (CRAAS) consisted of an approach scale and an avoidance scale. These were the coping measures used in the study to assess the relationship between coping and outcome. A regression analysis was used, with the stepwise entry of approach and avoidance, followed by the stepwise entry of the quadratic terms for approach and avoidance, followed by the entry of the linear interaction between approach and avoidance (carried by their cross-product), followed in turn by the stepwise entry of the additional interaction terms (approach times avoidance- squared , avoidance times approach- squared , and approach- squared times avoidance-squared) . In cases where a demographic or situational variable was significantly correlated with both a coping measure and a specific outcome measure, this non-coping variable was entered into the equation first. In no instance did ' ^ *T I ' ‘VHv..liyriA •i-'T f.l’''- I T'4$' ;'»'t '< > I Jt- 1 /fiflii ; 0 ' * .'; '* ,- , _ ' ojj 0 , • I \:> J V (.'' tr(, V* r'i iysx.^i'z' H\. ", .„ , ’Al ”‘- ' * -III III iM|iii«i«, ''" '' ' ' ‘ i , If no im' y fi: "'*' ,t- • ••> 'I y{ JSt'm: • « -»; >.< - t ft . r w*a»ia 0 1 , • "^- *.'^''' ^ . • ^ I.. « • ' 'ftk'W ’i!:» , ' • *•?%', -Vi'j^ '•' f • . N'^-tfn; , vf :•;• « -<'J , V/.:,- y^'' J :Yu 'y.til-riSli -i-4 tf.j v<{ v.‘’Vi *;*(») ••r.w n m.' 'lU'J' •V .» i I ;r, ,4 .,,±.\tjr ), r^*'4^'«sij,. • "' • Kitt II • t iU§ >• *‘ c J'- ,'>.|'l>'»t«r/.f,- it U'-. #i:^^}5r^.;-;4|i:’'' 75 this procedure result in a significant difference from entering approach and avoidance alone. Thus the regression data presented below do not include any demographic or situational variables. A variable was considered significant for a particular outcome measure if the regression model following its entry was significant and if the variable contributed significantly to the regression model as evidenced by a significant change in R^, the outcome variance accounted for by the model. Those outccme measures which had significant interactions and/or quadratic results will be discussed separately. The more straightforward measures, described below, found either an effect of approach, an effect of avoidance, or both. Effects of approach and avoidance . In order to minimize the possibility of chance findings due to large nunbers of analyses, the following plan was used: regressions were first performed on global outccme measures, such as the Global Symptom Index of the SCL-90 or the overall measure of the Social Adjustment Scale. If the global measure produced a significant regression, then the appropriate subscales were examined in greater detail. In general terms, the results were quite surprising, because neither approach nor avoidance was found to be associated with better outcome on any measure. In fact, both coping styles, but especially avoidance, were found to be significantly related to worse outcome on nunerous measures. The specific findings are outlined in Table 7. For the Global Symptom Index (GSI) of the SCL-90, the entry of avoidance produced a significant regression (see Table 7 for specific data for this and subsequent regression analyses). The subsequent entry of approach produced a significant increase in R^. Thus both approach and avoidance were found to be predictors of outcome; the direction of the effects, as mentioned above, was more coping predicting more symptcms. J i !.**. , ^ f '" ' . / , d' ttiit tffli f |*J 1# 1^. ^4,;;|i)»‘' jg| ^ M 9 fi .Vctj |g.t,‘ ,.pf;jili| Mti (j?;rtw S^'K ' '' . -• h Wl ;.. ' ' • i* r'"‘ 15^? ^>,Cr8 )0 - I U‘W ''» ' ' :'' ' > ''-'h aM iviu'iT jwcs'f?' , ‘ ' '' ' ’ ''.,^1'^ -.r ; '’^^> i lij ran nj u! 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I H* O. |X > Table 7 oontinusa o m "i •V s ti 4 2 ) ' b 78 * * 31 y n 9 S? E J8 1 t-J rj s GQ T .01 c* u .001 a J? '< a 8^ GO 5- j? 8iu & II II s . S. '— o W o II 4 8f? « He I 5=^ « s.II s_x UJ II ^ Jr s J= s o 5=K) 5=^ ?1=?0 5^ « o O - o > g- 3" < g? 1 g? o N.-X ^ N— ^ H- (JQ ®I05 Q. II ^ II II 3 5=K) - o • o II - o • V ' gl II <1) II ^ II § II ^ U1 II " II b ,06» ^ b m .053 79 The outcome variable "Casenesa," defined as whether or not the subject fit Derogatis’ (1983) definition of a clinical case based on the SCL-90, had the same pattern of results as GSI. Avoidance alone produced a significant regression model and the entry of approach led to a significant increase in R^, Continuing with the subscales of the SCL-90, the findings for depression, anxiety, and somatization all followed the same general pattern as the global measures described above. For all of these outcome variables, both approach and avoidance contributed significantly to an overall R^. Two other SCL-90 subscales, hostility and psychoticism , had significant contributions to their respective regression models only from avoidance. The remaining subscales of the SCL-90, obsession, interpersonal sensitivity, and paranoia, had significant contributions from the quadratic component of avoidance (carried in the regression model by avoidance- squared). These findings will be discussed below with other outcome measures which also had significant quadratic trends. Turning to social adjustment, as measured by the Social Adjustment Scale-Self Report, overall adjustment was found to have a significant contribution from avoidance, but not from approach. This pattern was echoed by all of the social adjustment subscales, except marital adjustment, which was significant for both approach and avoidance. Ihe specific results are listed in Table 7. Social adjustment will be discussed in more detail below, because it also had a significant quadratic component for avoidance. For the purposes of the regression analyses, the three sexual satisfaction scales (satisfaction, global satisfaction, and partner satisfaction) were combined by arithmetic averaging into a global scale of sexual satisfaction. Like most of the social adjustment scales, poor sexual satisfaction was predicted . : n " •7-V/.V- •V.: i\ ’ ' ' ' ' '' ' ' ' '— ' - • .' ' ''> ", ',, !4L'.V 4,- ' .V ' ..'^> !•» . _ e ^ttb^onq !>Aei;)ti, ' ' " '- '" . • , 'S^y. ''7i5lki i ^ ^ \%feD« noil? - - ’i/o .><•• ih nol' r. ...4'' .. V : i :i» p •'’}.> brct »j|}eiM4op{cx^q t»na .iutiova eisboin .'• ' / ," J ' i a ac^ , Y 1 , nnUt ^dd i_4.TP-.10e: ' }•- ^.»/ir^,)mo•.; r :JaTi?sc-p^ . iftdil e^tbl to.l! n>|i7oa‘ irt^'o ^’7 .^t n(Vt*pe-9Ci'3«t>l0v^ ;^te|ar$i'i|»'t' laA .y Ii\u ed'u.iaaofn n^rtSo ,.,5- ': ' /> ' ,v. ij'M3et>c,L'A j»xjci61 !wli V .1. ]?9 ^9- , 43 asi • f.cl : i.ljjid 3 0VS41 »J rjnwol sl^ T*' I?*--! •' 9 4W uri^lioo’ ?..r!' •\.1-?a&>jq33:;43O'l(0;;4j(' .'V ?a« £a4lt5«t ri^ '•.* 1: ^r,-? - ,- rST'Y-T . h'!»JH|!9)-.; . , , ‘ . r.-uc': ,w :isa aei-Jft -vc;i. *'' w<* ^o3 t'OARbXdVto nqt. tu Let* no.UoBleiiftfr ' ' ' ' '*^ ' ' ' ' ' ;ai*saM X«3^ H»f, '*i i« flK)}/5«1'eJt.tf‘<.< rn^tj ya ji* ' • •;,»^ .. o'-l 80 by the use of avoidance strategies. There were no significant effects of approach. Interaction effects . The intrusion scale (lES-I) and the three sub scales of the Modified Fear Survey (MFS) used in the analyses all had significant contributions to their regression models of the linear interaction between approach and avoidance. The specific results of the regression analyses are listed in Table 7. In a regression analysis, the presence of a significant interaction between two variables signifies that the linear regression of one predictor variable on the outcome measure is different at different levels of the other predictor. To evaluate the meaning of the interactions in this study, the sample was split at the median into high approachers and low approachers and high avoiders and low avoiders. Since the regression of one variable onto an outcome measure is equivalent to a simple correlation, Pearson correlations will be presented for avoidance with outcome for high and low approachers, and approach with outcome for high and low avoiders. High Approachers Low Approachers n = 33 n = 32 ** Intrusions -.125 .486 .Cr All fears .567 • CO unit Rape fears .631 -.045 Non- rape fears .620 .031 p < .05 p < .01 ««« p < .001 ' ' .." »• • «' w -!i. •’.» ,j i'mii yg^ t^UiboH ^ hj! »». S*..: ewif ,.,t»vi55«d i; ^'-'- • ' . •* ' ! < V .; . vt' i>iev i j ^ fj(i ' Vi|‘ ' * .? '».v -‘ >vj. umipMvm i'K- ’r'« ..> • 'X * il *»• *V'i*i ' '* ' < ... Vv^c», tijS ^ '.’W w:; . m. '>'rj' -'v»y „. ' ’- i':, :- X'MMj 81 High Avoiders Low Avoiders n = 34 n = 29 Intrusions .503*** .801 All fears .358* -.096 Rape fears .355* -.032 Non- rape fears .332* -.129 * p < .05 p < .01 »*« p < .001 For approachers, the level of avoidance is a good predictor of how much fear a woman will have following a rape. For non-approachers , however, the level of avoidance predicts intrusions but does not predict fears. Seen from the other perspective, approach is a good predictor of both intrusions and fears for high avoiders, while only predicting intrusions for low avoiders. Thus for intrusive symptoms, not approaching is good and neither approaching nor avoiding is even better. For fears, avoiding is bad and both avoiding and approaching is worse. Quadratic effects . It was mentioned above that several outcome variables had a significant contribution to the regression model from the quadratic trend component of avoidance. None of the variables, however, were significant for the quadratic trend of approach, or for interactions between either coping variable and the quadratic component of the other. For the variables with significant avoidance-squared effects, the nature of these effects was consistent. For non-rape fears, obsessions, interpersonal sensitivity, paranoia, and social and leisure adjustment, a moderate level of avoidance predicted worse outcome while a low level of avoidance predicted better outcome. A very high level of avoidance, however, was associated with Vt i •» • • |ft5. Wr . IT a- S3fif- : • I./.V. j; .<., jL \i< ^ .ii 'l.\V^t!>i'Vi / f.’ . V' . , ^ T9'«fiS'''fl«gtM -nci • '. I..-.: t:*!H»iq ' jo(* 5ts‘‘';-ji;#4' #iK>^lfefc " . '' \; ' ivs- \;.r : 'I I .'T -o.-ii -t?! u' ms , :^ ‘ *, 'A', , -.-i!^' ti?Vf 8’i ^ ’ --. -.