Sexual Assault :Mental Health Assessment and Care

TG 545

Peace Corps
Technical Guideline 545

SEXUAL ASSAULT: MENTAL HEALTH ASSESSMENT AND CARE

1. PURPOSE
To provide evidence-based trauma-informed care that meets the emotional needs of
Volunteers who have been sexually assaulted. The vast majority of sexual assaults are
assaults on women, and for the purposes of this guideline the language used assumes that the
Volunteer is a woman. However, the same principles should be used when responding to a
sexual assault on a man.
2. BACKGROUND
The goals of Peace Corps mental health support to a Volunteer after an assault are to educate
the Volunteer on post-assault reactions including acute stress disorder (ASD) and Post
traumatic stress disorder (PTSD), inform Volunteers about what promotes post-trauma
recovery, provide support options, and develop clinical care treatment plans.
Technical Guideline 540 Clinical Management of Sexual Violence, provides background
information concerning sexual assaults and describes the medical procedures, and mental
health screening appropriate in managing reported assaults. This guideline provides more
specific information on the emotional support of victims of sexual assaults.
PCMOs receive training on how to clinically support a Volunteer who has been a victim of
sexual assault. PCMOs should maintain their support skills by attending continuing education
events and consulting with the Counseling and Outreach Unit (COU). After a sexual assault,
the Volunteer may seek out someone she trusts and from whom she expects to receive
support. Any sexual assault case brought to Peace Corps attention requires the PCMO be
involved to support and assess the Volunteer. It is strongly advised that Volunteers who
report a rape be accompanied at all times unless the Volunteer requests to be alone.
Volunteers should be provided psycho-education about normal traumatic stress reactions and
the recovery process as early as possible. They should be encouraged to allow PC staff to
monitor their progress coping with the assault.
The Volunteer should be encouraged to regain control of her life. In fact, most individuals
have strong reactions in the immediate aftermath of a trauma; most display the symptoms of
posttraumatic stress disorder in the first days post-assault. These reactions are normal, and
naturally lessen over time without mental health treatment (Rothbaum, Foa, Riggs, Murdock,
& Walsh, 1992; Steenkamp, Dickstein, Salters-Pedneault, Hofmann, & Litz, 2012). The recommended
early and repeated assessments of Volunteers post-assault reactions is a collaborative way to
track and facilitate recovery.
When a Volunteer feels recovery is taking longer than she is comfortable with, evidencebased trauma-focused intervention through Peace Corps should be provided. For the rape
victim, effective trauma treatment will enable her to move beyond the event and get back to
her own life in a relatively brief period of time, usually two to three months time or quicker
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(Foa, et al., 2007; 2009; Resick & Schnicke, 1993; Resick et al., 2002; Resick et al., 2008).

The Volunteer
should be encouraged to speak with a licensed mental health professional with specific
evidence-supported trauma treatment expertise.
Many Volunteers are worried about what to say and how to handle the reactions of people
who know about their experience. The utmost care must be taken in observing medical
confidentiality and in respecting the privacy of the Volunteer. PCMOs play a role in
providing education to all non-medical staff involved of the confidentiality requirements.
3. PCMO RESPONSIBILITIES
The PCMOs responsibility is to attend to the immediate emotional and physical needs of
the Volunteer. The PCMO should:

Assure the Volunteers physical safety and help her gain a sense of control.

Provide psychological support through a warm, non-judgmental approach.

Offer calm acceptance of the Volunteers range of feelings, and provide psychoeducation
about post-trauma reactions, including reassurance that whatever the reactions are, the
Volunteer will be supported and helped.

Help the Volunteer identify people and things that she would find supportive and
comforting.

If a sexual assault forensic exam (SAFE) is to be performed through an official SAFE

facility in-country, accompany and support the Volunteer to and during the exam.

After any SAFE is performed, evaluate the Volunteers psychological and physical
condition. Refer to Technical Guideline 540 Clinical Management of Sexual Violence.

Offer counseling through medevac (to Washington, DC or home of record), by phone by

COU, or with a mental health provider in country who has specific evidence-supported
trauma treatment expertise. The Volunteer may decline medevac or counseling at this
time. (See below.)

Maintain medical confidentiality.

Maintain clinical notes regarding emotional support and counseling in a separate Sexual
Assault Medical record to attach to the regular Volunteer health record (See TG 540).

