Part 1 of 3

In order to more fully appreciate what the rape victim is a victim of, it is helpful to understand the dynamics of the offender. What prompts men to rape? What are such offenders like? Do they progress from less serious to more aggressive offenses? What determines their choice of victims? What can a potential victim do, when faced with such an assailant, to deter him? Will the offender return? These are some of the questions commonly asked about rapists, and it is difficult to provide simple and unequivocal answers to them. One of the major obstacles to the development of definitive knowledge about men who commit sexual assaults is access to such offenders.

Rapists and child molesters characteristically do not self-refer to mental health agencies for a variety of reasons. Some fear that disclosure will result in their incarceration in a mental hospital or correctional institution. Others do not appreciate that their behavior is inappropriate or symptomatic. And those who may voluntarily seek out consultation and treatment find few community-based programs and agencies responsive to their needs. Human service providers have not been trained to work with such clients. Even those sexual offenders who are apprehended and convicted will find few rehabilitation programs within the criminal justice system specifically addressing their needs. The result is that sexual aggressors, for the most part, have not come to the attention of behavioral scientists. Without an opportunity to work with and to study a sizable number of such persons, a body of information has been slow to develop regarding this form of sexual psychopathy. Rather than having a sense of who they are, what they do, and what motivates their offenses, we are left instead with stereotypes and myths about men who rape.

Although clearly a sexual offense, society has been slow to recognize rape as disordered sexual behavior. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) does not list rape as a sexual deviation, nor will it be found in the World Health Organization’s International Classification of Diseases (ICD-11). Rather than being understood to result from psychological determinants within the offender, rape is more often viewed as the outcome of external, situational factors.

Stereotypes of Rapists

There are two common stereotypes of the rapist. At one extreme he is regarded as a perfectly healthy, “red-blooded,” sexually aggressive, macho male, whose offense is simply an extreme product of his cultural conditioning elicited by a provocative and seductive but punitive woman. At the other extreme, he is thought of as a bizarre, demented, oversexed “fiend,” filled with lust and perverted desire, who stalks his prey at night when the moon is full. In the former situation the offender is seen as a totally normal individual who is essentially a victim of circumstance; in the latter as some type of inhuman creature whose predatory assaults are his only source of gratification. Both stereotypes reflect the erroneous but popular belief that rape is motivated primarily by sexual desire — the normal desires of a healthy male or the warped impulses of a sex fiend. This mistaken notion is an insidious assumption, for it follows from such a premise that if the offender is sexually aroused, then it must have been the victim who aroused him because it is towards her that these impulses are directed. From that point on, responsibility and accountability for the offense, to a large extent, become shifted from the offender to the victim, and it is she who becomes the accused by police, family, friends, and even herself. In court it becomes the central aim of the defense attorney to impeach the victim’s credibility by showing that by her dress, conduct, conversation, and/or behavior, she invited the assault; and either deliberately or unintentionally, that she aroused the sexual urges of her assailant, and he is the victim of her provocativeness.

Yet, in working with identified rapists, both convicted and not convicted, it becomes apparent that sexual desire is not the dominant motive in rape; nor is sexual frustration, for a variation on the myth that the victim has sexually enticed the offender is the view that the offender is a sex-starved male who must resort to rape to relieve his sexual tensions and frustrations. The majority of rapists we worked with were married and engaged in regular sexual relationships within, and often outside of, their marriages. Nor did many complain that their wives were inattentive or unresponsive to their sexual needs and interests. As one offender put it: “The only good thing about our marriage was the sex; we had good sex together, but that’s all we had. Out of bed we couldn’t talk; we couldn’t communicate; we had nothing going for us. Sometimes right after I had sex with my wife I would go out and rape someone.” Those offenders who were not married also were sexually active and had access to a number of sexual outlets in their lives. Masturbation, prostitution, and consenting heterosexual and/or homosexual relationships all offered opportunities for sexual gratification. In reality, no offender had to resort to rape to achieve sexual relations. If sex is not a primary motive, then what is?

Rape: Power, Anger, and Sexuality

Clinical work with offenders and victims reveals that rape is in fact serving primarily nonsexual needs; it is the sexual expression of power and anger. Rape is motivated more by retaliatory and compensatory motives than sexual ones; it is a pseudosexual act, complex and multidetermined, but addressing issues of hostility (anger) and control (power) more than desire (sexuality).¹ The defining issue in rape is the lack of consent on the part of the victim. Sexual relations are achieved through physical force, threat, or intimidation. Rape, therefore, is first and foremost an aggressive act and, in any given instance of rape, multiple psychological meanings may be expressed in regard to both the sexual and the aggressive components of the act.

Typology of Rape

The most basic observation one can make regarding rapists is that not all such offenders are alike. They do not do the very same thing in the very same way or for the very same reason. In some cases, similar acts occur for different reasons; in other cases, different acts serve similar purposes. From our clinical experience both with identified offenders and with victims of reported sexual assault, we find that in all cases of forcible rape, three basic components are always present: anger, power, and sexuality.² The hierarchy and interrelationships among these three factors, together with the relative intensity with which each is experienced and the variety of ways in which each is expressed, may vary from one offense to another. Yet there is sufficient clustering so that distinguishable patterns of rape become evident: the anger rape, in which sexuality becomes a hostile act; the power rape, in which sexuality becomes an expression of conquest; and the sadistic rape, in which anger and control become eroticized. In every act of rape, then, both aggression and sexuality are involved; but it is clear, however, that sexuality becomes the means of expressing other, nonsexual needs and feelings which operate in the offender and motivate his assault. Rather than being primarily an expression of sexual desire, rape is, in fact, the use of sexuality to express issues of power and anger. It is a sexual act that is concerned much more with status, aggression, control, and dominance than with sexual pleasure or sexual satisfaction. It is sexual behavior in the service of nonsexual needs and, in this sense, rape is clearly a distortion of human sexuality.

Anger Rape

In some cases of sexual assault it is very apparent that sexuality becomes a means of expressing and discharging feelings of intense anger, rage, contempt, hatred, and frustration; the assault is characterized by excessive brutality. Far more physical force is used in the commission of the offense than would be required simply to overpower and subdue the victim. Instead the assault is one of explosive physical violence to all parts of the victim’s body. This type of offender approaches his victim by striking and beating her. He tears her clothes, knocks her to the ground, uses abusive and profane language, rapes her, and frequently makes her perform or submit to additional degrading acts.

The rape experience for this type of offender appears impulsive more than premeditated. He will typically describe being in an angry, frustrated, and depressed frame of mind. Quite often a precipitating stress can be identified that involves a significant woman in the offender’s life — his mother, his wife, his girlfriend, or some such person. The conflict he experiences in this relationship reaches a crisis level and then becomes activated by some upsetting altercation or frustrating interaction with this individual. The resulting fury is released and discharged in a sexual assault against a victim who may be, but more frequently is not, the actual person towards whom the offender harbors such feelings. Nor does the precipitating event inevitably involve a woman. It may be that he lost his job, was rejected from the Armed Services, had an automobile accident, got into a fight at a local bar, or some such thing. What appears significant is that this type of rapist does not report feeling sexually aroused at the time of his offense, but instead is feeling troubled and hostile. His controls give way, and he describes a sudden surge of anger or a feeling of rage flooding through him. The aim of this type of offender is to vent this rage on his victim to retaliate for what he perceives as wrongs done him. Sex becomes a weapon, and rape is the means by which he can use this weapon to hurt and degrade his victim. Sex itself is regarded at some level of experience as base and degrading, and this offender typically finds little or no sexual satisfaction in the rape. His subjective reaction to the sexual act is frequently one of revulsion and disgust, and often he experiences difficulty in achieving or sustaining an erection during the assault.³ His intent is to hurt his victim, and his assault is brutal and violent. His motive is revenge and punishment. In extreme cases, this may result in homicide.