* '.yv't i . / 9 a\ X^l* iJ) M' Vi •v,--.f ,»9Xff^l n-iV y{it y ;'^ , ;Pti^^p$: •uri-i-.lrii’ iQ’l Yo ,<^Y‘V»-^'’;trj'[6,. "' wr,;;'fi ft K'^p i-'i •fU^ -yLi* io ' r.:';.t'.VjJ ;-''-'jiii ,tl"}^fs^ !»r»| i:JiL :^: r} j^ « 82 an intermediate level of distress; higher than that of low avoiders but slightly lower than that of moderate avoiders. This pattern was determined by plotting the regression equations. Discussion of the coping results . To summarize the regression findings presented above, it appears that in this sample, avoidance was a good predictor of poor recovery from rape on virtually all of the outcome measures used. Approach, contrary to expectations, also predicted poor outcane in the areas of overall symptoms (GSI and caseness) , depression, somatization, anxiety, and marital adjustment. As described above, the measures of fears and intrusions had significant interactions between approach and avoidance. Though overall it was true that a low level of avoidance was associated with better recovery, for certain outcome variables (non-rape fears, obsessions, interpersonal sensitivity, paranoia, and social adjustment) a moderate level of avoidance was the worst, vrfiile high avoidance was intermediate between low and moderate avoidance. In general, the coping findings outlined above are not promising for helping clinicians develop effective intervention strategies for the prevention of serious negative sequlae to rape. Not only do theoretically beneficial coping strategies (e.g., actively thinking about it, talking about it, thinking it through, and avoiding reminders of it, seeking distractions, and trying to forget about it) not work, they actually predict worse outcome. What does predict better recovery? The data on situational and demographic predictors and on the 13 best-recovered subjects suggest that reporting to police, seeking help fr<»n some professional source, and confiding in others soon after the rape are all associated with better outcome. In addition, several individual difference variables such as age, socioeconomic status, absence of prior history of sexual assault, a less . ' ' ^ :-; .w. • '.jss T,-%r^’'^! crKii*?tsi *.*c iiM 71'rfr .^^^>iove_ xin M tXM ,,,. ’JOI..' PT bd«» E r.a^ tOilG.blQvrj /dl4;ttut .^grti :iv., ' ,"‘X^h '.. *'^' :,,;S! ' go' ^ |ij' JfV''” __ •»nfct*#w Tr^cLshiiv sfi'^ »o Lift i J3u>^iv^'‘.**£^ t^fk ''^ . _ i^jc‘-' ' ^ 1- . ‘•i^.W w/j'-';. _. -'ll , '* S' '''^’' ’I ' ' • '! fifj. ,>. ' -:-? J' Ja*i3nfl»E ’" . »a<»t'ji.'v# bna tfbaortqqs* (i»z>wjo,^ fiJi r iv MW 9'3cia^ioV(fr 10 .'i-^v-jai ,4^ <5^, ^ ' '* '*3 .^. ', ^ ^ ‘J!^ j^'~ , vv : ,'>>E n^t»m e U.v^mSH, f:{5*J Xii V:et4,# ' ' ' ..^ '%.' ' . , 1 'srj.y ;’L™’i' 14»! 3n'X*iji(iioT',| .Ton Arna; »vod^, ;>i1;t to'i & Ht" il.. ' ' ® '*. i - : :SSiev ._ V-? 'M ifti iJ^'sn^'.ii Oft, V X.io ‘.-i 5^&^, iucifijt >^i;ii/.’>4 ,v?i' 4u^?^6^ 5nJ>C , MOI t9A Iii>t:' 3'ifii4v's»^, ,,t/ la e'l-?fifirrTty^' ..? ,,:^r ^ !' ' »90i>:. UTO r4»'.^/4«0Xi5 itft ri^alj 'wr,'i r''' ';n^ '''I '^.l^ .. K f1»V» - M ft ,4£V«tCM iflftilOK H6 V 83 forceful rape, rape a by norwacquaintance , and being an adult at the time of the rape rather than a child, are associated vdth better outcome. Unfortunately, these variables are not amenable to intervention. The finding that women who sought psychotherapeutic or rape- crisis intervention did not have a smoother recovery than other women suggests that current views of psychological intervention with rape victims are ineffective and inappropriately focused. Furthermore, there were no significant interactions between coping and therapy. That is, approachers were no more likely to benefit from therapy than the population as a whole, and women who sought therapy did not benefit from using approach strategies any more than women who did not seek therapy. One possibility raised by the coping results is that certain aspects of approach and avoidance might be beneficial, even though the main thrust of the scales is negative. However, an item-by-item analysis of the coping it«ns with outcome yielded no evidence of any subset of approach or avoidance items that were negatively correlated wit.h distress. The data presented above seem to be at odds with the theoretical formulation of coping proposed in the Introduction. That is, approach was not found to be generally associated with good outcome, and the effects of failing to either approach or avoid were not found to be negative. On the contrary, approach was associated with poor outcome on a few measures and avoidance with poor outcome on nearly all measures. How can this pattern be reconciled with the theoretical model? The model of coping was based on an ideal case, in which periods of approach, tampered by strategic retreats through avoidance, lead to an assimilation and resolution of the trauma. It was noted in the Introduction, however, that when assimilation is impossible, the costs and benefits of : , . :yAfr 'ii*r:}'*'di , 'i‘ , vW>'l? n * VT ft » iiX*l.#»*sr^ ‘le* - >7 • Si ' “ ' '' ''^11 ^ . : *.J^<^' j *WJL »"!* 'swiJi^v , ' rm i 'r ti^«^.^''.’»--sftj .. ' \.^M . % 0.1 .'W f idv# .'i.’.'S^i'v <. K'^AS V.'Ui eyi .,U' I .,fe/r “ '1 P' » T O t,j(il . ? T'T -4 .18 .1,/ ^ 0 #4 . ? 0 , „n 1': StMSU ('iU'iU, '‘'' jik. .f'V-jp i|.rl1 to tttifv ‘Bifc 1*1(5 o.;,ot.'cva . -;ft? A'tftrtst-V Jligr ‘l^>'l%l{i ' - . ^"'i '''WjifV'' ,' W' ' 1 far S'^noddJ , r)'(t,x'''r’f1 fw!' a'biio '3 ' «'** ;* '• .-'f V 4r,«iw i^:C0',.^4\u ,ef luf^* • •‘ i4> ?* . > vU (•' • » iytw^(fl 'i >.-• • .. . v; firfO \(i iiU a 4. pH fi'-. •A i hm to I*q ri»'i't:W'4i ,;.f ' • •'0 4 Mii»l < rw j 6 : :. : , T /tjSf :, .-tH . 84 approach and avoidance are quite different than in the ideal model. This idea is echoed by Silver, Boon and Stones (1983), who found that incest victims who continued to search for meaning for years afterwards were functioning worse than those who were not still searching. They concluded that for most of their sample the trauna was simply too overwhelming to be dealt with adequately by the approach-oriented strategy of continued search for meaning. As mentioned in the general model of coping, approach with no chance of assimilation becones unproductive runination. Similarly, the costs of avoidance rise in relation to the benefits when there are frequent reminders of the event and when the event is highly meaningful and significant in the person’ s life Several factors may contribute to an event being unresolvable. It may be too devastating to resolve adequately; it may be a fundamental threat to self-esteem; it may violate certain basic operating assijnptions of the person’s life; or it may exceed the resources available to the victim (such as tolerance for anxiety and adequacy of social support) . In the case of rape, all of the conditions which make it difficult to either assimilate the event or put it to rest by avoidance seem to apply. The reminders are constant: sex, interactions with men, harassment on the street, and many other situations all force a rape victim to remember the event. The rape itself is a highly significant and anotionally powerful event in the life of almost every victim. Nuerous writers have commented on the seeming disparity between the physical act of rape and the traunatic response that it engenders. In terms of aspects of the rape that interfere with adequate resolution, rape is clearly a devastating event: it violates the basic human assumptions n P-uv-., v)ro.l -c? O.T |^xtir;'-'-w#w, Porfi'iYllSanil’a ri|j I,VI. 'llOi idrio’o. »n i '(li* l<>. fiftoo .*»". ,\(;J-*^v!‘l mjts, I -<1^'fi,,^»fl'iru:T. «*{l? bt JOidfll'^.vrr^tt b/^Q ' ''' ' "' '/"'^W^' '4 k-y- lit' «J .X«4a6t ym ' stJ4 : !tJ Ajiii^i’'iQ''mMt!;^js -?i s^ttfiT- 3 ^ M ,,cr».i 'rtUv ai(> -?«':• crtxi^ly :ft V--S ..Tbi/uiOKn iSI^'- •)V-:* 85 of personal integrity, a just world, and self-preservation; it causes a severe damage to self-esteem and a women's sense of identity; and most women do not receive adequate support from their social networks after a rape. This last point is very important. Many rape victims report horror stories of the additional trauna caused by the insensitivity, anger, hostility, and titillation of people to v^om they have confided about the rape. Police officers, lawyers, judges, friends, lovers, family, have all been accused of not only failing to support victims, but of continuing the brutalization, dehunanization , and objectification of the rape experience. In the face of this type of hostile environment, adequate resolution is extremely difficult or even impossible. The idea of a hostile social enviroranent interfering with the resolution of trauma is not new; it is familiar from the experience of returning Viet Nam veterans (see, for example, Lifton, 1973), If rape is a trauna which is unresolvable , then the negative findings for approach and avoidance are not at odds with the theoretical model of coping. But is rape an idiosyncratic stressor in this regard? To address this question, further analyses were performed on the mixed-stress group studied in Experiment 1, As part of a separate experiment, many of these undergraduates filled out the SCL-90 at approximately the same time as they filled out the CRAAS. Regression analyses were performed for these 93 subjects, with approach, avoidance, their interaction, and their quadratic components predicting scores on intrusions and on the SCL-90 global scales and symptcm subscales. For avoidance, the pattern of the regression findings was the same for this sample as for the rape sample. In general the entry of avoidance led to a significant regression model with an R^ higher than that for the rape sample; the direction of the effects, more avoidance predicting more symptoms, was the same. For approach, the undergraduate mixed-stress 0 f . .f' 1 ;lW- , felv . « Si. '«««' Igfv ;\» iiJ'nA 1# a M ^lai .q "V!»(. 7 ta a . .,,, . . , '' '^'" ' fr/? 'WF--'r’ •*«:» i>. ipt /W , “« ?(< J O'ciij' # (5^ »M0': % 4|“^3 ik . ' rilOit '-e ' ^ !• i ’I" 'o’lJ'iOtJ r'?‘l M» . ijf'ytid' v' " . U'' i t (aSi> ‘t?! «0 < .^' tyait Jtkififl In /'.Tl inJ lil If SIM 1 V MM • - > , >., j^i t. V fd«s»i.r^ 4+ 'Ur ' -fe • V m *1 nir .tH t . Ib ,i' wtiMw- "W "• '•••»»• T;-: > a. _ i , ' “r i v@ r ,n fi':. ^ -J.** i»V/ ©Hi JMlJ f'% :»<*.»’. 1 1 I-? v» » 7 <‘aV'Cf;.;’5i(''^ »!* ta, >^™lB ifa”l'Vt'rd,l' ;.jt’ W 'rS^ Jbcna •l(>';^’i T^r'.'ji'V- . -: .fjj 7 ,i Vitna k-? ;M"I ’fc ’’•&»<< 'TOJ O&'.-T^lOt f S tKJ ’,w '•w‘ 3fi * .. :^t tfcW = J?fM*5i*»; 7 ^‘u.n - i>fli' to (*')'' ' }9 y V .iS' |j,x fM*}*p fft :'f'' ^•’ i'- ''®&' ’'' ' • . i 'k.” . iAt? -•»< ' Tafr' .-^B ^ m S! 86 sample did not show any positive effects, but the negative effects were considerably weaker than in the rape sample. In fact, the change in after the entry of approach was only significant for intrusions and somatization in the mixed- stress group. This finding was quite different from the rape sample, in which approach was significant for intrusions, somatization, GSI, caseness, depression, marital adjustment, and anxiety. There were no significant quadratic or interaction effects in the mixed-stress sample. In the light of the discussion above, the mixed-stress group can be considered to have consisted of seme stressors for which assimilation was possible, and hence approach was effective, while others experienced unresolvable traunas and were not helped by approach (thus the overall weak net effect). However, the strong negative effects of avoidance are difficult to explain unless one assunes that either the effects of avoidance are generally negative, or that the avoidance scale of the CRAAS does not tap the potentially beneficial aspects of avoidance. The mixed-stress coping results are useful for addressing an additional question as well. It was mentioned in the Introduction that the negative effects of avoidance might be an artifact of a sampling bias in which avoidance appears to be a poor strategy because only avoiders doing poorly would be interested in the study. This hypothesis can be ruled out because in the non- self- selected sample avoidance was associated even more strongly with poor outcome than in the self- selected rape sample. The mixed-stress sample is difficult to exanine in any detail because of the variety of stressors involved. There are other stressors, however, in which the effects of approach and avoidance can be assessed in the context of the resolvability of the traima. Manuel and Roth (1984) found that both approach and avoidance predicted good psychological adjustment in victims of 1 . • .