4. PREPARING TO PROVIDE MENTAL HEALTH SUPPORT

The PCMO must plan ahead in order to address the emotional needs of Volunteers who have
been victims of sexual assault. The PCMO should:

Identify locally trained counselors willing to complete specific online training (course
information provided by Peace Corps) in trauma-focused treatment; this will enable
them to meet Peace Corps standard for managing sexual assault survivors mental
health care (i.e., provide evidence-supported trauma-informed treatment);
Follow-up with the locally trained providers to identify those who have completed
recommended training, and are therefore ready to manage mental health care for
cases of sexual assault;

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Familiarize yourself with TG-545, especially the symptoms and assessment tools of
Acute Stress Disorder and PTSD.
Attend Peace Corps-sponsored and other continuing medical education avenues to
keep general counseling skills relevant, and to update knowledge and skills regarding
best practices for responding to sexual assault and other survivors;
Maintain psychoeducational material in the office on traumatic stress reactions, what
facilitates recovery, and services available to the Volunteer.

5. INITIAL MENTAL HEALTH SCREENING AFTER SEXUAL ASSAULT

Rape appears to be more likely than other traumatic events to result in PTSD (Frazier, Byrne, Glaser,
Hurliman, Iwan, & Seales, 1997; Kessler, 1995; Kilpatrick, Edmunds, & Seymour, 1992; Kilpatrick, Saunders,
Amick-McMuillan & Best, 1989; Ullman & Filipas, 2001). (The purpose of the initial mental health

screening after a sexual assault is to normalize post-trauma reactions and to identify individuals
most at risk for developing PTSD (Gartlehner, et al., 2013)). It is normal for individuals to have
strong reactions in the immediate aftermath of an assault. More severe reactions are predictive of
post-trauma difficulties (Rothbaum, et al., 1992; Steenkamp, et al., 2012) .
The screening assessment begins to determine severity of reactions. It is a means for quantifying
traumatic stress reactions, and one way to attempt to identify potential problems in emotional
recovery post-assault. The screening process begins one of several opportunities to discuss and
educate the Volunteer on several topics: stress reactions, what facilitates recovery, and services
available to the Volunteer to support recovery.
Proactive discussion of emotional responses after an assault normalizes reactions, and gives
permission to the Volunteer to share concerns about her reactions. This also promotes recovery:
it discourages avoidance of memories, thoughts and feelings about the rape and denial of
psychological reactions; at the same time, it communicates acceptance of the Volunteer, her
experience, and her struggle to recover from the assault (Ehlers, Mayou & Bryant, 2003; Halligan,
Michael, Clark, & Ehlers, 2003; Koopman, Classen & Spiegel, 1994; Resick, Monson, & Chard, 2010; Ullman &
Filipas, 2001; Ullman, Townsend, Filipas & Starzynski, 2007).

Please Note: Most survivors immediately post assault will screen positive (i.e. have symptoms of
PTSD); only a few will be at risk for PTSD long term (Gartlehner, et al., 2013). In the immediate
aftermath (from 24 hours to one month post assault) a positive screen means further mental
health assessment, including assessment of Acute Stress Disorder (ASD) is warranted.
First, perform an overall mental health assessment.
A. Mental Health Assessment
The Mental Health Assessment and ASD/PTSD Screening requires a PCMOs
observations and the Volunteers responses to a series of questions.
o Volunteers appearance (can choose all that apply): Neat/groomed; appropriate dress;
poor hygiene; under/overweight; poorly nourished
o Volunteers behavior (can choose all that apply): Un/Cooperative, relaxed, agitated,
aggressive, suspicious, guarded, preoccupied, withdrawn, evasive, bizarre, tearful,
nervous
o Volunteers speech: Normal, soft, mumbled, loud, slurred, hostile, pressured
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o Affect (can choose all that apply): Restricted, cold, flat, superficial, labile, giggly,
apathetic, ambivalent, tense, anxious, apprehensive, worried, afraid, panicked angry,
enraged, ecstatic, euphoric, irritable, sad, depressed, hopeless, worthless
o Mood: Ask, How are you feeling? Document the PCVs reponse in their exact
words with quotation marks.
o Suicidal: Ask, Do you have feelings of wanting to hurt yourself?
If yes, ask, Do you have a plan on how you would hurt yourself?
If yes, ask, What is the plan and do you have access to the method (weapon,
drugs, rope, etc.)?
o Homicidal: Ask, Do you have feelings of wanting to hurt someone (e.g. assailant)?
If yes, ask, Do you have a plan on how you would hurt someone?
If yes, ask, What is the plan and do you have access to the method (weapon,
drugs, etc.)?
o Thought Processes: goal-directed, goes off topic easily, vague, repeats self, illogical,
flight of ideas, gives minimal answers, cant find words, loose associations
o Hallucinations: olfactory, tactile, visual, auditory, gustatory
o Delusions: Control, persecution, sexual, grandeur, religious, somatic
o Perceptions: Magical thinking, phobias, obsessive thoughts, impulse to perform
repetitive behaviors
o Orientation to person, place and time (do they know who they are, where they are,
and the date/time).
o Consciousness: clear, clouded, delirious, comatose, drowsy, lethargic/intoxicated
Second, assess for acute traumatic stress symptoms, acute stress disorder, and post traumatic
stress disorder in this order as assessment results indicate. Use the following assessment tools for
this purpose.
B. Assessing for General Acute Stress Symptoms, Acute Stress Disorder, and Post
Traumatic Stress Disorder
The PC-PTSD screening instrument (PC-PTSD; Prins, et al., 2003) is a good tool to use
in the INITIAL screening for posttraumatic stress reactions because it is short, it covers
the basic groups of posttraumatic stress reactions, and works well as a springboard for
discussion of the Volunteers emotional response to the assault. As you ask the questions
on the PC-PTSD screen, help the Volunteer understand these reactions, provide psychoeducation about stress reactions, and explore her experience of each symptom she
endorses.
1) Administer the Primary Care PTSD Screen (PC-PTSD)
a. Use the PC-PTSD to determine if the Volunteers reactions are in response to the
assault for which they are seeking care.
b. If the assault is recent, then alter the timeframe on the screening instrument (e.g.
if the assault happened last week, ask the Volunteer, In the past week, have you
had.(symptoms)?
c. Tell the PCV that you are going to administer a few questions that will help
determine the severity of the Volunteers reactions to the assault. This screening
tool is used by primary care clinicians to assess if a person may need extra
emotional support after a traumatic event.
d. You may either ask the questions by phone or in person or ask the Volunteer to
complete the instrument herself.