The anger rapist finds it difficult to explain his assault, when he cannot deny it, except to rationalize that he was drunk or on drugs. Often the specific details are lost to his memory in that he becomes “blind with rage” during the assault. Satisfaction and relief result from the discharge of anger rather than from sexual gratification. Pleasure is derived from degrading and humiliating his victim.

His relationships with important women in his life are fraught with conflict, irritation, and irrational jealousy, and he is often physically assaultive toward them. His sexual offenses tend to be episodic and sporadic, triggered by conflicts in his relationships with these actual women in his life.

The anger rapist commits sexual assault as an expression of his hostility and rage towards women. His motive is revenge and his aim is degradation and humiliation.

Case: Derek is a 25-year-old married man and father of four. His mother abandoned the family shortly after his birth. Throughout his life, his father reminded him that his mother was a “whore and never to trust any women; they were no good.” During his adolescence, Derek became acquainted with his mother and once, while drunk, she exposed herself to him and asked him to fondle her. He fled, terrified. In vain efforts to win his father’s recognition and approval, Derek put a premium on physical toughness. In high school he played sports “like a savage” and then entered the Marine Corps. He had an outstanding service record and after discharge got married (against his father’s wishes) and attended college. One day he got into a dispute with his female history teacher over the merits of the Vietnam War and felt she was ridiculing and humiliating him in front of the class. He stormed out of the room, very angry, thinking “women are dirty, rotten bastards” and went to a bar for a few drinks. On his way to his car, he spotted a 40-year-old woman (whom he described as looking older) in the parking lot. He grabbed her by the throat, hit her in the mouth, ripped off her clothes, and raped her. Prior to this offense, Derek’s criminal record consisted of arrests for gambling, loitering, and drunkeness.

Power Rape

In this type of sexual assault, the offender generally employs only whatever force is necessary to overpower his victim and gain control over her. The evidence of such power and control is that the victim submits to sexual demands on the part of the offender. The offender places his victim in a situation through verbal threat, intimidation with a weapon, and/or physical force where she cannot refuse or resist him, and this provides the offender with a reassuring sense of power, security, strength, mastery, and control. In this fashion, he compensates for underlying feelings of inadequacy, vulnerability, and helplessness.

This type of rapist often shows little skill in negotiating interpersonal relationships and feels inadequate in both sexual and nonsexual areas of his life. Having few other avenues of personal expression, sexuality becomes the core of his self-image and self-esteem. Rape becomes the means by which he reassures himself of his sexual adequacy and identity, of his strength and potency. Usually the aim of the assault is to effect sexual intercourse as evidence of conquest and, to accomplish this, the victim is often kidnapped, tied up, or rendered helpless in some fashion.

Because it becomes a test of his competency, the rape experience for this offender is one of anxiety, excitement, and anticipated pleasure. The assault is premeditated and preceded by an obsessional fantasy in which, although his victim may initially resist him, once overpowered, she will submit gratefully to his embrace since she will be so impressed with his sexual abilities. In reality, this offender may often be handicapped by impotency or premature ejaculation. If not, he still tends to find little sexual satisfaction in the rape. The assault is disappointing for it never lives up to his fantasy.

Often he must convince himself that his victim became attracted to him, really wanted sex but could not admit it, and clearly consented nonverbally to, and enjoyed, the sexual contact. Yet at some level he realizes that he has not found what he is looking for in the offense; he senses that something he cannot clearly define is lacking. He does not feel reassured by either his own performance or his victim’s response to the assault and, therefore, he must go out and find another victim — this time the “right one.”

The offenses become repetitive and compulsive. The amount of force used in the assault may vary, and there may be an increase in aggression over time as the offender becomes more desperate to achieve that indefinable experience that continues to elude him. Usually there is no conscious intent on the part of this offender to hurt or degrade his victim; his aim is to have complete control over her so that she will have no say in the matter and will be submissive and gratify his sexual demands. Aggression, then, may constitute a show of force or a reaction to resistance on the part of the victim. That is, when the victim resists the advances of her assailant he retaliates by striking or hitting her. Aggression here usually becomes expressed less as an anger motive and more as a means of dominating, controlling, and being in charge of the situation. Rape becomes an assertion of the offender’s virility or a reassurance of his competence — a reflection of the inadequacy he experiences in terms of his sense of identity and effectiveness.

The power rape may be precipitated by some perceived challenge from a female or threat from a male which activates the offender’s feelings of inadequacy and insecurity. Rape then constitutes the way in which this person asserts his identity, potency, mastery, strength, and dominance; the way in which he denies his feelings of worthlessness, rejection, helplessness, inadequacy, and vulnerability.

Case: Warren was a 20-year-old single male on leave from the military. He picked up an 18-year-old student he met at a bar and drove her to a secluded area. She begged to be let go, but he grabbed her and said, “You don’t want to get hurt, baby — you want to get laid. You want it as much as I do.” He forced her to submit to intercourse and then offered to buy her dinner. While out on bail, he committed an identical offense. As an adolescent, Warren had been involved in a number of sexual incidents involving exhibitionism and sexual play with children. He was seen for treatment at a local mental health center. As a teenager, he had no steady girl friends and in the service, he was being supported by a 30-year-old man in exchange for sexual favors. Warren, however, does not regard himself as a homosexual. Apart from his two rape offenses (and two earlier ones for which he was never apprehended), he had been arrested for motor vehicle violations. Although of above-average intelligence, his academic and vocational accomplishments were mediocre. The only activity he has pursued with any degree of diligence has been body-building.

Sadistic Rape

In the sadistic rape, aggression itself is eroticized. The offender derives satisfaction in the sexual abuse of his victim. Sexuality and aggression become intertwined into a single psychological experience: sadism. The assault itself appears ritualistic and usually involves bondage and torture. Sexual areas of the victim’s body — her breasts, genitals, and buttocks — become the focus of injury. The rape experience for this type of offender is one of intense and mounting excitement. He finds pleasure in the victim’s torment, anguish, distress, and suffering. His assault is deliberate, calculated, and premeditated. The victim is stalked, captured, abused, and in extreme cases, murdered. The nature of the assault may or may not involve the offender’s genitals — the victim may be raped with an instrument or foreign object, such as a spoon or bottle. In some cases, sexual penetration may take place after she is dead.

Such assaults are repetitive, but interspersed with other less dramatic offenses, such as consenting sexual relations in the offender’s life. For this sadistic offender, anger and control become sexualized in terms of the offender’s finding intense gratification in controlling, hurting, degrading, and often times destroying his victim.

Case: Eric was a 30-year-old divorced man charged with first-degree murder. His victim, a 20-year-old woman he picked up at a singles bar, was tied to a tree, whipped, raped, sodomized, and slashed to death. Although found to be sane, Eric claimed he was high on drugs and couldn’t remember what had happened. He had a criminal record that included assault and battery, breaking and entering, nonsupport, and motor vehicles violations. At the age of 17, he had tied a 13-year-old neighbor girl to a bed and assaulted her. He beat his children and burned his wife with cigarettes during intercourse. Shortly after his conviction, Eric committed suicide.