-V ,»1"| # ,' - '.•< • I . i ’1,^: » .,*y .dO^ 'J,;.' 'i ^ “ ‘ '»'T.»rflP, , ,\t#i rm; l rt' 'K.U *7.* c;>t»JkT*o 4 ><|T : ' -j;; v!C i .*t^ ? ' : ?;.'«^, :jf^ .l^i 7wg:<« 1 ^ Jlrt-'^ K «rt.1 .]>6 el*. •oit#v<'»v|. i'o'' ^ ' . '-'i_- ,. 4?\! •s,.-. *«iri{igFaHh; . H i ‘ 1^ ai .tM ;v ? ; ' ^ U ^* f i'Si'' Jn s^r f:8' ' ".'hA^' 'iW!' . .. 7 dv itoi'r '(•» »Lbi 'IV "' ' ' % *y/;»v.i |>W./ .»u,li '' ' ’ ' lv^..-.••^- ,L ' . , -^. -M wA'ftif Ik . J.n . * '*’ - -''1 n -.tf ' vr- . ,>u kup» ^fc-7 pii yJ^A y\ft j jt .’ 'Tkr^y >•, '* '-Cr ' L'lilmSm . ^iqrtfcfjr mtt^. '•m »c 1 . : 4'r^ ;-i' 6CU^.^: '’bf i‘i4j -1 j- V . . 'V. . >d[«i ' , 4-7 f-6r 0714* ^toipo fW'' yrif} '' • , !» ' Joa :io«<;i/ Wiuo I iw^/ 7fl J >'n*J«irr^.-> ^ ^~. iMWmm, , 87 head and neck cancer. How does this stressor differ from rape? First of all, many patients had physical warnings that something was wrong, and so were not overwhelmed by the diagnosis of cancer. The cancer, while certainly ego-alien, was not an assault on self-esteem or identity, nor did it impact on the patients’ values in the same way that rape does. Most of the patients also received positive support from their spouses, family, friends, and the medical community. Finally, we know from the work of Kubler-Ross (1970) that people are able to assimilate the idea of their own death; acceptance is the final phase in her outline of the stages of facing death. It is ironic that a sexual assault is less easy to integrate into one’s personal schema than a life-threatening illness. In bereavenent, like serious illness, the trauna is quite severe, but is eventually resolvable. Perhaps the key element of resolvability in both instances is the inevitability and universality of death. There is a story about the Buddha, in which a young woman refuses to acknowledge her child’s death, and searches for a medical cure. Everyone scoffs at her except the Buddha, who tells her that she must seek a special herb, but that it must come f1“om a house in which no one has ever died. After hearing the tales of sorrow of each house at which she asks for the medicine, the woman understands the reason why she was sent on her mission, and takes her child to be buried (Kim, 1983). Despite the horrifying nunbers of rapes and child molestations each year, these experiences are still experienced as solitary, unexplainable, and manifestly unfair. The perception of rape as an unresolvable experience helps explain the relationship between coping and outcome, but is inconsistent with the fact that some of the rape victims in the study were doing quite well at the time of the testing; some were functioning even better than the average nonvictim. » ii^Mm '<» ''®' £R’'« IJt tli!> ;10>1 * . ‘ .t*:i 7 ^^! » % •.'»./ L.'i. , ,,^„ !* IH' COTvf) ,i.» ri •^ . a. 7 L , ‘ " # ' - .ii4 >^./ - mrR IfliTf/e TSV|. n 74 ml ,.iT'^ ^'.W: i Hui , V'^t f>icip *4. '.';.!„ ,, „, 4i ;-jO ?jJ vt 6*i*n •! fr.'i A ii -' ;• i i . . fi^S^..'rt < ’ , lafd , v 5 ' f j-,y ' If. " • '* - I . vk- f'ilX l!*d Jk >", 1 1i ..>'?••; po<»i|'n»y^' itvifl -I* :n: ' f} ., pH i i f, Wtn , ;t0‘4 m %>: 4 "<#J V ^ 1 &' ,m K,ii!'?KF ' ' ' ' "''' ' ' '• • > 4 'IS -tjj rjld ^ ' ’' ' {• , . l .> It follows from the discussion above that those women doing well have either resolved the trauma or put it away effectively. It makes sense that women who were raped as children, raped by a relative or acquaintance, raped forcefully or brutally, and/or had a prior history of sexual assault would have more difficulty either resolving the trauma or putting it away. Conversely, reporting the rape to the police and/or confiding in a professional or a confidante can be seen as active steps towards resolution or putting it behind oneself. As was seen with the coping and outcome results, the implications for treatment or prevention based on the analysis above are not clear. There is no evidence for evaluating the differential effectiveness of approach and avoidance. The crucial factor seems to be not whether a rape victim approaches or avoids but whether the coping strategy used is effective. The above discussion assumes that the correlation between coping and outcome is due to coping strategies having either a positive or a negative effect on outcome. However, it is possible that the direction of causality is reversed, with level of distress determining level of coping behavior. That is, women in greater distress have greater need of coping; women in less distress have less need. It is clear, however, that as a general principle the idea that level of distress determines level of coping does not suffice to explain the data on response to stress. In many situations the coping strategies of approach and avoidance have been found to be correlated with less distress rather than more distress. These findings suggest that coping sometimes helps with recovery from stressful events. The main question raised by the rape sample, therefore, is why the coping processes used by these women did not effectively reduce their distress. The modification of the model of coping that is presented above suggests *“Val . liewB »i*ss*4'Kwo«|r t3% " bUo«^, '‘’to Y4Ql|lA/-^giT^%sac;p^ ' ,' ik\ ifi "4u.; xiilnoa',' *j&;V|«a::. i't>«.'tS«¥l “ " ' ..,3^ ii§? ti.'; , 'jB& „ , ''< . JOff xf '£ 'li-Mifft, im 'Wl»‘ i^f i » • i .Vi;39 : itOif-S S' • v‘ !#•>*» -» -»^ ?Vi’ii,W ' ‘ ' fCifl .nl *Tb' ‘ " • '.I-. . ^aIe« 4, ' h'H vi : .t- xiic • <4i» -M 'W'. '^' *'-“*' .,/', -i ^ :'~r' ,,,.Tt4i:»,*, I/I.I ''y?,f(‘<4!’'V 'il i«fi ' *"• 4 7 4'^/ ,V!Uf ';n4 O.t '^' "4i m£ lr4<^'i>SiS/ri W:'46' 89 that approach and avoidance are not generally effective in the case of rape because of the difficulty of either integrating or putting away this event. 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I 3 .-. t3TT>viTtt Lancv|.fa/-in^*<>*tl Wvil'N ,? ':^ \ nai^'-tt: 1 ti^ 7 'lo: ' -r '/.V.v^'' - '' .' ,";1fiii , 1; . 97 Libow, J.A., & Doty, D.W, (1979). An exploratory approach to self-blame and sel f- derogation by rape victims. American Journal of Orthopsychiatry, 670-679. Lifton, R. J. (1973). Home from the war: Vietnam veterans, neither victims nor executioners . New York: Simon & Schuster. Lindemann, E. (1944). Symptomatology and management of acute grief. American Journal of Psychiatry. 101 , 141-150. Long, J.S. (1983). Confirmatory factor analysis: A preface to LISREL. Beverly Hills: Sage Publications. Manuel, S., & Roth, S. (1984). Coping with cancer . Manuscript submitted for publication McCahill, T.W., Meyer, L. C., & Fischman, A. M. (1 979). The aftermath of rape. Lexington, Mass: Lexington Books. McGlashan, T.H., Levy, S.T., & Carpenter, W.T. (1 975). Integration and sealing over. Archives of General Psychiatry , 32 , 1269-1272. Miller, N. (1 959). Liberalization of basic S-R responses. In S. Koch (ed.). Psychology: A Study of a Science, Vol. II , New York:McGraw Hill. Miller, S. (1979). Controllability and human stress. Behavioral Research and Therapy , 17, 287-304. Miller, S. (1980). When is a little knowledge a dangerous thing? Coping with stressful events by monitoring vs. blunting. In S. Levine & H. Ur sin, (EdsJ, Coping and Health , New York: Plenimi. Miller, S. & Mangan, C.E. (1983). Interacting effects of information and coping style in adapting to gynecological stress: When should the doctor tell all? Journal of Personality and Social Psychology, 45 . 223-236. • ,-<.t .- ) •, .* .'4 ,6 rti. .USB. iJ-AiJiiidi ' l« * : -47<5t -'M. r; ,j I f : w i,kfj; a. ' Ui tstiQ'i ^'';a '! .H ?ni v»j' .2 aV' , '’ ;? i'dn iii , 1 h \ #4 r- Ii» cBt'W' :i ,cj» , . 98 Mullen, B,, & Suls, J. (1982). The effectiveness of attention and rejection as coping styles. Journal of P sychosomatic Research, 26 , ^3-49. Myers, J.K., & Bean, L.L. (1 968). A Decade L ater; A F ollow- up of Social Class and Mental Illness . New York: Wiley. Nadelson, C.C., Notman, M.T., Zackson, H., & Gornick, J. (1 982). A Follow up study of rape victims. American Journal of P sychiatry, 139 , 1266-1270. Norris, J., & Feldman-Summers, S. (1981). Factors related to the psychological impacts of rape on the victim. Journal of Abnormal Psychology. ^ 562-567. Notman, M.T., & Nadelson, C.C. (1 976). The rape victim: Psychodynamic considerations. American Journal of Psychiatry, 133 409-412. Pennebaker, J.W., & O'Heeron, R.C. (1984). Confiding in others and illness rate among spouses of suicides and accidental death victims. J ournal of Abnormal P sychology, 93 . 473-476. Pennebaker, J.W., & Hoover, C.W. (in press). Inhibition and cognition. In R. J. Davidson, G. E. Schwartz, & D. Shapiro, (Eds.), Consciousness and self-regulation . Vol . 4. New York: Plenun. Petrie, A. (1978). Individuality in pain and suffering. Chicago: University of Chicago Press, 1978. Resick, P. A., Calhoun, K. S., Atkeson, E. M., & Ellis, E. M. (1981). Social adjustment in victims of sexual assault. Journal of Consulting and Clinical Psychology, 5 705-712. Rogentine, G.N., Van Kammen, D.P., Fox, B.H., Docherty, J.P., Rosenblatt, J.E., Boyd, S., Bunney, W.E. (1 979). Psychological factors in the prognosis of malignant melanoma. Psychosomatic Medicine, 41 , 647-655. Schuker, E. (1979). Psychodynamics and treatment of sexual assault victims. Journal of the American Academy of Psychoanalysis. 4 , 553-557. ' ’ ¥oi I’ol { .- r)^^.V ,V^ .m:.t-mr -.^11 ' ' ' ' ''.'I* n,-y ' ' m' Unr*^.?^^^ ' to laiTHUoi'' . ^ ^ a rv t ">rtOVc1 : ffl-W 0?'V' . ' f jiiLL"f±^ • '•n..' * tim ?nirt;tn ''at ' -- "' ' . _ ?t)C'' . ' ‘-'Wf , ' '' rf ?• _ 1!'. * ’^’ '. 'U i n .M ,.*i'tuf a "i '.‘’^:t^'M 'h '•it- a<-/T’ t(ii i a I 1. -iftiiMsi.i /.'I ,-:» , f .1 V 3 « a -KniiP'': 99 Seligman, M.E.P., Maier, S.F., & Solomon, R.L. (1971). 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Social adjustment by self report in a commuiity sample and in psychiatric outpatients. Journal of Nervous and Mental Disease, 166 , 317-326. Williams, J. E., & Holmes, K. A. (1981). The second assault . Westport: Greenwood Press Wol pe , J., & Lang , P. J. ( 1 964 ). A fear surv ey sched ule for use in behav ior therapy. Behavioral Research and Therapy, 2, 27-30. Wortman, C.B., & Erehm, J.W. (1975). Responses to uncontrollable outcomes. In L. Berkowitz, (Ed.), Advances in experimental social psychology, Vol. 8 , New York; Academic Press. Zilberg, N.J., Weiss, D.S., & Horowitz, M.J. (1 982). Impact of event scale: A cross validation study and sane empirical evidence supporting a conceptual model of stress response syndromes. Journal of Consulting and Clinical Psychology , 50 , 407-414. i •Of..,,71“ ' ' ? I.;' N' 1 * ' ' :• '7^' "* ,1 ^,-ti '.'liVJLt ir«ttr|||!