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Primary Care PTSD Screen (PC-PTSD)

The PCMO should ask: In relation to this event:
Have you had nightmares about it or thought about it when you did not
want to?
Tried hard not to think about it or went out of your way to avoid
situations that reminded you of it?
Were constantly on guard, watchful, or easily startled?
Felt numb or detached from others, activities or your surroundings?

Yes or No
Yes or No
Yes or No
Yes or No

e. Scoring: A score of 3 yes responses or greater means the Volunteer has

screened positive for PTSD.
i. During the first days and weeks posttrauma, this can be considered
normal. If the Volunteer displays more symptoms, severe distress in
additon to a positive PC-PTSD score, and it has been less than a month
since the assault, assessing for Acute Stress Disorder (ASD) may be
warranted. (Refer to Section 2 Assess for Acute Stress Disorder
below).
ii. A positive PC-PTSD more than a month since the assault, indicates a
need to assess for PTSD (Refer to Section 3 Assess for Post
Traumatic Stress Disorder below).
f. Regardless of the score, use the PC-PTSD tool to provide psychoeducation about
traumatic stress reactions and natural recovery.
g. For PC-PTSD scores of 3 or greater, the PCMO should seek consultation from
COU on how to support the Volunteer.
h. Ask Volunteer if she would like to consult with a counselor in COU directly.
2) Assess for Acute Stress Disorder
Acute Stress Disorder represents a stronger posttrauma response than most survivors
experience. Meeting diagnostic criteria for ASD in the first month post trauma is
associated with later meeting criteria for PTSD (Brewin, Andrews, Rose & Kirk, 1999).
For this reason, it is important to assess for ASD among survivors with a positive
PC-PTSD screen who are also reporting intense distress. Individuals meet diagnostic
criteria in DSM-5 for ASD if they exhibit has 9 of the following 14 symptoms listed
below (APA, 2013).
1. Recurrent involuntary & intrusive
memories of the trauma
2. Recurrent distressing dreams of the
trauma
3. Dissociative reactions: flashbacks
4. Intense or prolonged psychological
distress or marked physiological
arousal reactions to internal or
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8. Efforts to avoid distressing memories,

thoughts or feelings about or related to the
trauma
9. Efforts to avoid external reminders of the
trauma (e.g., people, places, conversations,
activities, objects, situations) that arouse
distressing memories, thoughts or feelings
10. Sleep disturbances
11. Irritable behavior and angry outbursts
(without provocation)

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external reminders of the trauma

5. Persistent anhedonia
6. An altered sense of reality of
surroundings or of oneself
7. Amnesia for important aspects of the
trauma