Multiple Motives Underlying Sexual Assault

Although different patterns of rape are apparent, they all have a common motivational base: power. In some cases, the offender asserts his power³ by controlling his victim (the power rape); in other cases, by controlling and hurting his victim (the anger rape); and in still other cases, by controlling, hurting, degrading, and destroying his victim (the sadistic rape). Anger, power, and sexuality are evident in all rapes, but the role each of these components plays and the pattern in which they interface may vary from one offender to another.

Rape is a complex, multidetermined act which, in addition to expressing anger and asserting control, also serves to compensate for feelings of helplessness, to reassure the offender about his sexual adequacy, to assert his identity, to retain status among peers, to defend against sexual anxieties, to achieve sexual gratification, and to discharge frustration. In this sense the act of rape is equivalent to a symptom: It expresses the conflict, defends against anxiety, and partially gratifies or discharges the impulse.⁴

Rape: An Act of Aggression

The proposed conceptualization of the issues of power, anger, and sexuality in rape have several implications. Clinical work with offenders and victims indicates that for both the initial impact of rape is not sexual. Although the act is sexual, what is traumatizing to the victim in the offense is the jeopardy her life is in, her helplessness and loss of control in the situation, and her experience of herself as the object of her assailant’s rage. This is important to appreciate because the etiology of the vicitm’s trauma is the offender’s pathology. To acknowledge a rape assault means to recognize that there is a victim and an offender. Rape is more than an illegal act and more than an extreme of cultural role behavior. From a clinical point of view, it is important that rape be defined as a distortion of sexuality and that the pathology of the offender be recognized.

Rape is an act of aggression. In some offenses, the assault appears to constitute a discharge of anger. In other cases, the aggression seems to be reactive to the resistance on the part of the victim; i.e., when the victim resists the advances of her assailant, he retaliates by striking, hitting, or hurting her. Hostility is quickly triggered and released sometimes in a clear, consciously experienced state of anger, or in other cases, what offenders will describe as a state of fear or panic. In still other offenses, the aggression becomes expressed less as an anger motive and more as a means of dominating, controlling, and being in charge of the situation — an expression of mastery and conquest. And in a fourth variation the aggression itself is intrinsically gratifying. It becomes eroticized with respect to the offender finding excitement and pleasure in both controlling his victim and hurting her whether or not sexual contact is achieved. These variations on the theme of aggression are not mutually exclusive and, in any given instance of rape, multiple meanings may be expressed both in regard to the sexual and the aggressive components of the offense.

Those offenders who sexually assault children show similar dynamics. Sex may become a weapon and a means of discharging anger and frustration when it plays a part in the battering of a child (the anger assault). It becomes an expression of power and control when the offender uses threat, intimidation, and force to overcome his victim’s resistance and gain sexual access to the child (the power assault). Aggression as an erotic experience is seen in the offender who finds excitement and pleasure in the deliberate and intentional infliction of pain and sexual abuse on the child victim (the sadistic assault). These types of assaults are essentially rapes where the victim is a child. Fortunately, the majority of sexual encounters between adults and children are not marked by violent aggression or brutality. The most common means of achieving sexual contact with a child victim is through enticement (the pressured assault). In this encounter, the adult attempts to enlist the child’s cooperation and participation in sexual acts through bribing the child with gifts or treats, rewarding the child by misrepresenting moral standards, and/or exploiting his position of authority as an adult. In the pressured offenses, the child is generally highly valued by the offender. He sees children as loving, affectionate, warm, trusting, clean, and attractive. He feels safer and more comfortable with them and in many respects idealizes and identifies with them. There is no intent to harm the child. The risk of such encounters is more psychological than physical: the premature exposure to adult sexuality and the forfeiture of more age-appropriate, developmental sexual experiences; the use of sex to gratify nonsexual needs, such as approval, recognition, acceptance, and the like; the burden of maintaining secrecy and guilt and fear surrounding disclosure; the sense of exploitation and betrayal by trusted persons; etc.

The sexual victimization of children ranges from encounters at one extreme, where there is no physical contact between the adult and the child (such as in indecent exposure), to encounters at the other extreme that result in the death of the victim (the lust murder). In order to assess the impact of such victimization, attention needs to be paid to such variables as the type of sexual activity encompassed in the assault, the relationship between offender and victim, the duration of the sexual involvement, the means by which the offender gains access to the child, and the motives underlying the sexual assault.

Recognition of the various determinants in the psychology of the offender may help counselors more fully appreciate the impact of sexual assault on the victim. Dispelling myths and misconceptions about the offender helps to prevent the compounding and perpetuation of the victimization.

Summary

Accounts from both offenders and victims of what occurs during a rape suggest the issues of power, anger, and sexuality are important in the understanding of rapist’s behavior. All three issues seem to operate in every rape, but the proportion varies and one issue seems to dominate in each instance.

The proposed conceptualization of the issues of power, anger, and sexuality in rape have several implications. Clinical work with offenders and victims indicate that the initial impact of rape is not sexual for either group. Although the act is sexual, what is traumatizing to the victim is the life-threatening nature of the assault, her helplessness and loss of control in the situation, and her experience of herself as the object of her assailant’s rage. This is important because the etiology of the victim’s trauma may be interpreted as the offender’s pathology. The clinical typology offers one approach to differentiating offenders with regard to identification, disposition, treatment planning, and prognosis.

Part 2 of 3

Rape Trauma Syndrome

Sometimes I think the feelings are more intense now than they were at first. I was on the trolley and two guys came and sat down across from me. They looked like the two that raped me. I could almost feel like I was being grabbed again. I just have to keep thinking intellectually that it isn’t going to happen. I know intellectually it won’t, but my gut reaction is so intense…I feel people are following me. I still look at every car that goes by even though I know the guys are locked up… Sometimes it gets so intense; seems worse than it ever was.

— Rape victim, age 21, three months following the rape

The above quote captures some of the distressing and repetitive symptoms that a victim continues to experience long after the rape. The symptoms this victim describes are mentally and physically reliving the rape, fear of seeing the assailant again, and fear of another attack.

One of the conclusions we reached as a result of our study of 146 rape and sexual assault victims was that victims suffer a significant degree of physical and emotional trauma during the rape, immediately following the assault, and over a considerable time period afterwards. Victims consistently described certain symptoms over and over. We define the cluster of symptoms that most of the victims experienced as the rape trauma syndrome (in contrast to two other syndromes described from the study of accessory-to-sex and sex-stress). The rape trauma syndrome has two phases: the immediate or acute phase, in which the victim’s lifestyle is completely disrupted by the rape crisis, and the long-term process, in which the victim must reorganize this disrupted lifestyle. The syndrome includes physical, emotional, and behavioral stress reactions that result from the person being faced with a life-threatening event. This chapter discusses the two-phase reaction as well as the counseling implications of the syndrome.

The Acute Phase Disorganization

Immediate Impact Reaction

A prevailing myth about rape victims is that they are hysterical and tearful following a rape. We did not find this to be necessarily true in our victim sample. To the contrary, victims described and indicated to us an extremely wide range of emotions in the immediate hours following the rape. The physical and emotional impact of the incident may be so intense that the victim feels shock and disbelief. As one victim said, “I remember doing some strange things after he left such as biting my arm…to prove I could feel…that I was real.”