^-::' :i . .• •ia? -ii'.sj'e'tejt tife:- : 4jLia'?a64*tt .••'> I y» 'r 0. 3^ 4(11^ „ :f; .. »?'; ..'•'11 .» ;; " f f !»;• '.iii APPENDIX A 101 jtEnmrsil^ HO*TM CAIiOblNA OC^ARTMENT of psychology telephone 9l9~6aA— 4321 DUKE COPING STUDY Thank you for agreeing to participate in tne Duke Psycnology Department study of coping with sexual assault. Tne study is aimed at finding out how different women cope with this stressful experience and how we can help provide better services for rape victims in the future. You may be assured of complete confidentiality. You do not have to put your name anywhere on the questionnaire or on tne return envelope. After completing the questionnaire, you may attend a free informational session on coping witn rape, which will be held at tne Duke Psychology Clinic. To schedule a session, please call us at (919)-68^-3645. We ask that you fill out the questionnaire before attending tne session, but please call if you have any questions or immediate concerns. If you wisn, you may also schedule a free individual session with one of our researcners to discuss the questionnaire and any questions or feelings it may have raised for you. Again, we ask that you complete the questionnaire before scneduling sucn a session. We are also offering a free therapy group for victims and a free support group for partners. To find out more about eitner of these groups, or about other counseling resources, please call us. You are free to decide after reading over tne questionnaire that you do not wish to participate in tne study. You may still attend the free informational session or the free groups. Thank you very much for your assistance. Sincerely, Susan Roth, Ph.D. Project Director ‘ "t’i lwi»« «i .. 'i : il»-: ., 4 ;' ..^ - - ei'i'iii ail I#' u >3 L'-o , • .. :ut' •.I'twi'l Jd T f r 1 • f o W:> « a*. !lir,j((' ;i. L i^Si f. % 111 "’ “ ji^.- tfu(; i>J t"‘itr) c>;-. Wi:J^ 3'tt .« ’ I'Qv .4wii ji'SiK. vV, , '^ •»v.\ . • . ‘•#*S rnj j.?.wr 5itj »;i! B iC] i fi *t , Htf# \\ 3rijtTyb3ju'«.-i!i"ftfW S'' -b ;.t?v ill -' ; ‘./''4/.^ /'I4 ''*'.ti/'-iV, APPENDIX A, Continued 102 1. Section I: The first questions are about the sexial assault itself. If jou have been assaulted 2. more thai once, refs' to the most recsit event in aiswering this tjjestiomaire. Vhen did the assault oocir? 6. Did you tell arome aiocxJt the assault? (Month and year) 1 No, Cb to questicxi 9. Itiich of the foUovdng best 2 Yes, Answer cjuestions 7 4 8. describes the assailant? (Circle nunber) 7. did yxi tell aomeon^ (Circle nunber) 1 strange' 1 Less than 1 hoir later 2 seei before, but not a fhiend 2 1 hou" to 1 day later 3 date 3 2 days to 7 days later 4 co-wcrker or fhiend 4 8 days to 3D days later boyfl~iend 5 5 1 mcnth to 1 year later 6 ex-bo yfhiend, ex-husband, 6 0/er 1 year later cr estranged hu^and 8. Was the incident reported 7 co-habitant to the police? (Circle nunber) 8 hjsband 1 No 9 other (specify) 2 Yea 3. Vhere did the assault occir? (Circle nunber) 1 my residence Everyone answer questions 9 and 10. 2 assailant's resideice 3 out-of- 4 other (specify) following placed (Circle all that apply) 4. What type of force was used 1 emergency room in the assault? (Circle all that apply) 2 rape crisis center 1 verbal threats 3 gynecologist or family doctor 2 physical restraint 4 payohiatrist or psychologist 3 physical violence 5 other (specify) 4 displayed or implied 10l Have you ever been sexually assaulted that he had a weapan before the time referred to in this 5 used a weapcxi questiomaird? (Circle nunber) 6 othe' (please explain) 1 No, Cb to Section II on page 2. 5. Ihe assault ocnsisted of: 2 Yes, Answer question 11. (Circle nunbers of all that apply) 11. Did the earlier sexial assajlt(s) occir 1 sexual intex»U'se when you were a child, an adult, 2 attanpted sexial intercoirse or both? (Circle nunber) 3 other sacual act 1 Child 4 other (please explain) 2 Adult ;v' Ji :, . '.'^.fw-JI ?0l __. ftg;i iiaitliii axXlKTaSttk3jf> ijVi^fti3hj|y a»«f Vifi*»^ fits* Ki^Ui.^b vt':5 .? > T'jinat*»ri- .e-f 'V j,^'^ ' ''® :-RWti»4' U^'-> ‘' '* Mliirf' 4 : -W*’ VC*' II t%'-.it uni .'X” HMy,l rt‘i f Crf Tilj'i'f ts; -»fi> 5 € 9 ... a&'i-Kv' j 'Ht e*‘v? £. a? r\(!t li -jjyji u*v.r oJJt ai f t Tir^ f -'vO () ., '°^!l , '‘A (g^ffr^ ^v^sfcpftf •jj| .r«£^ ,6i' ''rni\>ir ^!y\{^ > iijdtl'tiji' .n r v>f 4 " wS?ii(*» -mtum ** kac 5 .'.:/: 5 ^ m : :s artJ In \ffc' tW ,?' .'.£v4^ L4 iftiTU;';',' ! • -v-xiitJ (;;£.• : s:. ' ”V'Sc*:0.'1|t twt r « 2ei isica0C0 t a '. ( » «3f^ 'tH .Wl ,5 , .•'L,£*r--. '.;;Lv4fr»- •fit;’* ut £ u.'.-,.* iu- oa Urfci»-* iAilaal* .fvHYvi -ftCsihri* *' • '. n rJ6«5«ir. a j:; ,<#f • -f/ rnCJi,..' t^efA i f '''*m fMt .ftUot^ » * J»» UCf r»W ' L. i*o r i'mt: ' '. ifi[ APPENDIX A, Continued 103 Section II: Pages 2-3 consist of questions about your reactions to the sexual assault you experienced. We would like to know how well each of these comments describes your reactions. Please fill in each blank with the number that best describes how true each comment has been for you. Not at all true Somewhat true Very true ( 1 ) (2) (3) (5) 01 . I thoLgnt ^ut it when I didn't mean to. D ia I was tetter off if no one troLgnt it up. I OZ I couldn't help but remember it. I tried to keep my memory fhebn about what AP .03. I wrote down my thoi^hts about it. happened. 1 _(W. Any remirda* brougnt up feelings about it. ether things kept making me think about it. AP 05. I tried to deal with my feelings about it. I felt that people who dwelt on those AP 06. There were things about it that I tried to kinds of things were just find out more about. looking for trotble. I was sure things would work out. 22. I found that things almost never reminded I found myself collecting things fhom that me of it. AP time. -23. I tried to think about what I should do. Al’ 09. I wanted to talk about it with people wno 24 . I woke up in the middle of t'ne nigne would under stand, without knowing why. AP 10. I tried bo get straight in my head exactly I avoided letting myself get upset when I what happened. was reminded of it or thoLgnt about it. I I 11. I couldn't get my mind off things that 26. I had troLble falling asleep or staying happened. asleep. AV _1Z I tried bo keep it out of my mind. When someone brought it up, I usually D .13. My mind sometimes went blank. tried to change the subject. I in. I had waves of strong feelings about it. ^ 28. I thougnt over and over about what would I felt that things were great; no happen to me. AV problens. 2 9. I tried to just put it all benind me. AV wasn't 16. I tried not to think about it. 0 ^3a I felt as if it hadn't happened or 17. I was aware that I still had a lot of real. feelings about it but I didn't deal I tried to forget it. AV with them. 32. I tried to distract myself. I-intrusion D-denial Av-avoidance AP-appraoch ' cs LA ".. ' f*‘ , ® :)ii 1.0 ;itlr«:,i|.0'<>||*$, a*SBt- '^»tl r«4 Y *>in Jiu* 8 «* -Ein^ lc. . «0 r . ,»# ^*r5 X 1 .iififti*^ *'•! ^^.C!J-fl''vM 'Tl. im '«.' : «.|il'T^ W o*i 1 »i>^ «3»tl>rf ,./6.v TC-'^ ''SSiS i ini -J.r 9 nuirofl ‘Ci».6‘9 SUtS.' 4 ftC(S*e» 9E ^ »v VI# V „ ..„, ..,^- *W’ “ „ , -^'r'' ,i'^^ £‘' ' '"'®' a - '4f2 ' qp&fi 4*eSwa*.’l S9 ‘ 4t*V ."SsTi Vfrrss^ Vci Q1»^K cd tJsW i- ;,ii jj^jods. *4|!?»4r!S^ rwi* ^ .C6e%i5art , :- an '‘^' - I c- I ^1 •^•*4 sp 'toriO XS^ ‘ ’ — tS' u je:,:.*, 5r';'r(.^ ^ ' sidicn'’ tiil S--^ .Atojfeiw -:a\^p .'acci* fir.i.nJ Xi^iJ b«4(? 1 . <2S^ 2 tr Jj. \q «ra S5 «S^:J 1A --4 5 >S5 -sj uitsTti ] a{S iuffft ,v-il ilCii . !T' Kijrftjko^ ,.' ’ ' ' Jf- . '^ 5i.' — -i'.J -c ii JS**/ ; V -j-w. , ,_, '^"i'^'-"'‘‘ HililM* •Vi’» j-itf t.T.'- :> cjifciti srilial didjOT^ i'tar. I JST_ ' "': .>/''•*' -w' j-' ,.' 1'!;h-,.,i, ., /Sa^y- ’/A J isaawa* , 3 ;i issufnrt [W. t , >" I !' ^5 " ,i0 ^x?!p ' :',W"‘ . .x.;:u: .:.i '•» #iil' -S tt).£ ' ^ r ItO'.StciC t«^ , 6 • '4£' .ii ^Wjricn APPENDIX A, Continued 1C4 Not at all true Somewhat true Very tru CD (2) (3) (4) (5) AV D 3S It didn't really have any long term impact 49. I tried to get on with mv life arxd not cn me. think too much about it. T AP ±, 34. I kept thinking about it even though it 5a I thought ova* and over about wnat it all upset me. meant. AV AP 35. I tried to remove it fhom memory. 51. I tried to figu-e out a way to live with D 36. I already knew more thsi I needed to know this experience. I about it. 5A Pictures about it popped into my mind. AP D 37. I thought about what could keep it fhom 53. I remember ve'y little about it. D happening again. 54. I didn't give it much thought. D AV 38. I’ve almost forgotten all about it. c:: Vnen people asked me about it, I usually AP 39. I tried to find out what experts cr people felt I'd rather not talk about it. AP with similar experiences had to say 56. I tried to find out how other people ^ut it. handled it. I AV 4a I had dreans about it. 57. I stayed away from reminde's of it. T\ AP 41. I tried to find people who would U 58. Ky feelings about it were kind of nunb. AV understand. 59. I tried to think about othe* things I 42. I found myself thinking ixout what I could instead. I have done differently. 6a Sometimes I found myself acting as if I AV 43. I tried not to go over the details of it were back in that time. AP too muon. 61. It's a memcry I'll live with for tne rest I 44. I tnought over and over ^ut what was of my life. AV really important. 62. I kept myself busy to avoid thinking too AV 45. I tried not to talk about it. muon about it. AP I 46. I tried to think about what would happen 63. I found myself thinking ojer and o/er in the long run. about wnat should have been done. D AP People told me I seemed to have no 64. I forced myself to think it throogn. feelings. AP 48. I tried to think i)out what I could do to keep it ft-on happening agaLn. " C-i ' •!ii I^i8 jn» j., .1) nitafl* 'HtWift'Vaftf '• Kii! s«» -ww«;,|^)i! ' " ’•» ^ ,1 , p^riv yt r ]i\r M M '1( • .* oik' *a . isu*c '< of f C, 'isSw^' 3 ; .-• •• '/. 0SS^'-' . L-«u> , '• ',,, " ,. ,,, m .. : ...... , ,, ,ipi 63. , .;, ; T Vv',i3rn tfti^ .Ifi' c'XIJ.i!l,', ;,,,,*• . . :. .,. *f fc- a’.iirt' - o(>r*1 „ ' ' »' ' '.. "i ' ,1 2 ^al6 VO CC^f *:lSk ', Iiis.','«!i . -3nje .ivsyiil O-^ lOV^' , .jjjjfVl, • .J:*i towitfitpfeg.:-.' tv 4 ^ •. iiiti Ji*v;r irwv '. 'v:; 6. K'dl M'.t , fv 'J 40^21 ' ''^] .ml ' ' , .-"UX .var-^o mV^ 'W 'y' '>-*v « 'W3' bir*W’' '';'^‘‘’!(‘ rJbi'Wttt I.. St’i :•'.. >/^». Tbuo :- - -.'as^n ieiorw m. U.\ j: r.iM iui<«v/Ti bs^fiitArl S-T!^, cx? 'WV* '' :<:" 'i ,.; 'p': APPENDIX A, Continued 105 Section III: Another important purpose of this study is to learn about the effects of sexual assault on sexual satisfaction. 