12. Hypervigilance (looking over ones

shoulder)
13. Concentration problems
14. Exaggerated startle responses

8. Assess for Post Traumatic Stress Disorder

More than half of individuals who are sexually assaulted recover substantially and do
not meet diagnostic criteria for PTSD by three months post assault (Foa, et al., 2007,
Resick et al., 2002, Steenkamp, et al., 2012). However, as stated earlier in TG-545
(Sec. 5, paragraph 1), the trauma of rape is associated with high rates of lifefime
PTSD (Ullman & Filipas, 2001; Ullman et al., 2007; Rothbaum et al., 1992; Steenkamp et al., 2012).
Between one and three months post assault, many sexual assault survivors may still
struggle with their reactions to the assault.
a. Volunteers whose PC-PTSD score is 3 or greater and are one month post assault,
may be assessed for PTSD using a measure of PTSD symptoms such as the
PTSD Checklist (PCL; Weathers, et al. 1994) or PTSD Symptom Scale (PSS;
Foa, et al., 1993). This assessment provides a better sense of their reactions, their
frequency, severity, and type.
b. Volunteers who score in the PC-PTSD screen problem range (3 or greater),
should be provided more targeted education about what facilitates recovery after
an assault, and encouraged to talk with a COU therapist to get further information
about trauma reactions, recovery, and available treatments.
c. PCMOs should provide the Volunteer with written materials that highlight trauma
reactions, recovery, and available treatments.
6. SUPPORT IN THE IMMEDIATE AFTERMATH OF A SEXUAL ASSAULT
Recovery from sexual assault is a natural process (Bonanno, 2004; Ozer, et al., 2003). Between
50% and 80% of survivors of sexual assault recover without professional psychological help
(Rothbaum et al., 1992; Steenkamp et al., 2012). The length of time to recovery from a sexual
assault may vary, but most individuals who have been sexually assaulted resolve post-trauma
symptoms within about three months and do not meet criteria for a diagnosis of PTSD
(Resick, unpublished manuscript 2002; Rothbaum, et al., 1992; Steenkamp et al., 2012).
Immediate Support
The only evidence-supported immediate post assault care is that endorsed in the United
States Veterans Administration/Department of Defense Clinical Practice Guidelines (US
Department of Veterans Affairs, 2010). Notably, there is no research support for the
effectiveness of psychological first aid for preventing PTSD and there is evidence that
critical incident stress debriefing may be harmful (Gartlehner, et al., 2013).
To assist in the immediate aftermath of an assault the PCMO should:

Provide concrete help (e.g. food, warmth, and shelter) (US Department of Veterans
Affairs, 2010).
Soothe and reduce states of extreme emotion (US Department of Veterans Affairs, 2010).
Increase controllability (US Department of Veterans Affairs, 2010).

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o Support the Volunteer as being in charge of when, to whom, where she talks
about the incident and other aspects of her personal history. The Volunteer should
be in charge of her history and tell it as she is able.
o Provide good information and psycho-education can help survivors make the
decisions they need to make. She needs to regain control of her life, starting with
the small decisions, such as what to take with her to the capital and where to stay
o Assist the Volunteer in making her own decisions regarding whether she wishes
to work within her own support network on her recovery, or her interest and
readiness to accept professional help from a trauma expert.
o Offer medical evacuation to Washington or home of record for counseling,
recuperation, and management of the trauma in a safe and familiar environment
o Discuss options with her:
Does she want to go to Washington for additional medical or psychological
support?
Does she want her family or friends notified?
Is there another Volunteer in the country who is able to provide companionship
and support?
As she is able, discuss any concerns about returning to her site. Should other
sites be considered?
She may be considering using annual leave or early termination instead of
medical evacuation. Reassure her that she is in control of these decisions, and
that medevac may be the best way for her to get help after an assault.

Assist survivors to help manage distress (US Department of Veterans Affairs, 2010).
o Provide psycho-education about trauma reactions, recovery post-trauma, and what
is known about what facilitates recovery (i.e., talking through the experience,
allowing feelings, talking about ones thoughts about why it occurred, etc).
o Provide psycho-education about the availability of highly effective treatments for
Volunteers who may struggle with post-trauma recovery, and that these
treatments may be available by phone in-country from COU staff, or in person
with COU staff via medevac to DC.
o Offer emotional support, and professional counseling (locally or with COU) as
appropriate.
o Consult COU if distress symptoms warrant consideration of medication
o See section 10 of this TG for further information about managing post traumatic
stress during a clinical examination.