We saw many of the victims at the hospital within the first few hours after the rape, and two main styles of emotion were shown by the victims: expressed and controlled. In the expressed style, the victim demonstrated such feelings as anger, fear, and anxiety. The victims expressed these feelings by being restless during the interview, becoming tense when certain questions were asked, crying or sobbing when describing specific acts of the assailant, and smiling in an anxious manner when certain issues were stated. In the controlled style, the feelings of the victim were masked or hidden, and a calm, composed, or subdued affect could be noted by the counselor.

Physical Reactions

Rape is forced sexual violence against a person. Therefore, it is not surprising that victims describe a wide gamut of physical reactions. Many victims described a general feeling of soreness all over their bodies. Others would specify the body area that had been the focus of the assailant’s force, such as throat, chest, arms, or legs. On telephone follow-up one victim stated: “I am so sore under my ribs. I can’t sleep on my one side. The pain just stays there; it doesn’t go away. I guess he really hurt me although the X-ray didn’t show anything. It hurts when I breathe and I can’t wear any clothes that fasten. It hurts to swallow and bothers me to eat. I think he loosened my teeth because they hurt.”

Sleep Pattern Disturbances

Rape victims have considerable difficulty with disorganized sleep patterns in the acute phase, complaining that they cannot fall asleep or, if they do, they wake up during the night and cannot fall back asleep. Victims who have been attacked while sleeping in their own beds may awaken each evening at that time again and find they cannot fall back asleep. It is not uncommon for victims to scream out in their sleep.

Eating Pattern Disturbances

A marked decrease in appetite following the rape is generally noticed by the victims. They may complain of stomach pains or describe loss of appetite, such as the food not tasting right. Frequently, victims feel nauseated just thinking of the assault. It is important to determine whether the symptom of nausea is related to the emotional reaction following the rape or is a reaction to antipregnancy medication.

Symptoms Specific to Focus of Attack

Victims will also report physical symptoms specific to the area of the body that has been the focus of the attack. Victims forced to have oral sex may describe irritation to the mouth and throat. Victims forced to have vaginal sex may complain of vaginal discharge, itching, a burning sensation on urination, and generalized pain. Those forced to have anal sex may report rectal pain and bleeding in the days immediately following the rape.

Emotional Reactions

Prevailing stereotypes of rape are that the main reactions of women are to feel ashamed and guilty after being raped. We did not find these to be the primary reactions in the majority of victims we saw. To the contrary, the primary feeling expressed was that of fear — fear of physical injury, mutilation, and death. It is this main feeling of fear that explains why victims develop the range of symptoms we call the rape trauma syndrome. Their symptoms are an acute stress reaction to the threat of being killed. Most victims feel they had a close encounter with death and are lucky to be alive. One victim said, “I am thankful it was not worse. It could have been worse. I am just thankful I am here today and that I have my life.”

Victims express other feelings in conjunction with the feeling of fear of dying. These feelings range from humiliation, degradation, guilt, shame, and embarrassment to self-blame, anger, and revenge. Because of the wide range of feelings experienced during the immediate phase, victims are prone to experience mood swings. One victim who was employed as a librarian said: “Sometimes I am nervous inside. A book falls at work and I jump. On Monday and Tuesday I was really jumpy. Now I sort of have some energy. I want to calm myself down and I try…I can feel the tension building up…and I can get quite irritated and snap at people at work.”

Many victims can realize their feelings are out of proportion to the situation they are in. They will report feeling angry with someone and later realize the anger was unfounded in that situation. Women become quite upset over their behavior which, in turn, produces more distress for them. One 21-year-old woman said, “I am on the verge of tears all the time. It is just awful! I am trying to be so independent; trying to live my own life, and I am falling on my face with each step I take.”

In a serious parenting situation, a 27-year-old woman went to a mental health clinic five days after the rape saying, “I am coming to pieces. I took a strap and beat my four-year-old son today for a minor thing he did. He didn’t cry that much, but I cried for two hours. I have never done such a thing before.”

Victims also report feeling irritated with people during the first few weeks when the symptoms are acute. Seeing a car similar to the one in which the woman was abducted, or seeing a man who looks like the assailant will evoke a strong emotional reaction. Victims become cautious with all people. One hospital employee said, “At work, one of the doctors grabbed me in a joking way and I gasped. I could hardly stand it. Three days ago I would have laughed back, but it was all I could do to keep from screaming.” Another victim said five days after the rape, “I came around the corner of a store and this guy bumped into me. I burst out crying. I expect [the rapist] to be everywhere. I don’t know if I cried because I was relieved it wasn’t him or what.”

Thoughts

The victim continually tries to block the thoughts of the assault from her mind. She will say she is trying to blot it from her mind, to push it from her mind, but the thought of the assault continually haunts her. Five days following the rape one victim said: “I have trouble keeping the whole thing from coming into my mind. There are just so many thoughts running through. Once at work the thought came into my mind and it hit me and I lost my breath, the feeling was so intense.”

Another victim said one week following the rape: “I try not to think about it, but the thoughts keep coming into my mind. I was at a friend’s house and saw a big long knife like the one he used on me and it freaked me out…I see beer and get the same reaction…I can be doing something and it just comes into my mind. I tried to sleep with the lights, on but that didn’t help. I haven’t even been able to sleep.”

There is a strong desire for the victim to try and think of how she could undo what has happened. She reports going over in her mind how she might have escaped from the assailant, how she might have handled the situation differently. However, she usually ends up saying that she would have been beaten or killed if she did not do what the assailant demanded.

Victims vary as to the amount of time they remain in the acute phase. The immediate symptoms may last a few days to a few weeks. And more often than not, the acute symptoms overlap the symptoms of the long-term process.

The Long-Term Process: Reorganization

A 20-year-old rape victim said, five months following the rape: “I still seem upset and edgy all the time. I just don’t feel like being with people. I just couldn’t stand to be near guys, so I went to Europe for a trip. I felt better after the trip; it forced me out to meet people. I went by myself and made myself not be afraid. I came back and hearing of murders in the city made me think back again. Still have dreams about it. Past couple of weeks have been thinking about it; even saw a guy that looked just like the rapist.”

The rape represents a disruption in the lifestyle of the victim, not only during the immediate days and weeks following the incident, but well beyond that to many weeks and months. Various factors seem to influence how the victim copes with the rape crisis, such as the victim’s personality type, the people available to her who respond to her distress in a serious and concerned manner, and the way in which she is treated by the people with whom she comes into contact after the rape.

In four lifestyle areas — physical, psychological, social, and sexual — we found that the victim had to cope with the following symptoms during the long term reorganization process.

Physical Lifestyle

Immediately following rape, victims report many physical symptoms related to musculoskeletal pain, genitourinary difficulties, gastrointestinal upset, and general malaise, as well as eating and sleeping pattern disruption. The health area that victims have most difficulty with over a long-time period is gynecological and menstrual. Victims report chronic vaginal problems and changes in menstrual cycle functioning.

Psychological Lifestyle

Dreams and nightmares are a major symptom with the rape victim and occur during both the acute phase and long-term process. One victim reported that her husband said she was screaming out in her sleep. He went to touch her to calm her down, and she screamed even more.