1. Are you curently involved in a sexial relatioaroF^? 4. In yoLT judgment, faow satisfying is yotr sexual (Circle nunber) relation^p3 for your pertner? Circle the 1 to, Qc to Sectian IV on page 5. nunb^ that best describes yocr aex\al 2 Yes, ArjswQ- questions 4-6. relatianaup ftom your partner's pierspective. 2. Below are some statanents about sexual satisfaction. Please indicate viiether each statement is true for 8 Could not be better you by circling either IBIE or FALSI 7 Excellent 1. Ibually, I am satisfied witn my 6 Good sexual partno" .•muE FAl^ 5 Above average 2. I feel I do not have sex 4 Adequate frequently enough .mLE FALSE Sonevhat inadequate 3. There is not enough variety 2 Boor in mv sex life .TRIE FAl^E 1 Highly inadequate 4. Lbually, after sex I feel 0 Could not be worse relaxed and fulfilled .reiE FALSE 5. Ibually, sex does not 5. Were involved in a spxihI relaticn^p at the 3. last long1 enough .TRIE FALSE time of the assault? (Circle nunber) 6. I am not verv interested in sex .TRIE FALSE 1 to. Go to section IV, page 6 7. Usually, I have a satisfying orgaan 2 Yes, Answer question 6 with sex .TRIE FALSE 6. Some women report that there is a period of 8. Foreplay before inte-ooirse is time aft^ a rape in Wiich they do not engage usually ve'v arousing for me .TRLE FAISE in sexual activity. Others do not experience 9. Often, I worry about my this. When did you first engage in sexual sexual performaxe .TRIE FALSE activity after the assault? (Circle nunber) 10. Usually, my pertno" and I have good 1 Less than 1 week later cdimunication ^ut sex .TRIE FALSE 2 1 to 3 weeks later 3 1 to 2 months later Below is a rating scale upon we would like you 4 3 to 6 months later to record ^ou* personal evaluation of how 5 More than 6 months later satisfying your sexual relablQn:^p is. Ihe 6 Have not resuned sexual activity rating is simple. Make yoir evaluation by circling the nunber that best describes present sexi.al rdaticnaiip. 8 Could not be better 7 Excellent 6 Cbod 5 Above avenge 4 Ajequate 3 Somevhat inadequate 2 Fbcr Highly inadequate 0 Could not be worse *';0 e'/'f* 1(ioS4 tiv'I# • • * • *1 ^ * • ^ J • f |#A I fc.0 • 6 f l' • * Uupu T*^*l,vw»Ai£illi»^jr • * lutt'SSP ”•*'#{ ' i • V -4T ^ W^fSJiT *.:<-• ,U*'0 ^v' r » *ir*X e • -^-xtA A t.'P'it.jU »^afW;3.? ^ '- •'.Ak^^UU' ’ ( -• r* vr -: . - . ...• nj ikii < ^ .c ./rt r -t»4r *: ' ' • i: • I A ?4*r* J*" . tfi ' " ' -»*-' ’*• •.i-i- : 1.', (i • - •':».::> ."2 i^iutp* ft! * : ;; ' -- ^ ., [fh.s '•; 'i5i» ‘Jt# }'>ibr l.ydtif J^im ' ' • j\ ' xtuahirt'i 'T* ,,^ W-i '• • } j » « V ‘ 4 i i>-'' r* >VW fi^Ti/TT’ ',« V»4A* » APPENDIX A, Continued 1U6 Section IV: The items in this section refer to things and experiences that may cause fear or unpleasant feelings. Fill in the blank with the number that describes how much you are disturbed by each nowadays. Hot at all A little A fair amount Much ?ery Much (i») ( 1 ) (2) (3) (5) 1. Parking lots 28. Fire 2. Being in a car alone 29. Thunder 3. People who seem insane 30. Watching violence on TV 4. Crawling insects or at movies 5. Falling 31. Answering the phone 6. Being on an elevator alone 32. Receiving injections 7. Human blood 33. Sight of deep water 8. Automobiles 3^1. Parting from friends 9. Anal intercourse 35. Seeing other people injected 10. People with deformities 36. Journeys by bus 11. Noise of vacuum cleaners 37. Enclosed spaces 12. Dogs 38. Doctors 13. Guns 39. Being criticized 14. Loud voices 40. Premature heart beats 15. Speaking in public 41. Homosexuals 16. Tougn-looking people 42. Emergency rooms 17. Darkness 43. Being awakened at night 18. Strange shapes 44. Sirens 19. Closed spaces 45. Binding clothing 20. Being teased 46. Failure 21. Going out with new people 47. Open wounds 22. Sick people _____ 48. Choking 23. Pregnancy 49. Cemeteries 24. Worms 50. Suffocation 25. Cats 51. Feeling disapproved of 26. Dentists 52. Being in a strange place 27. Entering room where people 53. Weapons are seated 54. Knives ' . ' '. ' ^ •nit'' . ' »P^“ , V ’.j, ‘ii a Si‘A • ... .Ky *»UfWfrO' ‘ ® ' * ^..5“ , . . #4«KI Y'^»I ri J»<|X ''I , >“) ur / v#riWi'4iit^ •i.r V?’ {!« . i; v'’ ijfnf.?**8^(VW:' n “13'; ' ’ ,4fi4 * -.. • rfloj.*4t^.i .vt'YJJwVfl' . >j(aR; ; '• ti 1^4 KjtkK; 13 jOflt.t' .jfg r' nt. 0,»J.,3t*-i - :.‘- I 4 ._; ^ inviiotAl, »ajt. . .. ><> }.; yiti ; ,. .' ^ » ^V,:(4iW1 „^'U: //rf* jfiscji /d t'VJ.'fy^.,«i jr. { yJ ‘H 3iJ0%i:V .4j! itlil^<»»4 / 'T''* .„ V" $t(iHC^ .414 # It'S ' Tl^^’; C , »l. 1 ‘l> J6l',^(i5'.;',.j^' 1c» lfc>V'.' •..{•^*tvl> . .r? J,.;.i J. *>» »a(»1, t * vliljf , 1^*. APPENDIX A, Continued 107 Not at all A little A fair amount Much Very Much ( 1 ) ( 2 ) (3) (4) (5) 55. Watching sexual activity on 88. High places on land TV or at movies 89. Animal blood 56. Walking on a dimly lit street 90. Looking down from 57. Pick-up trucks high buildings 58. Witnessing surgical operations 91. Testifying in court 59. Crossing streets 92. Feeling rejected by others 60. Being alone 93. Imaginary creatures 61. Sound of doorbell 94. Bats 62. Not being believed 95. Dirt 63. People playfully wrestling 96. Journeys by train 64. Drunken people 97. Journeys by car 65. Sudden noises 98. Losing control 66. Venereal diseases 99. Nude women 67. A man's penis 100. Airplanes 68. Dead animals 101. Crowds 69. Mice 102. Birds 70. Sexual intercourse 103. Medical odors 71. Parties lOi). Feeling angry 72. Stopping at a stoplight 105. People in authority 73. Blind dates 106. Flying insects 74. Dreams 107. Angry people 75. Prospect of a surgical operation 108. Dull weather 76. Looking foolisn 109. Talking to police 77. Strangers 110. Sight of fighting 78. Door slamming 111. Being watched working 79. Lesbians 112. Harmless snakes 80. Dead people 113. Large open spaces 81. People talking about you 114. Ugly people 82. Sleeping alone 115. One person bullying another 83. People behind you 116. Being ignored 84. Being in an elevator 117. Nude men 85. Shadows 118. Lightning 86. Sexual fantasies 119. Voices 87. Making mistakes 120. Bars i : ' , j ttpttt ' It ' '^'t^ Ttr n ten '^Ji »i',' . 3J 2 .„’i| 'ip.l /dCl' iJ^:' ttl?l1: , i(| in^l'Kal ;(t% ^ tuiuf'P eM. •* : ,D'" • ',.• . .'. ^]\\mjil i( / *’v^ i!t • M.'- ’A/if fi. * ' I . .‘.A. i ''.MX:, SV®' ,i(n- "• > : »it t ,, , , ,, ,*^4f . Ita i t.fh .€"11 . .i-n,. !Si. , /^4?J i:ta»?, .,4'iSM y , .j, _.l •vvfl a) <* # .1 st«i;«A ;. : « 1 1^9 %’’ 3,?!|A- f ;.*•»< Iftrt 'f I'lifr' '>,!^'I?t,'‘ ^ fUtJ fcri o'* •ii'.iif'ft'’ j. jniy »ow i>ifU>JftiH. »r iwl t-v uvfi'- ’'^' ^ ;rV , *.unirt»i:'|I'l ''.J.;' , -Art ' '7'wi ,..j;.. : .;;v ''ih/ ' ' 7,^p|mll APPENDIX A, Continued 108 SOCIAL ADJUSTMENT SELF REPORT QUESTIOfj;^IRE We are interested in finding out how you have been doing in the last two weeks. We would like you to answer some questions about york work, spare time and your family life. There are no right or wrong answers to these questions. Check the answers that best desaibes how you have been in the last two weeks. WORK OUTSIDE THE HOME 5. Have you felt upul, worried, or uncomfortable while doing your work during the last weeks? PUisa check the situidoo that best describes you. 2 lG 1 never fall upset. 2 i> lam lD a worker lor pay 4 0 retired do ( 2 G Once or twice 1 fell upset. 2 D a housewife 5 D unemployed 3 Hall the lime 1 fell upset. 3 a student G 4 G 1 felt upset most of the lime. Do you usually work for pay more than IS hours per week? 5 G 1 felt upset all of the time. iD YES 2DN0 di) 6. Hava you found your work interesting these last two weeks? Did you work any hours for pay in the last two weeks? iG My work was almost always interesting. ( 22 ) 1 YES 2D NO (16) 2 G Once or twice my work was not interesting. Check the ennrer thet best describes how you hive been 3 G Hall the time my work was uninteresting. in the last two weeks 4 Most of the time my work was uninteresting. 1. How many days did you miss from work in the last two weeks? 6 G My work was always uninteresting. lG No days missed. (17) 2 D One day. tVO/m A r MOM£ - HOUSEWIVES ANSWER QUESTIONS 7- 12. OTHERWISE. CO ON TO QUESTION 13. hall 3 D 1 missed about the time. 4 D Missed more than half the time but did make at 7. How many days did you do some housework during the lesst one day. lest 2 weeks? 5 D 1 did not work any days. 1 G Every day. (23> 8 On vacation all ot the last two weeks. 2 G 1 did the housework almost every day. 3 G 1 did the housework about half the time. If you have not worked any days in the last two weeks, go on to Question 7. 4 G 1 usually did not do the housework. 5 1 was completely unable to do houuwork. 2. Have you been eble to do your work in the last 2 weeks? G 8 G 1 was away from home all of the last two weeks. iD 1 did my work very well. (16) 1 well but had some minor problems. 2 did my work 8 . During the last two weeks, heve you kept up with your did well housework? This inciudei cooking, cleening, leundry, 3 G 1 needed help with work and not do about half the time. grocery shopping, and errands. the time. 1 did my work very well. (24) 4 G 1 did my work poorly most of lG all the tima. 1 did my work well but had some minor problems. 5 D 1 did my work poorly 2 G 3 G 1 needed help with my work and did not do it well 3. Hava you been ashamed of how you do your work in the about half the time. last 2 weeks? 4 G 1 did my work poorly most of the time. lD 1 never felt ashamed. (19) 5 0 1 did my work poorly ell of the time. 2 G Once or twice 1 felt a little ashamed. 9. Have you been ashamed of how you did your heusawork 3 G About half Iha time 1 fell ashamed. during the fast 2 weeks? of the lime. 4 G 1 tell ashamed most f never felt ashamed. (2&> all time. 1 G 5 G 1 felt ashamed the 2 G Once or twice 1 felt a little eshamed. 4. Have you had any arsumants with people at work in the 3 G About hall the time 1 felt ashamed. last 2 weeks? 4 G 1 felt ashamed most of tha time. along very well. lD 1 had no arguments and got (20) 5 G 1 felt eshamed all the time. had minor arguments. 2 G 1 usually got along well but than one argument 9 1 had mora 4 1 had many arguments. 5 G 1 was constantly in arguments. I.FH TM«f • t/7t ; ' 5 , [ kf> *-*W^ " ! ^ -Wfl m H »•' '''"^ V -., ^.*^'* 4»,- ,'.' h. fi\,i^ '*'1' i l*(Q* ti;Hf>:tt)^\-'*'MW ; -\ii .(»»*iw lit I'iwf. •'» 'i)il’ 12^', .' -1'^ li , w [jV;* 'iP^I •i\ ,u 1 .i.vV t .f ' I 4vi * ^ «».,». !tv.: ' ' ' • • . cf-" I tiOT f" 4 1 e, .)kv. ?9S®a *...4;;.* <>»'*. '' ''wit 41 *4k h-*» ,4)tiW |W S3.'£^ , ’ «(-tt I »•'/, l> 111 u*t 4 41 kitj .(fl^ ,l#»l^.>i tl»li'4»l( .' '^ ' i' ‘•' itt*><¥fi? wtv/i : ,. ' ' '. ‘ 1 'I** \kr^iki''lii^.i ; . !») ? fk t' ..Wit H'l ii4vt4 Si‘ . ,•«;..'< «*«a : , ; :? ' ''© ' >,..j^: # - •• V. I !.>‘.j , '• '-'^wy' ! .'iff APPENDIX A, Continued 109 10. Hivt you hid iny irgumtitb Mith ultipeopk, Utdivmtn 14. Hava you baen able to keep up with your class work in the 01 otighben in tlu list 2 «^««lis? last 2 weeks? 1 I hid no irgumenu ind got ilong wry well. ( 26 ) 1 G I did my work very well. (31) 2 D I usually got along well, but had minor arguments. 