Assist survivors on how to manage the repetitive, compulsive need to understand why it
happened or to attribute fault. (US Department of Veterans Affairs, 2010).
o Do not label the incident anything other than what the Volunteer calls it. If she
does not think a rape took place, but her history reveals that it does meet the
definition, do not use the term rape unless the Volunteer does. You may help her
to consider how not calling it an assault affects her thoughts and feelings and help
her understand that what one calls an upsetting event can affect ones recovery.

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o Empathize with the Volunteer and do not imply blame.

Offer support to other Volunteers who may be experiencing guilt, anger, or anxiety in
relation to the assault.

Recognize that the sense of belonging to the Peace Corps community can be therapeutic.
Peace Corps affiliation is healing because it offers a group identity at a time when the
victims identity is temporarily shaken.

Psychological treatment in the immediate aftermath of a trauma

Psychotherapy in the immediate post-trauma period (i.e., first days up to one-month posttrauma) may be helpful for some assault survivors. The available research evidence indicates
that the only psychological intervention shown to reduce post-trauma symptoms and help
prevent meeting criteria for PTSD at one-month post-assault is brief trauma-focused
cognitive behavior therapy (CBT) (Gartlehner, et al., 2013).
7. MEDICATIONS
**Consult with OHS before prescribing any psychotropic medications**
Use of benzodiazepines post-trauma is not recommended (Gartlehner, et al., 2013). Negative
effects of this class of medications for trauma reactions as well as anxieties in general far
outweigh any short term symptomatic relief. Anything but short-term use of benzodiazepines
increases the risk of PTSD (Gartlehner, et al., 2013). For this reason, consult with OHS
before prescribing any psychotropic medications.
Medications other than benzodiazepines better address symptoms associated with
traumatization. For example, Ambien for sleep onset difficulties and SSRIs for depressive
symptoms related to traumatic stress have fewer negative consequences (Bernardy, 2013;
Cates, et al. 2004; Cloos, 2010; Cloos & Ferreira, 2008; Department of Veterans Affairs,
2010; Lader, 2011; Mendelson, 2000; Perlis et al., 2005).
Please note, currently, there is insufficient evidence for the effectiveness of SSRIs in
comparison to Cognitive Behavioral Therapy to prevent PTSD (Gartlehner, et al., 2013).
8. ON-GOING MENTAL HEALTH ASSESSMENT AND SUPPORT

With the Volunteers permission, perform the PC-PTSD screening at these intervals to
assess for recovery status and to coincide with medical follow up testing:
Recommended Follow-up Services (if checked):
At 72 hours post assault:
PEP evaluation and tolerance (if PEP given)
Review of laboratory results (serum and cultures)
Assess mental and physical health
Perform a PC-PTSD
Give Hepatitis B booster

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At 2 weeks:
Repeat Pregnancy Test
Repeat Gonorrhea and Chlamydia test if symptomatic
CBC (if PEP given)
LFT (if PEP given)
Assess mental and physical health
At 4 weeks:
Perform a PC-PTSD.
HIV Test
At 8 weeks:
Repeat CBC and/or LFT if abnormal at 2weeks
Assess mental and physical health
Perform a PC-PTSD ( Can be done by phone if PCV not coming
into the office for medical testing.)
At 3 Months:
Serum test for Syphilis (VDRL or RPR)
HIV Test
Assess mental and physical health
Perform a PC-PTSD
At 6 Months:
HIV test
Hepatitis C Test
Assess mental and physical health
Perform a PC-PTSD

Research does not support encouraging the victim to repeatedly explain what happened
outside of the strict constructs of evidence-supported trauma treatment (Gartlehner, et al.,
2013) pp. 89, 96). Should the Volunteer express a desire to tell you, a trusted other or
writing about what happened may aid recovery. Volunteers should be encouraged to not
avoid thoughts, feelings and memories of the trauma.

Respect her wishes regarding the quality and quantity of communication with you.

Trauma experiences are often accompanied by feelings of grief and a sense of loss. The
Volunteer may have lost her sense of safety and security and may sense that shes lost her
way of life.

Encourage her to express all feelings regarding the assault, the assailant, and the
situation. Most reactions are understandable as related to traumatic assaults.

Recognize any fear, and respect it. Help her identify what is causing the fear, and
address any situations that still pose a threat. If fears are pervasive yet the Volunteer can
acknowledge she is not currently in danger, help her understand how fight/flight reactions
can fuel feelings of fear, and that this is normal and may persist for some time when
remembering the assault.

Recognize any feelings of anger and help her to identify its direction or target. Anger at
being helpless to prevent or stop the assault should be directed toward the assailant.