Victims report two types of nightmares following the rape. One type is a situation in which the victim dreams of being in similar circumstances and is attempting to try and get out of the situation, but fails. These dreams are similar to the actual rape itself. As one victim described her dream, “The man came back again and was trying to force me in the hallway, and I was screaming and trying to get away. I was fighting as hard as I could…and then I woke up.” Another similar dream theme was reported by one of our referral cases. The victim was seen for the initial interview in the intensive care unit of a suburban hospital. She had taken an overdose of assorted medicines upon hearing from the police that the assailant was out on bail. She was rushed to the emergency department of the nearest hospital when her condition deteriorated to the point of her becoming unconscious. The counselor talked with her the next day, while she was still in the hospital. During the interview, the victim reported the following dream:

“The guy was here in the hospital, and I kept telling the staff he was here. But no one listened; they made me believe they didn’t hear me. It was like no one believed me. The guy kept coming toward me…and I couldn’t get away. Then I woke up.”
In talking with the victim about her own interpretation of the dream, she said she was very upset over the fact that the assailant was out of jail, and she could not understand his being released. She said, “Here I am in the intensive care unit, and I have to have someone with me if I even want a cigarette. I am a prisoner sitting in here, and he is free out there.”

The second type of dream occurs as time progresses. The dream material changes and often the victim will report mastery in the dream. However, the dream content still is of violence, and this is disturbing to the victim. Often they will see themselves committing acts of violence, such as killing and stabbing people. Therefore, the power gained in this second type of dream may represent mastery, but the victim still has to deal with this violent image of herself.

In other dreams, the relationship to murder is also seen. In the case of four young women, three of whom were raped, one of the raped women reported this dream two months after the rape: “The three of us were out on a date with three nice guys. We came back to the apartment after the date. Someone said, “Is June home?” One of the men went in to open June’s bedroom door to see if she was home. He shut it quickly and came out and said to call the police. We all went to see what had happened. June was lying on the floor dead. She was killed with a knife, and there was blood and everything all over. She had sheets around her and it was so horrible.” This dream included feelings the victim had about the roommate escaping the entire incident as well as the victim’s feelings about the rape and what she felt had happened.

Phobias

A common psychological defense that is seen in rape victims is the development of fears and phobias specific to the circumstances of the rape. Victims will develop phobic reactions to a wide variety of circumstances. One such circumstance is being in crowds. As a victim stated, “I haven’t been socializing. I haven’t had any urge. This has really affected me. I haven’t been out in a crowd since this happened.”

Other victims are fearful of being alone after the rape. One victim said about entering her apartment, “I am still looking behind doors. I always leave the door open when I enter. It is all I can do to get into the apartment and turn the light on. I just can’t relax. I always think someone is there.” This victim was grabbed and raped six times after she entered her apartment by the assailant, who was inside waiting for her. He also removed all the light bulbs from their sockets and was wearing rubber gloves and a mask.

The woman may develop specific fears related to characteristics noted in the assailant, such as the odor of gasoline that one assailant had on his hands or alcohol which the woman could smell on the man. One victim who worked as a saleswoman said, “The other night, a male customer came in and had some of the same features — a moustache — as the guy who raped me. I could not go over and wait on him.” Some victims describe a very suspicious, paranoid feeling. One 25-year-old victim said that when she got on the bus she felt as though the bus driver and everyone on the bus knew she had been raped. She had extreme difficulty sitting on the bus for the duration of her ride. A 35-year-old woman said: “I get out of work and I am very nervous and afraid. I am not like I was. I leave work, and I can’t wait to get home. I think of it all the time. It is a real fear. I worry that something will happen to me; maybe I will get it again on the street. People know people, you know. My thoughts really scare me. Maybe someone wants to hurt me because of this.”

The occurrence of a second upsetting situation following a rape can easily produce additional fearful feelings. One 19-year-old victim said: “While at work, my typewriter and purse were stolen. It isn’t that unusual for such a thing to happen. But I just panicked. I would look behind me when I got off the trolley. I took my name off my mail box. I did everything I could to make myself anonymous. I got so paranoid from this incident. Really shook me for days.”

Some victims feel a global fear of everyone. Such feelings can be intense, even months following the rape. One 22-year-old victim said two months following the rape: “I keep jumping when I walk anywhere. People really frighten me. So many things scare me. I never used to be frightened; didn’t fear things. Now I can’t stand it. I moved to a fourth-floor apartment and when it is locked I wish it had bars on the windows. That would make me feel safe. One night I went to bed and my roommate was out. I started hearing sounds. I was certain someone was there. My heart was beating so fast, and I was trembling. Then my roommate came in and suddenly everything was OK. I thought I’d die till she came in.”

Social Lifestyle

The rape very often upsets the victim’s normal social routine. In some cases, not just one, but many aspects of the victim’s life were changed.

Many victims are able to resume only a minimal level of functioning, even after the acute phase ends. These women go to work or school, but are unable to be involved in more than business type activities. Other victims respond to the rape by staying home, by only venturing out of the house accompanied by a friend, or by being absent from or stopping work or school.

A common response was to turn for support to family members not normally seen on a daily basis. Often this meant a trip home to some other city and a brief stay with parents in their home. In most of these cases, the victim told her parents what happened. Occasionally the parents were contacted for support, although the victim did not explain why she was suddenly interested in talking to them or being with them. One 24-year-old teacher visited her parents and sister in another state during a school vacation. She said: “I did not tell my parents. Mother would be very upset and would worry about me every second that I might be raped again…She is also very Victorian about such matters. …My father might have a heart attack if he knew. But I did tell my sister. She was very understanding…She said she almost was raped a couple of weeks ago…But it was good to be home — a good change of pace.”

There is often a strong need to get away. One victim said: “I felt so caged in. I couldn’t open a window for fear something would happen again, and I felt like screaming at times. I had to get a change of scenery.”

Moving was another response that changed victims’ lifestyles. Many victims changed residence specifically because of the rape.

In one of our referral cases, four young women had to make decisions about moving. Three of the four roommates were sleeping in their apartment when three men broke in and robbed and raped them. In talking with one of the victims three months after the rape, she said: “I could never let my roommates know how I felt about their moving out. They just couldn’t stand it any longer. They had only been in the apartment one and a half weeks before the rape, and afterwards the place just got to them. Sue moved in with friends and plans to move into the dormitory as soon as she can. Nan took another job for the summer and moved out of state. My roommate who wasn’t here that night just comes and goes as she feels like and that makes me mad. I couldn’t tell them I resented their moving out because if I said that, they probably would have stayed. But the fact is they moved out and I have to depend on myself. I am all alone, but I plan to move in two weeks in with another girl. The apartment is on the fourth floor.”

Another victim described how she was looking for an apartment: “I figured out that the guy must have come in through the bathroom window — he jimmied the lock…This time in looking for an apartment I said no first floors, no easy accessible fire escapes, no windows that are ground level. I have to get one where no one can get me.”

Another change victims make in their lifestyle is to change their telephone number. Many victims request an unlisted number. The victim may do this as a precautionary measure or after receiving threatening calls. Victims fear that the assailant may gain access to them through the telephone. They are also hypersensitive to obscene telephone calls which may or may not be from the assailant.

Sexual Lifestyle

Many women report a fear of sex after the rape. The normal sexual style of the victim becomes disrupted following a rape. The rape is especially upsetting if the victim has never had any sexual experience before the rape in that she has no other experience to compare it to and no way to know whether sex will always be so unpleasant. For victims who had been sexually active, the fear increases when the boyfriend or husband confronts the woman with resuming their sexual pattern.