2 0 I did my work well but had minor problems. 3 D I had more than one argument 3G I needed help with my work and did not do well about half the time. 4 I had many arguments. 4 G I did my work poorly most of the time. 5 D I was constantly in arguments. 5 G I did my work poorly all the time. 11. Have you felt upset whili doing your housework during the last 2 weeks? 15. During tha last 2 weeks, have you been ashamed of how you do your school work? 1 I never felt upset. (21) ( 32 ) 1 G I never fell ashamed. 2 Once or twice I felt upset. 2 G Onu or twice I felt ashamed. 3 G Hall the time I felt upset. 3G About half the time I felt ashamed. 4 I fell upset most of the lime. 4 G I fell ashamed most of the lime. 5 I fell upset all of the lime. 5 G I felt ashamed all of the time. 12. Have you found your housework interesting these last 2 weeks? 16. Have you had any arguments with people at school in the last 2 weeks? 1 My work was almost always interesting. (26) 1 G I had no arguments and got along very well. (33) 2 G Once or twice my work was not interesting. 2 G I usually got along well but had minor arguments. 3 G Hall the time my work was uninteresting. 3G I had more than one argument. 4 G Most of the time my work was uninteresting. 4 G I had many arguments. 5 G My work was always uninteresting. 5 G I was constantly in arguments. 6 G Not applicable, I did not attend school. 13.FOR STUDENTS Anwef Questions 13- tS H you go to school halt time or more. 17. Hava you felt upset at school during tha lost 2 wtaks? Otherwise, go on to Question 19. (3«) 1 G I never felt upset. Whai best describes your school program? (Choose one) 2G Once or twice I felt upset. (29) 1 G Full Time 3G Half the time I felt upset. 2 G 3/4 Time 4G I felt upset most of the time. 3 G Halt Time 5G I felt upset all of the time. 8G Not applicable: I did not attand school. Check the answer that best describes how you have been the last 2 weeks. 18. Hava you found your school work intorasting these last How many days of classes did you miss in the last 2 weeks? 2 weeks? lG My work was almost always interesting. (3b) 1 G No days missed. (30) 2G Once or twice my work was not interesting. 2 G A few days missed. Half the time my work was unintcrasting. half 3G 3 G I missed about the time. 4G Most of the time my work was uninteresting. 4 Q Missed more than half time but did make at least one day. 5G My work was always unintaresting. 5 G I did not go to classes at all. 6 Gl was on vacation all of the last two weeks. r .4»M fftn »i*V • ai kl|i|« U ‘ •'*' < Jil! ’ft .![.> ,m,( „>• s i> vtf 'i'll ^'^.r . . .- M V4w ^,tA t ‘ k« iviAiii .it9 i»i; *v<4 ',ti> :;;1\. !' '. 4 \ ,«, Iii«f •V««J»a rtJli I •: -K. . iW'.i jr«_.| " Mifii)i.,.i.t ir, • .«•! II II »Milv» '. »,. I ' M i.. Ihlurvy’ < ‘ $?'''' I «.• V ih i« Of'ff v<1W9 P'f' ', M (|f \i ; 1 >1 ‘ti ' !'• jii'**' * 111 tbKiiu l , III 'y(l’-l •)ll ' ,(»ti*l'U*| I* <" I .•; ', .. .fc.'jtt , I I '. .( ii.^i it/ij, ! ' .... ' ' , ' ' ' 'I ,"...'' .'* ! , III *1 mA( [, «iii’*» .HU'»‘if,iK(.|iH'.' >iv‘ , , IWi • ' '* i* ' I I 'M' u i»n' .'^yuMt'iMiV . '^2.\ / .'I V' > /Iilll.: I', llirf ((I J *lfl IM'' ( ! 'H '( .Kl» . , f '. ., . VM.'I : jf** ! /ft*!*yi.'l-<.«l j.i. ii «( I i> ‘ '.,•* Vnt ii'c *!i(*l^ iJV 'll’ ;’m f I, ml V«if ' itH, 'OV'' ' ' ' 'i> »;i‘( v^i»Wi $4M I 'I W(if . 0 ^^' " ' 1 . ,'itih k*. appendix a, Continued 110 SPARE TIME - EVERYONE ANSWER QUESTIONS J9 27. 24. If your feelings were hurl or oHandad by a Iriand during the last two weeks, how badly did you taka it? Check the tntte/er rtjf b»it describes horn you hive been in ihe last 2 weeks. I G It did not affect me or it did not happen. (4i) 20 I got over it in a few hours. 19. How mtny frionds hovt you icon or ipoktn to on dit Uliphoni in thi last 2 wteks? 30 I got over it in a few days. 4 O I got over it in a week. 1 D Nine or more friends. 06) 5 O It will taka me months to recover. 2 D Five to eight friends. 60 Not applicable; I have no friends. 3 0 Two to lour friends. 4 O One friend 25. Have you felt thy or uncomfortable with people in the 5 No friends. D last 2 weeks? 1 O I always felt comfortable. U 2 ) 20. Have you been able to talk about your feelings and problems 2 Sometimes I felt uncomfortable relax with at least one Iriand during the last 2 weeks? 0 but could after a while. 1 I can always talk about my innermost feelings. (37> 30 About half the time I felt uncomfortable. 2 D I usually can talk about my feelings. 4 0 I usually felt uncomfortable. 3 O About hail the time I felt able to talk about my feelings. 5 O I always felt uncomfortable. 4 D I usually was not able to talk about my feelings. 8 O Not applicable; I was never with people. 5 D I was never able to talk about my feelings. 8 D Not applicable; I have no friends. 26. Have you felt lonely and wished for more friends during the last 2 weeks? 21. How may times in thi last two weeks have you gone out 1 O I have not fell lonely. (43) socially with other people? For example, visited friends, 2 O I have felt lonely a lew times. gona to movies, bowling, church, restaurants, invitsd half the friends to your home? 3 O About time I tell lonely. 4 O I usually felt lonely. 1 More than 3 times. (38) 5 O I always fell lonely and wished lor more friends. 2 D Three times. 3D Twice. 27. Have you fait bored in your spare time during the last 4 Once. 2 weeks? SD None. 1 O I never felt bored. (44) 2 O I usually did not feel bored. 22. How much time have you spent on hobbies or spare lima 30 About half the time I fait bored. interests during the last 2 weeks? For example, bowling, sewing, gardaning, sports, reading? 4 O Most of the time I felt bored. 5 0 I was constantly bored. 1 I spent most of my spare tune on hobbies almost (39) every day. ' Are you a Single. Separated, or Divorced Person not living with 2 I spent soma spare time on hobbies tome of the days. a person of opposite sex; please answer below: 3 I spent a little spare time on hobbies. 1 4 I usually did not spend any time on hobbies but did 0 YES, Answer questions 28 & 29. (43) watch TV. 20 NO, go to question 30. 5 I did not spend any spare time on hobbies or watching TV. 28. How many times have you bean with a date these last 2 weeks? 23. Have you had open arguments with your friends in the 1 Mora than 3 times. (46) test 2 weeks? O 2 O Three timet. (40) 1 O I had no arguments and got along very wall. 30 Twice. 2f] I usually got along well but had minor argumints. 4 0 Once. 30 I had more than one argument. 50 Never. 4 D I had many arguments. 5 D I was constantly in argumano. 6 O Not applicable; I have no friends. t . fix ’ Vf W',. Mti i;,4Mif 1 •(W^AJ.WfWi* *rti Mil*' ’ ''/ « • M ,lH(^i\tilt'ih# , |6li(' »Msi4p>P « >4111 i»i..> M tut i>.«'*v^lbAw‘jri’|>( . i.|.,'« SM t,v44'^H*-' 1-»'>'|^' ^f90ii) W^ij 0 I .yUlViHM' m *2 ,/'')ntul Wf/ip M tV('^•Alilrt vt»^l''t#t \pi)IkVOi "iT^ ''A . *>» .>M.4|| (Mil I > fitf tl«4li i»4tv. mAm« ' ' '" ’ "‘ *1 ' - • ''i' ‘(j, ,^.t, >«,( w>^^« .I. »-: v»«i* '•w<^»Wfif'i(u*»#'^!S^^^ I '.U' 'M \?,- , 'Ji. . W'«4'l' O K' '^' if' r?i SiS;': ;|,' W APPENDIX A, Continued 111 29. Hrv wMki. t1 you hivt not dated, would you have liked to? wanted in order to makt them angry during the last 2 w««ks? (47) 1 I was always interesied in dating. 1 1 D 1 never wanted to oppose them. (62) 2 Most of the time I was interested. 2 G Once or twice I wanted to oppose them. 3 D About half ol the time I was interested. 3G About half the time I wanted to oppose them. 4 Most of the time I was not interested. 4 Q Most of the time I wanted to oppose them. SD I was completely uninterested. 5 G I always opposed them. FAMILY 35. Have you been worried about things happening to your Answer Questions 3C 37 eboul your parents, brothers, sisters, relatives without good reason in the last 2 wcaks? in laws, and children not living at home. Have you been in in last weeks'^ contact with any o! them the two 1 G I have not worried without reason (63) G YES. Answer questions 30-37. 2 G Once or twice I worried. _ 2 G NO, Go to question 36 3 Q About half the time 1 worried. 4 G Most of the time I worried. 30. Have you had open arguments with your relatives in the 5 I have worried the entire last 2 weeks? G time. 8 Q Not applicable; my relatives are no longer living. (48) 1 G We always got along very well. 2 G We usually got along very well but had some minor EVERYONE answer Questions 35 and 37, even it your relatives arguments. ere not living. 3 G I had more than one argument with at least one 35. During the last Two weeks, have you been thinking that relative. you have let any of your relatives down or have been 4G I had many arguments. unfair to them at any ume? in SG I was constantly arguments. feel 1 G I did not that I let them down at all. (64) 31. Have you been able to talk about your feelings and problems 2 G I usually did net feel that 1 let them down. with at least one of your relatives in the last 2 vweks? 3G About hall the time I felt that I let them down. 1 I can always talk about my feelings with at least one O 4 G Most of tne time I have felt that I let them down. relative. <49) SG I always felt that I let tnem down. 2 G I usually can talk about my feelings. 37. During the last Two waeks, have you been thinking that 3 G About hall the time I felt able to talk about my any cl your rolativas have let you down or have been feelings. unfair to you at any time? feelings. 4 G I usually was not able to talk about my 1 I never felt that tney let me down. (66) feelings. G 5 G I was never able to talk about my 2 G I felt that they usually did not let me down. 3 G About half the time I felt they let me down. fell 4 G I usually have tnat they let me down. 32. Heve you avoided contacts with your relatives thesa last two weeks? 5 G lam very bitter that they let me down. Are living with your spouse or have been living with a 1 G I have contacted relatives regularly. (so) you person of the opposite sea w a permanent relationship? relative least once. 2 G I have contacted a at me. 3 G I have waited for my relatives to contact 1 Q YES, Please answer questions 38-46. (66) 4 G I avoided my relatives, but they contacted me. 2 0 NO. Go to question 47. 5 G I have no contacts with any relatives. 3B. Have you had open argumenQ with your partner in (ha 33. Did you depend on your relatives for help, advice, mensy lest 2 weeks? or friendship during the last 2 weeks? 1 G We had no arguments and we got along well. (57) 1 G I never need to depend on them. (&i) 2 G We usually got along well but had minor arguments. them. 2 G I usually did not need to depend on 3 G We had more than one argument. them. 3G About half the time I needed to depend on 4 O We had many arguments. 4 G Most of the time I depend on them. 5 Q Wa were constantly in arguments. 5 G I depend completely on them. • Hi I »' 4,«llMfcL^**’• - ... -'i...::^ :j,-.^ k .' • ^ .UB .. t ~jt*\ n.