Volunteers who are distressed by their reactions may be offered a phone consult with a
therapist/trauma expert from COU. Explore this option the Volunteer at any timepoint in
the process.

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9. COMMON EMOTIONAL REACTIONS TO SEXUAL ASSAULT

The most widely studied psychological consequence of sexual assault is PTSD. Data from a
large study in the US that compared the effects of different types of traumas suggested that
sexual trauma is more likely to lead to PTSD than other types of trauma events (Kessler et al.,
1995). Kesslers study found that 45% of women who reported having experienced a rape met
criteria for having PTSD at some point in their lives; this was significantly higher than the 38.8%
rate among men who had experienced combat. Sexual assault is extremely difficult for men as
well: 65% of men who reported having experienced a rape met criteria for PTSD.
Symptoms of PTSD include re-experiencing the trauma, negative changes in mood or thoughts,
avoidance of situations associated with the trauma, emotional numbing, dissociative reactions,
and hyper-arousal. Perhaps the most dramatic trauma-related reaction medical providers may see
is dissociation.
Dissociation can involve a range of phenomena including altered awareness, attention to
flashbacks, or out-of-body experiences. Dissociative reactions may be triggered by a strong
emotional reaction such as terror, surprise, shame, or helplessness, or feeling trapped or exposed
Any of the symptoms of PTSD can be triggered in or around a medical setting. This is
particularly so in the immediate aftermath of a sexual assault, but may occur during routine
annual examinations too. Specific procedures such as dental, gastrointestinal, and gynecological
exams can potentially trigger a posttraumatic reaction in patients who have experienced sexual
trauma. In particular, pelvic exams, colonoscopies, endoscopies and other procedures that
involve placing an instrument into a bodily orifice may be sufficiently reminiscent of the sexual
trauma to evoke a posttraumatic reaction.
It is important to recognize that reactions to sexual assault vary. However, there are several
common ones that may recur for weeks or even months after the attack (APA, 2013). The
Volunteer should be provided psycho-education about post-trauma reactions, and factors that
promote and hinder post-trauma recovery. Again, please remember that most sexual assault
survivors recover within 3 to 4 months post-assault without professional intervention (Resick,
unpublished manuscript, Rothbaum et al., 1992; Steenkamp, et al., 2012).
Common post-trauma reactions include:

Recurrent disturbing memories.

Physical and emotional distress with memories.

Fears of many kinds

A need for continuous support from family or close friends.

Difficulty in sleeping, recurrent nightmares, intrusive thoughts about the event.

Negative thoughts about oneself and others.

Increased use of alcohol and/or drugs or other means to decrease intrusive thoughts of the
trauma.

Periods of depression or anger.

Feelings of guilt or shame.

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A sense of being damaged or unclean.

Feelings of paranoia that other people are talking about her or laughing at her.

Feeling spaced out or feeling distant or out-of-touch with herself.

10. MANAGING POST-TRAUMATIC STRESS REACTIONS DURING THE

SEXUAL ASSAULT EXAMINATION (Sharkansky, 2011).
Despite providers best efforts, sometimes posttraumatic stress symptoms occur during an
exam. If this happens, dont panic. Use grounding techniques with the patient:

Speak in a calm, matter of fact voice and avoid any sudden movements
Reassure the Volunteer that she is in a safe environment, and although she is having a
reaction, she will be okay.
Explain that you are examining her asking permission to continue the examination.
If the Volunteer requests, stop the examination.
Ask the patient (or remind her) where she is.
Offer the patient a drink of water, an extra gown (to cover up), or a warm or cold
washcloth for her face.
If possible, go with her into a different room to provide a change of environment..

11. PSYCHO-EDUCATION TO THE VOLUNTEER

Provide psycho-education about trauma reactions, recovery post-trauma, and what is

known about what facilitates recovery (i.e., talking through the experience, allowing
feelings, talking about ones thoughts about why it occurred, etc).
Provide psycho-education about the availability of highly effective treatments for
Volunteers who may struggle with post-trauma recovery, and that these treatments
may be available by phone in-country from COU staff, or in person with COU staff
via medevac to DC.
PC-PTSD Screening tool use and frequency of assessment
Provide the Volunteer with parameters to judge her own progress in recovering from
the assault, e.g., PTSD screening scores. The PCMO may consider directing the
Volunteer to a reliable website on PTSD treatment such as: www.ptsd.va.gov

Services available to the Volunteer

(Educational trifold under development)

11. PCMO SELF AWARENESS, RESPONSE, AND CARE

The PCMO should be aware of his or her own response to the Volunteer who has been
sexually assaulted:

Understand the differences in how the PCMOs culture and American culture define and
legally manage rape and sexual assault. Knowing ones own cultural biasesand keeping
them to oneselfis very important when working with traumatized individuals.