Some women are explicit about their lack of sexual desire after the rape. One victim said: “I don’t feel like having anything to do with men. I’d rather just avoid them. I had my boyfriend stay here with me for protection. He slept on the floor. He knew how I felt, and he was good about it. He didn’t like it, but he didn’t hassle me.” Other reactions can be noted with men in general. One victim commented as follows six months later: “For the first month, it was no go. I couldn’t let [my boyfriend] get near me. I wouldn’t let him know it bothered me, but every now and then I would get this awful feeling. I still get it…just a couple of weeks ago I was with my family and an old family friend of my father gave me a hug, and I got cold and stiff. I said to myself, “If Dad wasn’t here you would probably do something to me.” That was a terrible feeling to have this paranoid feeling toward an old friend, but it is still how I feel about men, I guess.”

There are also women who are not currently involved sexually with a man when the rape occurs. One victim stated on hospital interview that she was glad she was not involved with a man at that point because she would be fearful of how she would handle the sexual part of the relationship. But two months following the rape, this victim said: “At first I thought it was good that I wasn’t close to any man at that point in my life. But now I have a big question in my mind as to how I will be in a close relationship with a man. I know it has affected me in a sexual way, but I have no idea to what degree.”

Implications Counseling Rape Trauma Syndrome

We found that counseling based on the following assumptions was effective in working with rape victims manifesting the rape trauma syndrome.

Short-Term Issue-Oriented Model

Victim counseling is an issue-oriented crisis treatment model. The focus of the initial interview and follow-up is on the rape incident, and the goal is to help the victim return to her previous lifestyle as quickly as possible. The rape represents a crisis which, in turn, disrupts the victim’s lifestyle in four areas: physical, psychological, social, and sexual.

Crisis Requests of the VictimThe victim is considered normal, that is, an individual who was managing adequately in her lifestyle prior to the crisis situation. In this context, the victim is viewed as a customer of emergency services who has specific requests; one who seeks particular services from the professional.

Crisis Intervention

The rape is viewed as a crisis situation, and previous problems that are not associated with the rape are not considered priority issues for discussion in the counseling. This would include such issues as interpsychic or interpersonal issues, family problems, academic problems, and drinking and drug use problems. Victim counseling is not considered psychotherapy. When other issues of concern are identified by the victim that indicate another treatment model, referrals are generally offered to the victim if so requested.

Counselor-Initiated Model

The counselor takes the active role in initiating the follow-up contact. This approach is different from the traditional methods where the patient is expected to be the initiator. The counselor goes to see the victim and also makes the first telephone contact as opposed to having the victim make an office appointment for follow-up.

Compounded Reaction to Rape

In our victim sample, we also saw people who described a past or current difficulty with a psychiatric condition, a physical condition, or behavior patterns that created difficulty for them living in this society. These victims were frequently known to other therapists, physicians, or agencies. It became quite clear in working with these victims that they needed more than crisis counseling. We did provide support for these victims, especially if they pressed charges against the assailant, but we then assumed a secondary position in the belief that the professional or agency already having a relationship with the victim should provide the main support. It was noted that this group developed additional symptoms, such as increased physical problems, depression, increased drinking or drug use, suicidal behavior, and psychotic behavior.

It appears that under the stress of rape, the victim will regress according to her vulnerability. Such vulnerable positions are portrayed with a history of previous psychiatric symptoms, a poor access to a social supportive network, or with simultaneous problems, such as family, financial, or academic, as well as recurring problems such as alcoholism. A careful study of such background data helps to predict the victim’s vulnerability and allows the counselor to deal with it or be prepared to refer the victim for psychotherapy, or to enlist the aid of a previous therapist with the victim’s permission.

Silent Reaction to Rape

It seems to be a fairly well-accepted statement made by police and law officials that there are many victims of rape who do not report the assault. Such information should alert counselors to a syndrome that we call the silent reaction to rape. This syndrome occurs in the victim who has not reported the rape to anyone, who has not dealt with feelings and reactions to the incident, and who, because of this silence, has further burdened herself psychologically.

We became aware of such a syndrome as a result of listening to life history data reported by the victims we saw. A number of our victims stated they had been raped or sexually molested as children or adolescents, as well as when adult women. Some of the victims never told anyone and kept the burden within themselves. The current rape reactivated their emotional reaction to the prior experience. The victim would talk as vividly about the previous assault as the present one, thus indicating that the incident had never been adequately settled or integrated as part of a victim experience. Rather, victims had carried the unresolved issue.

Counselors who suspect the patient has a history of being raped should be sure to include in this evaluation interview questions relevant to the possibility of the victim’s having been subjected to rape, attempted rape, or other molestation. The most effective treatment when a silent reaction to rape has been diagnosed is to refer the client for victim therapy.

Summary

Rape trauma syndrome is the acute or immediate phase of disorganization and the long-term process of reorganization that occurs as a result of attempted or actual forcible rape. The acute phase includes 1) the immediate impact reaction (either expressed or controlled emotions); 2) physical reactions; and 3) emotional reaction to a life-threatening situation. The long-term process includes changes in lifestyle, specifically physical, psychological, social, and sexual.

There are two variations to the rape trauma syndrome. In the compounded reaction to rape, the victim experiences not only these symptoms, but also a reactivation of symptoms of a previously existing condition such as a psychiatric illness. In the silent reaction to rape, various symptoms occur, but without the victim ever mentioning that a rape had occurred.

Specific therapeutic techniques for each of these reactions are described in this chapter. Crisis counseling is effective with victims developing the typical rape trauma syndrome. Additional professional help is needed for victims with compounded reactions. And the silent rape reaction means that counselors must be alert to certain clues that indicate the possibility of rape even when the person never initiates mention of an attack.

Part 3 of 3

Neurobiology of Rape Trauma

What has been done in the basic sciences on the topic of violence and psychological trauma? What are the etiological factors to symptoms encountered in the trauma response? This chapter reviews some of the basic research, indicating that sexual violence creates changes in the nervous system that have lasting consequences to victims. These consequences become a challenge to our clinical efforts and to the development of intervention services.

Basic Research

From the beginning of our work with victims who had been raped and/or sexually assaulted, we have believed that a certain type of learning occurred during the assault. This learning had to be understood on a sensory, perceptual, cognitive, and interpersonal level. We have pursued our thoughts about the presentation and level of symptoms. This has led to an assumption that this special type of learning is a manifestation of dysregulation of primary processes related to fundamental operations in the management of information, that is, information generated internally as well as in the environment. This assumption that something structurally and functionally changed because of the trauma and that this change was basic to the array of symptoms that we witnessed is now more clearly documented in basic research regarding brain, behavior, and posttraumatic stress disorder (PTSD).

The brain may be understood to be an array of neurons organized into circuits. Different circuits process different kinds of information, and they do so in different ways. Researchers are giving much more attention to the question of just how and where experience-dependent circuit changes take place, because that is how and where memory is stored.