«ti. ». >."B . ,n ‘""' ' \i|Mj(f ai • »•' » III') l< 4 ')•<*• biM'U N'W^ •V. 1 i.Mf Ii» >•' ..,• , ..Cl.V'titiM ,,l(|VVi»,t»» ’ *m^JI/I 1' ': I «) V,»iini M^i'' . *A'»HfW ' ftl'lf’ 1'^ ,1.^1 ''(«<•! V A‘ /<»*'•'« ,,.,0 «.| . .. .)> (#vtiiiH*'-M«MV ’-i W* 5^- ' 'I '^LvLil ^ " ' *'* ftitji .'w i',;;'; ii .,. .'‘-vo ivH',1**' ' i' W' ).i><^4^y«'..'i.i,i^ .. . m«i»f W[Jif « V!"-' .Jt' •'• *'•••! ) 1 (' ft kl0* f-fjl* %< ^'.;. ( •'•'..• '•*»»«.» 'Vift 'yiv '»“ • • ''»"' • T ,,,|J ....l. - vf Mt WJ»4./ Jp®f' •u'i . «i| '* kWn'Si Vu 1. '-lift '' ' ' .*’ ,- ' - . / i WID K a ' .. •ID' ’ • - i»i-i r>i< •,••'-<• •• . '•"• „ 1 , ’t . , ryi’.'t.V-lv’'r , 'A •'<4 ’%.yiv V I ' »’ ’ 'f ft, i'*j • |. '(•r »uti» ?|J|^ «»;', .;^y I, iW'lii'a (;,'• ;* (<| , /, ' .4' '., • to* .1':.')^. 1 ’ V*' • |)|MI llt,).ft ,». .ftlf Vi:ii ' ''I,' APPENDIX A, Continued 112 1 39. Htvt you bMn ibli to alk ibout your tnlingj ond 44. How many times have you and your partner had probitmt with your pirintr during tbs Int 2 wotki? intircoursa? talk freely about feelings. <^>8) 1 More than twice week. <®3) D I could always my G a talk about my feelings. 2 Once or twice a week. 2D I usually could G 3 D About hall the time I felt able to talk about my 3G Once every two weeks. feelings. 4 G Less than once every two weeks but at least once in able to talk about my feelings. the last month. 4 I usually was not never able talk about my feelings. 5 Not at all in a month or longer. 5 D 1 was to G 40. Have you been demanding to have your own way at home 45. Htve you had any problems during intercourse, such as during the last 2 weeks? pain these last two weeks? having <89) 1 D 1 have not insisted on always my own way. 1 None. (6a) insisted having own G 2 D I usually have not on my way. 2 G Once or twice. 3 D About half the time I insisted on having my own wav. 3G About half the time. 4 G I usually insisted on having my own way. 4 G Most of the time. 5 D I always insisted on having my own way. 5 G Always. 41. Have you been bossed around by your partner these last 6 G Not applicable; no intercourse in the last two weeks. 2 weeks? <6°) 1 D Almost never. 46. How have you felt about intercoursf during the l»t 2 G Once in a while. 2 Maks? 3 G About half the time. 1 G I always enioyed it. (6i) 4 G Most of the time. 2 G I usually enioyed it. 5 G Always. 3 G About half the time I did and half the time I did not enioy it. 42. How much htve you felt dependent on your paaner thisa last 2 weeks? 4 lJ I usually did not en|oy it. tSD 5 G I never enjoyed it. 1 G I was independent. 2 G I was usually independsnt. 3 G I was somewhat dependent. 4 G I was usually dependent. QUESTIONS 47-54 On Next Page. for everything. 5 G 1 depended on my partner 43. How have you felt about your pannei during the last 2 weeks? 1 G I always felt affection. 2 G I usually felt affection. half the 3 G About half the time I felt dislike and time affection. 4 G I usually felt dislike. 5 G I always felt dislike. ", I' L .J*r .flj. ff J ,v .^lmn ' ' " ' " . " 1 ""y o, w,, ^ rs*?' I ii#w. i^f «3 «fc, r*iW * LliM WL'ini - ' .1 .?l_ 0 '-i' , ^iW M' s|i# f:r:» «i0 tffrt'n/l# mSxi'' I • 'll! , -V '^. i§^. &>, ?(l4 V# ‘f APPENDIX At Continued 113 CHILDREN FAMILY UNIT Him you hod unmsrritd childrtn, stepchildrtn, or hstir Have you ever been married, ever lived with i person of the chUdnn living it bomi during tl)t last two weaks? opposite sex, or ever had children? Please check 1 YES, Annvtr questions 47-50. (66) 1 G YES, Please answer questions 5)-53. 2 G NO, Go to question 51. 2G NO, Go to question 54. 47. Heve you been interested in whet your children ere doing - SI. Heve you worried about your partner or any of your school, pley or bobbies during the last 2 weeks? children without any reason during the last 2 weeks, even if you ate not living together now? 1 I was always intaresied and actively involved. (67) involved. 1 G i never worried. (72) 2 D I usually was interested and 2 Once or twice I worried. 3 About hall the time interested and half the time G not interested. 3G About half the time I worried. 4 O I usually was disinterested. 4 G Most of the time I worried. 5 G I wasl always disinterested. 5 G I always worried. 8 G Not applicable; partner and childrtn not living. 48. Have you been able to talk and listen to your children during the last 2 weeks? Include only children over the 82. During the last 2 weeks heve you been thinking that you age of 2. bive let down your partner or any of your children at any time? with them. (68) 1 G I always was able to communicate with them. I all. 2 G I usually was able to communicate 1 G I did not feel let them down at (73) communicate. 3G About hall the time I could 2 G I usually did not feel that I let them down. 4 G I usually was not able to communicate. 3G About half the time I felt I lat them down. to communicate. 4 Most of the time I have felt that I let (hem down. 5 G I was completely unable G age 8 G Not appliuble; no children over the of 2. SG I let them down completely. During the last 2 weeks, heve you been thinking diet your 49. How have you been getting along with the children during 53. partner or any of your children have let you down at any the last 2 weeks? time? and along very well. (69) 1 G I had no argumenu got 1 G I never felt that they let me down. (74) well but had minor argumenu. 2 G I usually got along 2 G I felt they usually did not lat me down. argument. 3G I had more than one 3 G About half the time I felt they let me down. arguments. 4 G I had many let 4 G I usually felt they me down. in arguments. 5 G I was constantly 5 G I feel bitter that they have let me down. 50. How have you felt toward your children these last FINANCIAL - EVERYONE PLEASE ANSWER QUESTION 54. 2 weeks? 54. Heve you had enough money to take care of your own felt affection. (lO) 1 G I always and your family's financial npeds during the last 2 weeks? 2 G I mostly felt affection. affection. 1 G I had anought money for needs. 3 G About half the time I felt with minor problems. feel affection. 2 G I usually had enough money 4 G Most of the time I did not them. 3G About half the time I did not have enough money 5 G I never fait affection toward but did not have to borrow money. 4 G I usually did not have enough money and had to borrow from others. SG I had great financial difficulty. . ' . *„ • ^ lift’ ••T ! XI »1 ir«iht«)| W iiwiww 4)^y ttt yii.4 M ' '’ ‘ " " ‘ " ' “ t ,i»***t s .i^ *» |C l.'ivit tar' rif )hti4> )"** ,...... w«» ft'-'. f'« ' ' , (j, ^ Uk .(I4 1* f.^>ll> AVilf ‘'|.y ( ‘«i .Hi.,..-. . i,.yr*»;i')iM)y.i««i'*«»<'y •lyt-ih H» t fft I t$ii> '.. •WW| Hk (••.‘i kMty •v#4 ;,i;|. m k- «. <**H M ">i«m; (W'^W ' ' • • -'^n :u4 M( |fi«V >wi»ti,'t:f^ f t»**#ii» v>* "^ : tiytrytt m.(,*T;V»yU l.»t k .»*-") tM <«i(1|^'''Q'<;, . .^.ftfc»f»f''M w*(» . 'i, V4/ff . ,,.,-j Mill dhr'ifiiiain; ' ^ KiM>'i|iIi0 i'll. f,..„g*. IIIM I,ii, 4ir«il»<4 vr4#i frill (.i %9m'f r>H »* O' friiir < ' \ tit.,1 ||"H ,’»io«' Cl'fr' 1 fO'd ., ' .. ;i' .5 , . ;. .thi, . :S.; I )lM*tw» . ';| **^^T‘r0*O-ii' , Jn . >. appendix Af Continued 114 INSTRUCTIONS B«iow b list of probbim and complaints that people sometimes have. Read each one carafcilly, and sebct one of the numbered descripton that best describes HOW MUCH DISCOMFORT THAT PROBLEM HAS CAUSED YOU DURING 2 THE PAST weeks including today. Place that number in the open block to the right of the problem. Do not drip any items, and print your number clearly. If you change your mind, erase your first number completely. Read the example below before beginnini^ EXAMPLE Docriplon Oncriptoa HOW MUCH WE RE YOU DISTRESSED BY: O Not at aii HOW MUCH WERE YOU DISTRESSED BY: 0 Not n til t A unia bit 1 A iittta bit j 2 MexSarataly 2 Modarstaly 1 Ex. Body Aches Ex. [3J 3Quii»abit 3 Quha a bit 4 Extramsly 4 Extramaiy 1. Headaches 28. Feeling blocked in getting things done , . . 2. Nervousness or shakineu inside 29. Feeling lortely O 3. Repeated unpleasant thoughts that won't leave your mind. 30. Feeling blue CD 4. Faintrwu or dizziness 31. Worrying too much about things CD 5. Lots of sexual interest or pleasure 32. Feeling fio interest in things CD 6. Feeling critical of others 33. Feeling fearful - 7. The idea that someorte else can control your thoughts . . . 34. Your feelings being easily hurt B. Feeling othen are to blame for most of your troubles. . . 35. Other people being aware of your privata thoughts . .... 9. Trouble remembering things 38. Feeling others do not undentandyou or are 10. Worried about sloppiness or carelessness unsympathetic I I 1 1. Feeling easily annoyed or irritated 37. Feeling that people aie unfriendly or dislike you. . 12. Pains in hean or chest 38. Having to do things very slowly to insure correctness . . . 13. Feeling afraid in open spaces or on the streets 39. Heart pounding or racing 14. Feeling low in energy or slor^d down 40. Nausea or upset stomach 1 5. Thoughu of ending your life 41. Feeling inferior to others .... 16. Hearing voices that other people do not hear 42. Soreness of your muscles 17. Trembling 43. Feeling that you are watched or talked about by othere. . 18. Feeling that mosT people cannot be trusted 44. Trouble falling asleep 19. Poor appetite 45. Having to check and doublecheck what you do . . 20. Crying easily 46. Difficulty making decisions 21. Feeling shy or uneasy with the opposite sex 47. Feeling afraid to travel on buses, subways, or trains. . ... feelings being trapped or caught 22. of 48. Trouble getting your breath scared for no reason 23. Suddenly 49. Hot or cold spells CD 24. Temper outbursts that you could not control 50. Having to avoid certain things, places, or activities because .— 25. Feeling afraid to go out of your house alorte they frighten you I— 26. Blaming yourself for things 51. Your mind going blank 27. Pains in lower back 52. Numbrtess or tingling in parts of your body. . . PAGE ONE 4 1 n : |)o|l" M «‘'^N^k •ma ,j»^ '‘3 sesr":. )«• fc ^i,\.‘* ;Vlfl t«.j» . '4 r , t»....«^ f -TJ •• ^ A»%tf 1 1| u( ‘ 'T - - • - ' • » I A'. ''( i;if - v»'”r hv,,nr;^,^ ., f A m'iKivAntm‘>*hn #*%.* 'Mf \uv «AuV.u '(a. « "1 • r; - r. KM < ^ i.s;i ' '^A } M^ n ... ^#(ff ti5fe|'^ • -,v ',’ , ^n i.i^U 4h*4'd •if :JMm ^*1111. 1•'>' APPENDIX A, Continued SCL-90-R O*cchptort Deschpiori HOW MUCH WERE YOU DISTRESSED BY: HOW MUCH WERE YOU DISTRESSED BY: 0 Not M •!! 0 Not at all 1 A little bit 1 A linia bit ^ 2 Modaritaly 2 Modaratsly 3 Quit* bit 3 Quita a bit 4 Extremaly 4 Extramaly lump in your throat 71. Feeling everything is an effort Q 53. A n^ 54. Feeling hopeless about the future 72. Spells of terror or panic CH 1— 55. Trouble concentrating ^ 73. Feeling uncomfortable about eating or drinking in public . 