Common inappropriate responses are denial, downplaying the trauma, and telling the
Volunteer that things really arent so bad.

Another common inappropriate response to a Volunteer is to focus on what went wrong,

what she might have done differently or what mistakes she made. Explain to the

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Volunteer that people who respond in such a way probably do not mean to judge as much
as they need to deal with their own anxiety about the event.

Some may respond with criticism or judgment of the Volunteer. In particular, some men
may be dealing with their own anxiety about the aggressive use of sexuality by members
of their own sex. Men who are able to respond with sensitivity and understanding may
have a particularly helpful effect in providing support.

When working with a Volunteer, if the PCMO senses culture is interfering with
understanding of the situation or the ability to comfort the Volunteer, the PCMO should
feel free to (and be encouraged to) connect the Volunteer to COU for a consult. High
distress can exacerbate cultural and language differences straining communication and
the patient-provider relationship.

Take care of yourself. Recognize how hard it is to provide this kind of support and care.
Be sure to allow yourself some space, distance and support when managing a sexual
assault. Be informed about the effects of vicarious trauma.

REFERENCES:
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders,
fifth edition. Arlington, VA: American Psychiatric Association Press.
American Psychiatric Association (2013). Highlights of changes from DSM-IV TR to DSM -5.
Arlington, VA: American Psychiatric Association Press, p.1-13.
Bernardy, N. (2013). The role of benzodiazepines in the treatment of posttraumatic stress
disorder (PTSD). PTSD Research Quarterly, 23, 19.
Brewin, C. R., Andrews, B., Rose, S., & Kirk, M. (1999). Acute stress disorder and
posttraumatic stress disorder in victims of violent crime. American Journal of Psychiatry, 156,
360-366.
Cates, M. E., Bishop, M. H., Davis, L. L., Lowe, J. S., & Woolley, T. W. (2004). Clonazepam
for treatment of sleep disturbances associated with combat-related posttraumatic stress disorder.
Annals of Pharmacotherapy, 38, 13951399.
Cloos, J. M. (2010). Benzodiazepines and addiction: Myths and realities (Part 1). Psychiatric
Times (July), 2629.
Cloos, J. M., & Ferreira, V. (2008). Current use of benzodiazepines in anxiety disorders. Current
Opinion in Psychiatry, 22, 9095.
Department of Veterans Affairs (2010). VA/DoD clinical practice guideline for posttraumatic
stress disorder. [October 4, 2012].
Ehlers, A., Mayou, R. A., & Bryant, B. (2003). Cognitive predictors of posttraumatic stress
disorder in children: A prospective study. Behaviour Research and Therapy, 41, 1-10.

Office of Health Services

September 1, 2013

Page 12

Sexual Assault :Mental Health Assessment and Care

TG 545

Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged Exposure Therapy for PTSD:
Emotional Processing of Traumatic Experiences. New York, NY: Oxford University Press.
Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. A. (Eds.) (2009). Effective Treatments for
PTSD, Second Edition: Practice Guidelines from the International Society for Traumatic Stress
Studies. New York, NY: The Guilford Press.
Foa, E. B., Riggs, D. A., Dancu, C. V., & Rothbaum, B. O. (1993). Reliability and validity of a
brief instrument for assessing post-traumatic stress disorder. Journal of Traumatic Stress, 6,
450473.
Frazier, P., Byrne, C., Glaser, T., Hurliman, E., Iwan, A., & Seales, L. (Aug. 1997). Multiple
traumas and PTSD among sexual assault survivors. Paper presented at the annual meeting of the
American Psychological Association, Chicago, IL,
Gartlehner, G., Forneris, C.A., Brownley, K.A., Gaynes, B.N, Sonis, J, Coker-Schwimmer, E.,
Jonas, D.E., Greenblatt, A., Wilkins, T.M., Woodell, C.L., Lohr, K.N. (2013, April).
Interventions for the Prevention of Posttraumatic Stress Disorder (PTSD in Adults After exposre
to Psychological Trauma. Comparative Effectiveness Review No. 109. (Prepared by the RTIUNC EPC under Contract No. 290-2007-10056-I). AHRQ Publication No. 13-EHC062-EF.
Rockville, MD: Agency for Healthcare Research and Quality.
www.effectivehealthcare.ahrq.gov/report/inal.cfm
Halligan, S. L., Michael, T., Clark, D. M., & Ehlers, A. (2003). Posttraumatic stress disorder
following assault: The role of cognitive processing, trauma memory, and appraisals. Journal of
Consulting and Clinical Psychology, 71, 419-431.
Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic
Stress Disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 10481060.
Kilpatrick, D. G., Saunders, B. E., Amick-McMullan, A., & Best, C. L. (1989). Victim and crime
factors associated with the development of crime-related posttraumatic stress disorder. Behavior
Therapy, 20, 199-210.
Kilpatrick, D. G., Edmunds, C. N., & Seymour, A. K. (1992). Rape in American: A Report to the
Nation. Arlington, VA: National Victim Center.
Koopman, C., Classen, C., & Spiegel, D. (1994). Predictors of posttraumatic stress symptoms
among survivors of the Oakland/Berkely, Calif., firestorm. American Journal of Psychiatry, 151,
888-894.
Lader, M. H. (2011). Benzodiazepines revisited will we ever learn? Addiction, 106, 2086
2109.
Mendelson, W. B. (2000). Hypnotics: Basic mechanisms and pharmacology. In M. H. Kryger, T.
Roth, & W. C. Dement (Eds.) Principles and Practice of Sleep Medicine, 3rd edition.
Philadelphia, PA: W. B. Saunders Company.
Office of Health Services