As background for the presentation of neuroscience findings related to response patterns to rape trauma, it is important to organize the symptoms into two broad categories: positive symptoms and negative symptoms. Positive symptoms refer to those manifestations of hyperarousal. This arousal can be of a consistent tonic nature, e.g., someone is consistently tense, or it can be phasic with episodic periods of being startled, frightened, or terrorized by external and internal cues.
This is in contrast to the group of symptoms that are classified as negative symptoms. These symptoms range from a sense of numbness, apathy, and depression to various states of dissociation. The assumption is that this presentation of positive and negative symptoms occurs after traumatic events and represents compensatory patterns of organization of a damaged alarm system. This disregulatory process is responsible for the biphasic characteristics of one outcome of the trauma response which is PTSD. The mounting scientific evidence indicates that the disruption of the alarm system is central to the basic processes and operations for coding, sorting, sequencing, and developing information systems, be they visual, auditory, kinesthetic, olfactory, motor, or gustatory.^1,2,3

To begin to understand why there is disruption in arousal and numbing processes, we have to remember that the natural response set of the human being is to protect and promote survival. All incoming information is processed on the most fundamental level of awareness of threat. The major neuro-arrangement for the intake of stimulation, its categorization, and its organization of action begins in the systems that relate to the flight/fight/freezing aspect of the alarm system. These primary points for directing and regulating response are located in the pons and limbic system and the cerebral cortex. Research on the impact of trauma on neurological systems and ultimately on higher cortical functioning will elaborate on this major premise.

Pitman⁴ evaluates research on the arousal and alarm system and its relationship to PTSD by organizing the key symptoms as follows. First are the tonic symptoms: These are the symptoms a patient manifests most all of the time, especially when evoked by salient environmental stimuli that reminds the person of the traumatic event. Next are phasic symptoms: These are frequently intermittently experienced symptoms. They are the dramatic symptoms of flashbacks, reliving experiences, nightmares, and intrusive, recollective thoughts of the traumatic events. The third are a mix of tonic and phasic symptoms which are not necessarily tied directly to salient cues in the environment, but are presented when there is mild or sometimes no stimuli. These symptoms are hypervigilence, insomnia, and exaggerated startle response as well as generalized physiological reactivity (phasic). There are also the avoidant symptoms, such as a diminished interest, numbing, estrangement, and avoidance of reminders.

Giller⁵ arranges the symptoms in terms of their specificity to the traumatic event itself: Intrusive symptoms, such as flashbacks, are those symptoms most closely allied with the event itself. The next are avoidant symptoms, including the numbing, detachment, and restricted affect. These symptoms are most often a direct response to the psychic representation of the traumatic events, i.e., a memory. Last are the least specific symptoms in that they can be associated with situations and stimuli that have minimal connection with the actual event. These are the irritability, hypervigilence, increased startle reaction, and difficulty concentrating.

Krystal⁶ explains this constellation of symptoms by a variety of models derived from animal and human research, thus laying down the foundation for the biology of trauma. First is the Noradrenergic-Alarm Model or LC Model (Locus Coerulus). Research basic to this model suggests that the LC activation impacts on the limbic system during stress. This activation is aimed at not only alerting and preparing of the organism, but through elaborate feedback systems, modulates the surge of noradrenergic hormones. In trauma, research suggests that this basic regulation of the LC process is altered resulting in a flooding of noradrenergic and adrenergic hormones that lead to overlearning and stimulation of key areas of the limbic system as well as the activation of the opioid, diazapine systems that lead now to the numbing, amnesias, and dissociative experiences.

A second model, supported by animal and clinical research, is the Fear-Enhanced Startle Model.⁶ This model suggests that during a traumatic experience, there is a sensitization of pathways that involve the startle response during a fear provoking situation. Subsequently there is an enhancement of the fear response without direct association to the traumatic stimuli. Neuroscience theories considered in this model are those that focus on the suspected phenomena of “kindling.” The area of sensitization assumed is the amygdala in the limbic system. This nonassociative fear enhancement is felt to be central to the long-lasting fear response found in many survivors of trauma.

A third model is the Traumatic Alterations in Neural Activity and Memory.⁶ This model attempts to explain three major characteristics of memory disturbance associated with trauma. One is the long-lasting effects, if not lifelong disturbances of memory. Second is the impairment and fragmentation of memory experienced as intrusive thoughts, nightmares, and flashbacks. All of these characterized as if the event, upon recall, is being relieved. Third is the hyperarousal and defensive posture (lack of trust) found in unrelated stressful situations. The assumptions here, gathered from research on the Aplysia snail, is that microstructural changes appear to play a role in the long-lasting traumatic enhancement of alarm, avoidance, and memory. Transient avoidance learning operates through a spectrum of intracellular processes that increase or decrease the activity of simple sensorimotor systems. The activation of this system is via the brain stem and limbic system. Severe or repeated exposure to aversive stimuli produces long-lasting enhanced reactivity in the snail. This activation impacts on the long- and short-term memory of the snail. Evidence for molecular change was obtained when products were injected that blocked gene transmission material (RNA) and gene translation material (DNA). When these products were given (during traumatic exposure), long-term avoidant learning disappeared. When they were not given, long-term avoidant learning occurred. Further, if the gene products had appeared, the blocking agents did not work after the trauma; thus, there was a chronic state of avoidance. There was a proliferation of certain receptor sites and a reduction in others under conditions of trauma and trauma with injections.

A fourth model explaining the manifestations of PTSD is that of Inescapable Shock (IS). Van der Kolk³ has summarized the findings from primate studies and human subjects. The research on monkeys, dogs, and humans under different stressful situations in which escape was limited or prevented provides evidence for massive multisystem brain activation. This activation results in the depletion of noradrenergic, dopaninergic, and serotonergic neurons, in the alterations in receptor function systems as well as benzodiazepine and endogenous opiate systems.

These animal studies, combined with the poignant studies on maternal deprivation and its impact on affective regulations, social behavior, and vulnerability to stress have led to a fifth model on the biology of trauma. This model combines the IS, maternal deprivation findings, and the concepts of hormonal dysregulation. This combined model suggests that the PTSD symptoms may arise purely from activation-induced disturbances in homeostatic neuronal systems and not as goal-directed, learned responses. Rather, stress-induced dysregulation may produce learned behavioral syndromes that adaptively dampen arousal through mechanisms, such as cognitive patterns that decrease the level of arousal or phobic avoidance.

Implications of Models for Human Response to Trauma

The implication of these models and the latter in particular, for clinical practice, resides in a movement away from mentalistic explanations regarding the symptoms of victims. We suggest that social, behavioral patterns are more profitably understood as adaptive responses to biologically driven phenomena than as psychologically derived conclusions. For example, the woman who remains in a battering situation may be more directly assisted in moving to protect herself when the overwhelming numbing state is addressed as an adaptive response to the disorganizing experience of a noradrenergic flooding. Her self appraisal is altered, if not impaired by biological alterations that impact on differentiation and discrimination of internal and external cues. Rather, repetitive nonfunctional behaviors dominate. To interpret her behavior in terms of psychological motivations, that is, feeling deserving or to blame, is better understood as psychological reasons given by the woman to explain her confusion in taking more functional actions. That is, she blames her response selection on personal will and motivations, rather than on a biological response to overwhelming threat.

Pitman⁴ reviews the major positions put forth in the animal models with existing studies of traumatized human populations and cautions in extrapolating from animal models to human models. Nevertheless, human clinical studies deriving many of their hypotheses from animal models do suggest a strong argument for the biological underpinnings for much of the behavior we witness in people who have been traumatized.

The pattern of response to trauma, abstracted from the models and research data, can be summarized as follows. Basically, three key circuits are activated when a person is confronted with a traumatic stressor. First, the preparatory circuit mobilizes the body for an emergency and is influenced by the locus coeruleus and Raphe nucleus that secrete two known catecholamines that are associated with different states of stress. There is the noradrenergic hormone associated with arousal and serotonin, which has a major function in modulating the noradrenergic system initiated by the locus coeruleus. This is the seat for arousal and when in a disregulated state, is a source of unresolved stress and positive symptoms.