56. Feeling weak in parts of your body 74. Getting into frequent arguments '— 57. Feeling tense or keyed up 75. Feeling nervous when you are left alone '— 58. Heavy feelings in your arms or legs 1— 76. Others not giving you proper credit for your achievements D 59 Thoughts of death or dying 1— 77. Feeling lonely even when you are with people 60. Overeating D 78. Feeling so restless you couldn't sit still d) 61. Feeling uneasy when people are watching or talking — 79. Feelings of worthlessness (d you I— about 80. The feeling that something bad is going to happen to yoa CD 1 1 thoughts that are not your own 1— 62. Having 81. Shouting or throwing things CD Having urges to beat, imjure. or harm someone LJ 63. n 82. Feeling afraid you will faint in public CD Awakening in the early morning 1— 64. Feeling that people will take of if 1 83. advantage you you — repeat the same actions such as touching. let them '— 65. Having to ^ washing 1 counting . — 84. Having thoughts about sex that bother you a lot <— 66. Sleep that is restless or disturbed 1— 85. The idea that you should be punished for your sins CD things 1 67. Having urges to break or smash — 86. Thoughu and images of a frightening nature CD ideas or beliefs that others do not share L_ 68. Having 87. The idea that something serious is wrong with your body . . CD 69. Feeling very self-conscious with others 1— 88. Never feeling close to another person CD or . 70. Feeling uneasy in crowds, such as shopping at a — 89. Feelings of guilt CD 90. The idea that something is wrong with your mind CD , j< *)^' ^ '!''•* uoy ""iL , "’ •' • 4... . V >1 '• • ' ”'‘i ^ 4 _ . »U^ w< : Q: , ,.,k ‘'***^' ' —* ..(4 t,*«-i( ^ a ... ii» / ' *' '»t ' k*i.*' 'VV' ,»VI»V'- i* *A' •»>;^l" « J r > * i,rii>t\'*\ iW.-fk , K .f, Urtiii *N«M |vw*« ' ,' (' I ; 'l * "i'.v’;j>7,! APPENDIX A, Continued 116 Section VII: Finally, we would like to ask a few questions about yoirself to help interpret the result^. 1. Wiat is jour present marital status ij. Iftiat is yoir p’esent age in years?: (Circle nunber) Years 1 Neve- married 5. Uiat is the hi^iest level of education that you 2 Parried have completed? (Circle nunber) 3 Divorced 1 No formal education Separated 2 Seme grade school 5 Widowed 3 Conpleted grade school 2. Are you presently: (Qrcle nunber) M Seme high school 1 Bnployed 5 Oanpleted high school 2 Lhanploved 6 Seme college 3 Retired 7 Completed college 4 Full-time hctnanaker 8 Some graduate work 3. Flease describe the usual ofyjyation 9 Q-aduate degree of the principal wage earner in jour 6. VMch of the following best describes yotr housenold. (If retired, describe the racial or etinic identificatiori? (Circle nunber) usual work before retirment.) 1 Black (Negro) Title 2 White (Caucasian) : Kind of work you do: 3 Other (specify) Kind of conpaiy cr business: 7. Flease wite today's date: If you feel that there are importait aspects of yoer reactions since the sexial assault that were not covered by this questlannaire, please feel free to write them on this page. "***''^ fit - y^^rntm: .•« iritili ' '^» ruirtuu itt tm ^ p-k^'> .fp '4 ’'^ 'Vifl'* Uo.;*i ; p. "h ip ' t-'Ii'' 'V \ ' • flt.lv ' ^''’^^ |i;\? ^..^ •ski^TO ,*f ' til '»f:ru/t ' ' ' ,' • .'- f •I, ii» ' viffleyr Iv fi ;W ; *: Jflj? . . 117 ^pendix B: Revised Cohen Roth Apfsroach Avoidance Scale This questionnaire consists of questions about your reactions to the sexual assault you experienced. We would like to know how well each of these comments describes your reactions. Please fill in each blank with the number that best describes how true each comment has been for you. lot at all true Someuhat true Very true (1) (2) (3) (4) (5) 01. I tried to deal with my feelings about it. 02. There were things about it that I tried to find out more about. 03. I wanted to talk about it with people who would understand. 0^. I tried to get straight in my head exactly what happened. 05. I tried to keep it out of my mind. 06. I tried not to think about it. ^07. I tried to think about what I should do. 08. When someone brought it up, I usually tried to change the subject. 09. I tried to forget it. 10. I kept thinking about it even though it upset me.“ 11. I tried to remove it from memory. 12, I tried to find people who would understand 13. I stayed away from reminders of it. _14. I tried to think about other things instead 15. I forced myself to think it through. ' •Wr# ( »» f j-'.rn ' "c V :i« ri' W- , (Pi I C ^ -I ts -*1.: t W APPENDIX C: sample advertisement iia Pailicijoanls sougliL for a research project on COPING wrril RAPH conclueted by the Duke University Psychology Department Subjects Needed Women who have been \ictims of rape at any time in their life Research Involves Filling out a conlklential quest ionnaire Services available for iiarticlpants, if desired Group information sessions on coping with rape Treatment groups Support groii[)s tor jiartners Referral to siqiport groiqis or individual therajiy YOUR PARTICIPATION CAN HELP US LEARN TO IIELP OITIERS STRICTLY CONFIDENTIAL For more information, call Dr. Susan Roth 684-3(545 3 7 APPENDIX D: Raw Data tor Experiments 1 and 2 RAW DATA FOR EXPEPl^'El^;T \: UNCERGRADUATE SAMPLE EACH line is a single SUBJECT FIRST 6/1 COLiJMMS ARE SCORES ON COHEN RuTH APPROACH AVOIOA THE LAST FOUR COLUMNS WERE NOT USED IN I MIS STUDY BENIN DATA A/n3S/4ilSSAS33'4i3231A3131bH3iSS53pa3llll33l3^331l4S/l5dl5PP^ll‘iai3l50l 33S3ASSlE55Aiq3?Niij^aii3liSl2«iiliaiA5lll3bli4/4Pl5yia'llltai5ll35iaoO(T/4 5SqSaa33513apt)l3ll5'3ll5P4qiq^S33l5232iq55a3225l33555llR.5553P53aqa5 43 I 3 3/1 1 1 53 3-45524 3^ I 'i;-iN^?3 1 5 •.535132/14422553322 1 34234 1 5/'?3'i4 1 35221 4 I I 5555'i'^5l 5555 I 5 15 3 51 5MS51 5 13.35551 55 15 155553515153555)1451552 555508 0 2 3 334‘>5413 3442 51 32223 1 3523323^ 1 1 2 33.' 114) 121251 2l 13251 2222233 1221 24804 2 5l.3 425llS24l23'424 2l22'.)l422l525.s5ii3S5i2i54354l5511l3442434ii4iii605 44 I 44J4/I4t444 13 '455534224 1 33 4 5544333345 32 I 24445525 4 444 3 444P4325234 1202 331 2 5 3124? 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THE VARIABLES ARE LISTED FUR EACH LINE, FOLLO^vEO BY the Column numbers they occupy, if the variable includes decimal places, these are indicated in parentheses, the SECOND section DEFINES THE VARIABLES, AND THE THIRD SECTION DEFINES the VALUES OF THE VARIABLES, FOLLOWING THESE KEYS THE DATA FUR ALL SUBJECTS ARE LISTED, SECTION i: LINE l; SU8NUM 1-3 TIME ^-7 (?) ASSl TO ASSIO 8-17 LINE 2: Cl TO C6A 1-6^1 LINE 3: SEXl 1-2 SEX2 TO SEXA 3-5 MARSTAT b SES 7 AGE 8-9 RACE 10 SCLl TO SCLlO 11-aO (?) GSi i»l-i<3 (2) PST aA-«5 PSDl 06-08 (2) SASl TO SAS8 09-72 (?) LIME 0; MFSl TO MFS50 1-50 LINE 5: MFS55 TO MFS1?0 1-66 NOTE: IF A LIST OF VARIABLES PRECEDES THE COLUMN NUMBERS, THEN DIVIDE THE SPACES EVENLY ACROSS THE VARIABLES SECTION 2: SUBNUM "SUBJECT NUMBER" TIME "years SINCE ASSAUL1" ASSl "ASSAILANT" ASS2 "PLACE OF ASSAULT" ASS3 "FORCE USED" ASSO "TYPE OF ASSAULT" ASS5 "ArJYUNE told?" ASS6 "WHEN TOLD" ASS7 "REPORTED TO POLICE" ASS8 "SOUGHT HELP" ASS9 "PRIOR ASSAULTS" ASSIO "AGE OF PRIOR ASSAULT" Cl TO CbO "ITEMS UF COhEN RUTH APPROACH AVOIDANCE SCALE" SEXl "SEX satisfaction" SEX2 "Global satisfaction" SEX5 "PARTNER SATISFACTION" SEXO "TIME BEFORE SEX" MARSTAT "MARITAL STATUS" SES "SOCIOECONOMIC STATUS" AGE "CURRENT AGE IN YEARS" SCL-90 SUBSCALES: SCLl "SOMATIZATION" " s r I p " n ^ SCL3 "INTERPERSONAL SENS" SCL« "DEPRESSION" SCL5 "ANXIETY" SCL6 "HOSTILITY" SCL7 "PHOBIA" SCL8 "PARANOIA" SCL9 "PSYCHOTIC" SCLlO "ADDITIONAL" GSI "global severity INDEX OF SCL-90" i “ » ^5. » .ji-rt in: ' •3^1,,-./ . ?* , i j . .' ..' f ^<*1 .t > ! - 1 4 j • I ,A 6 •»? Uft .k-7i ^ J .•i t.f : '\ >.'r»i#aj4cH- *;q:,y 7':frl;4'i|i " •', 'I : „ fc ) M'' j \ t' ti' l2'o PST J^POSITIVE SYMPTOM TOTAL OF SCL-90" PSOI "SYPt. DISTRESS INDEX OF SCL-90" social adjustment scale subscales: SASl "WORK" SAS2 "SOCIAL" SAS3 "EXT family" SASa "MARITAL" SAS5 "PARENTAL" SAS6 "FAMILY" SAS7 "ECONOMIC" SAS8 "OVERALL" MFSl TO MFS 120 "ITEMS OF MODIFIED FEAR SURVEY" SECTION 3: VALUE LABELS ASSl 1 "STRANGER" 2 "SEEN BEFORE" 3 "DATE" 0 "FRIEND" 5 "BOYFRIEND" 6 "EX" 7 "CO-HAB" e "HUSBAND" 9 "RELATIVE"/ ASS2 1 "MY RES" 2 "HIS RES" 3 "OUTSIDE" 9 "OTHER" / ASS3 I "THREAT" 2 "RESTRAINT" 3 "VIOLENCE" a "SHOW WEAPON" 5 "USED WEAPON" 9 "OTHER"/ ASSa 1 "INTERCOURSE" 2 "ATTEMPT" 3 "OTHER"/ ASS5 1 "NO" 2 "YES"/ ASSS 1 "< 1 HOUR" 2 "1 HOUR TO 1 DAY" 3 "2 DAYS TO 1 rtEEK" U "fl TO 30 DAYS" 5 "MONTH TO YEAR" 6 "> 1 YEAR"/ ASS7 1 "NO" 2 "YES"/ ASSB 1 "SOUGHT HELP" 0 "DID NOT SEEK HELP"/ ASS9 1 "NO" 2 "YES"/ ASSIO 1 "CHILD" 2 "ADULT" 3 "BOTH"/ SEXl 10 "HIGHEST"/ SEX 2 8 "HIGHEST"/ SEX3 8 "HIGHEST"/ SEX4 1 "< 1 WEEK" 2 "1-3 WEEKS" 3 "1-2 MONTHS" U "3-6 MONTHS" 5 "> 6 MONTHS" 6 "NUT RESUf^ED"/ MARSTAT 1 "NEVER MARRIED" 2 "MARRIED" 3 "DIV" U "SEP" 5 "WID"/ RACE 1 "BLACK" 2 "WHITE" 3 "OTHER"/ SES 2 "HIGH" 3 "MIDDLE" A "LOW" NOTE: MISSING DATA ARE CODED AS 9 FOR EVERY DIGIT BEGIN data 01319081 191212121 335393313932191233391 1911 1192531 19225199 /1B29221B253511292922S259 1 07792232201 70201 1 lOb9oaoo3i0 19()A3 0 2000009639l21l50 1 78l63l78999l33100169 929229222222522559 Zj<42121 21 1 2953?1??19 1<43221233222293 9 0 152922 3 31 2322591 21 9252222933 3321 31 22932921 19 1331 11 3933233321 3329?2 01200501 131212119 5555553195529512129531559595231319115159951525153555113521295955 0666992282 1 06 1 80 089? 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I \ 1 I * Wf f ‘ ii piJ » a GS '. o i >y 0 c, i ^>^^ pjil *- r . ,;. I, 5. i;-$^ pe X «»• » HI)' I i . t : 0 i ' rtf tv ‘i'S.Si '}"l ' • I V's’ >i / (»i;>/Uf;|4i'|i . . 133 Biography Lawrence J. Cohen was born September 2, 1958, in New CS"leans, Louisiana. He attended Haver ford College, receiving a B.A. in 1980. He graduated magna cun laude with honors in psychology, and was elected to Phi Beta Kappa. While at Haverford Mr. Cohen authored a paper with Henry Rothschild, M.D., Ph.D. This paper, entitled "The Bandwagons of Medicine," was published in Perspectives in Biology and Medicine, 22 , 1 97 9 Following graduation from Haverford, Mr. Cohen received a J.E. Duke Fellowship for the study of clinical psychology at Duke University. His masters level thesis, "Coping with Abortion," was published in the Journal of Human Stress, 10 , 140-145, 1984. Susan Roth, Ph.D., his advisor on that project, co-authored the paper. A modified version of the masters study, "Anxiety and Depression in Abortion Patients," was presented at the annual meeting of the Southern Psychiatric Association, Hot Springs, Virginia, October, 1984. Dr. Roth and Dr. Alvin Cohen were co-authors of that paper. Mr. Cohen's teaching experience has included two courses taught at Duke, Psychology and Literature and Freud's Case Histories, and a part-time teaching assistantship. From July 1984 to June 1985, Mr. Cohen served as the Clinic Coordinator for the Duke Psychology Clinic. He has accepted a clinical internship position at the Tulane University Medical Center in New Orleans ' %' . U'i . '.'4* 1 ' ' i Xi *(, - .. - W>'j aX f'S - •«" .1-1 .• ’ • JiVKS »npm' , fui 'ji&i; ' ± . jsia^ km ‘ « xj C'%fi« I'ii ' I .V *%f ‘^ «,ini: Mfj&m,, I ir •-.. i ,ijv<. & myi<9 :m>f- ''i j I * . l : . ,tiU i»?i;'a k ,,( frtssw'^ V •i'M tWrtAJ-lflSUQf i titi ,v:». Jc ^•tO ttr.tn n1 ^ 1(> ,4’ ‘ , wr ! •'••t, in 3’^! ei,:-' v [m. * ' *“ *'“»«'; ,-ii' . 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