September 1, 2013

Page 13

Sexual Assault :Mental Health Assessment and Care

TG 545

Perlis, M. L., Jungquist, C., Smith, M. T., & Posner, D. (2005). Cognitive Behavioral Treatment
of Insomnia: A Session by Session Guide. New York, NY: Springer.
Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P., Hugelshofer, D. S., Shaw-Hegwer, J., et
al. (2003). The primary care PTSD screen (PC-PTSD): Development and operating
characteristics. Primary Care Psychiatry, 9, 914.
Resick, P. A. (2002). Prospective analysis of natural recovery after sexual and non-sexual
assault (unpublished manuscript).
Resick, P. A., Galovski, T. E., Uhlmansiek, M. O., Scher, C. D., Clum, G. A., Young-Xu, Y.
(2008). A randomized clinical trial to dismantle components of Cognitive Processing Therapy
for posttraumatic stress disorder in female victims of interpersonal violence. Journal of
Consulting and Clinical Psychology, 76, 243258.
Resick, P. A., Monson, C. & Chard, K. A. (2010). Cognitive Processing Therapy for PTSD
Therapists Manual, Military/Veterans Version. Washington, DC: US Department of Veterans
Health Affairs.
Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., & Feuer, C. A. (2002). A comparison of
Cognitive Processing Therapy with Prolonged Exposure and a waiting condition for the
treatment of chronic posttraumatic stress disorder in female rape victims. Journal of Consulting
and Clinical Psychology, 70, 867879.
Resick, P. A., & Schnicke, M. (1993). Cognitive Processing Therapy for Rape Victims. Newbury
Park, CA: Sage Publications.
Rothbaum, B.O., Foa, E.B., Riggs, D.S., Murdock, T. & Walsh, W. (1992). A prospective
examination of posttraumatic stress disorder in rape victims. Journal of Traumatic Stress, 5, 455475.
Sharkansky, E. (2011). Sexual trauma: Information for womens medical providers. National
Center for PTSD. Retrieved from: http://www.ptsd.va.gov/professional/pages/ptsd-womensproviders.asp
Steenkamp, M. M., Dickstein, B. D., Salters-Pedneault, K., Hofmann, S. G., & Litz, B. T.
(2012). Trajectories of PTSD symptoms following sexual assault: Is resilience the modal
outcome? Journal of Traumatic Stress, 25, 469474.
Ullman, S. E., & Filipas, H. H. (2001). Predictors of PTSD symptom severity and social
reactions in sexual assault victims. Journal of Traumatic Stress, 14, 369-389.
Ullman, S. E., Townsend, S. M., Filipas, H. H. & Starzynski, L. L. (2007). Structural models of
the relations of assault severity, social support, avoidance coping, self-blame, and PTSD amoung
sexual assault surivors. Psychology of Women Quarterly, 31, 23-37.

Office of Health Services

September 1, 2013

Page 14

Sexual Assault :Mental Health Assessment and Care

TG 545

Weathers, F. W., Litz, B. T., Herman, D., Huska, J., & Keane, T. (1994). The PTSD checklist
civilian version (PCL-C). Boston, MA: National Center for PTSD.

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September 1, 2013

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