Second, the stress response circuit is known for increasing the secretion of the corticotropin releasing factor (CRF) and in some cases cortisol. This is one of the main hormones mobilizing the body to fight/flight (handling the emergency). This hormone is regulated by key structures in the limbic system. The pituitary gland responsible for CRF interacts with the hypothalmus (limbic structure). This circuitry is innervated by the adrenergic system. In PTSD, there is an increase in norepinephrine and a decrease in cortisol. The ratio of norepinephrine/cortisol is a biological benchmark for PTSD. This circuit interacts with the third circuit and accounts not only for fight and avoidance responses but accounts for negative symptoms, such as detachment, dissociation, and apathy.

Third, the blunting circuit is regulated by hormones secreted from the opioid-benzodiazepine system. This response blunts the feeling of pain. This circuit includes the locus coeruleus, hypothalamus, and amygdal, which registers strong emotion.

Stress and/or trauma have been shown to alter all three key circuits. These circuits interconnect via feedback loops that aim at achieving homeostasis. Rather than these adaptive systems being depleted, they accommodate the imbalance to preserve a protective response as well as homeostasis. These accommodations err in priming the alarm system to react with less provocation and less capacity to discriminate error.

Disorder behaviors are assumed to arise out of stress/trauma overwhelming these adaptive systems, throwing them into states of dysregulation via processes of hyposecretion and/or hypersecretion. Dysregulation occurs in the primary center for the regulation of major life-engaging functions, e.g., sleep, memory, attachment, sexual behavior, aggression, and self-defense (limbic system). Stress/trauma is seen to have a significant effect on personal and interpersonal behavior patterns. This includes actions and thinking.

After Circuit 1 has been activated and a person has moved into Circuit 2, the release of CRF can lead to an increase in plasma cortisol, which leads to an increased tryptophan hydroxylase (which is a neuro activator, activating seratonin circuits) which, because of sustained stress/trauma results in decreased serotonin, which results in a decrease in its modulating effects. The result is an unchecked excretion of norandrenalin from the locus coeruleus. This is just one example of dysregulation. There can be dysregulation in the HPA axis or between the opioid system and the noradrenergic system.

All three circuits influence memory. Experience is remembered at a basic level that some refer to as taxonomic or primarily categorical memory. The key aspect of this memory is that it is sensorimotor and not related to time and space. Therefore, it is immediate, as if it is happening.

The primary memory system is basic to higher order memory structures. When there is dysregulation of sensory input, alterations in primary memory influence the elaboration of secondary memory. When there is inference with basic categorization (discrimination, sorting, etc.), there is disruption in the processing and storing of information on a secondary level. For example, the interpretation cues that clarify the intentions and motivations of others can be disturbed because basic patterns of response are limited by a restricted repertoire of responses, which is also biased to produce avoidant responses.

Trauma and its Impact on Cognition

The pursuit of the biological underpinnings of trauma suggests that trauma response may be understood as an adaptive consequence of change in the alarm system of living organisms. The call to arousal and preparation for fight/flight and the analgesic inducement to manage and control physical pain and injury and maintain psychic integrity are basic operations in the survival of the species. When there is an accumulation of stress due to factors that restrict the resetting of the various innervated hormonal systems, adjustments occur that influence the basic structures and operations of the brain. Alterations in the behavior of victims can be seen in victim assumptions regarding cause and effect; in attention, cue selection, and interpretation; in the presentation of self; in attributional patterns; in memory and sequencing of intra and interpersonal experiences; in levels of consciousness; in self-appraisal capacities; in the modulation of emotion; in repetitive behaviors; in disturbed sleep patterns; and in the integration and expression of moral judgment. While psychological explanations have been useful to some extent in the treatment of victims, the maintenance of severe symptoms over time suggests a need for a broader frame of reference for understanding and treatment.

For years, there has been an emphasis on higher order cognitive function, direction, behavior, and motivation. MacLean⁷ stated that it came to him as a wondrous insight, that thought emanates from the “animal brains” in man. In his famous discussion of the “triune brain,” he posits that the initial response to introceptive and proprioceptive stimuli is addressed first in the primitive brain areas and elaborated in the more advanced area of the brain, such as the cortex and the frontal lobe.

Recognition that symptom formation may reflect learning has been basic to the behaviorist position. Pitman,⁴ adopting a behavioral perspective, suggests that the symptoms of PTSD might be explained by two types of learning, classical conditioning and operant conditioning or instrumental learning. He suggests that there is nonassociative learning and associative learning, thus explaining the generalization of fear/anxiety responses.

Foa and Kozak⁸ challenge this traditional two-factor learning paradigm and suggest that symptoms of PTSD are best explained by fear structures in memory that take into account information about the feared stimulus situation; information about verbal, physiological and other behavioral responses; and interpretive information about the meaning of the stimulus and response elements of the structure.

Edelman’s model of memory and learning⁹ suggests more complex alterations in basic perceptual categorization processes, which are highly dependent on basic survival. In turn, these alterations at the primary level of consciousness influence higher-order consciousness.

While this does not rule out the appraisal schema proposed by Foa and Kozak,⁸ it suggests that at a primary level of consciousness, categorical discriminations and categories are reorganized. This reorganization influences the higher-order consciousness, in particular, conceptualizations of the present state of events. Thus, the response on the primary consciousness level shapes and influences reorganization of the higher-order consciousness. This hypothesis then makes some of the judgment errors in victims who are subject to revictimization as understandable as victims who manifest exaggerated fear to innocuous situations.

The important point is that the fear schema arises out of a primary consciousness that consists of basic memory processes that for all intents and purposes are out of awareness and are only suggested in the higher-order consciousness. The survival, adaptive orientation of the primary consciousness is such that trauma alters saliency and discriminatory mappings. This leaves to clinical efforts the task to search out and identify these alterations and devise interventions that reestablish more flexibility at the level of primary consciousness as well as at the level of higher consciousness. The model of learning assumed by Pitman appears simplistic as to what is known regarding brain functioning and the fear schema suggested by Foa and Kozak can gain strength by the theoretical proposition of Edelman.

Dissociation, Trauma, and Memory

In trauma, there is biological evidence that the alarm systems functioning is severely altered. Of particular importance are the alterations in arousal and analgesic systems. The result is discontinuity in the basic operations of selecting and categorizing new and ongoing experiential stimuli and developing new memory constructs.

The influence of dissociation and hyperarousal on memory and learning at this basic level alters thinking (solving problems) and is at the heart of understanding the impact of trauma on cognition.

Altered states of consciousness was pivotal in Pierre Janet’s conceptualization of causes of repetitive behaviors, be they reenactments of a basic upsetting experience or fragmented stereotypes. He believed that altered states of consciousness brought about these patterns because of severe trauma which had, with its contextual basis, been dissociated from conscious awareness. He believed that trauma overwhelmed and impaired the capacity of the individual to feel, think, and act in a unified, purposeful way. The key lay in how memory is stored, retrieved, and integrated in the face of “vehement emotional” experiences.¹⁰

Freud¹¹ struggled with the concept of fixation and the concept of repetition compulsion throughout his intellectual career. While Freud viewed psychological trauma rooted in infantile sexuality, Janet noted how a variety of traumatic experiences result in the disruption of personality and behavior and are marked by disturbances in memory.¹² Van der Kolk and van der Holt¹² concluded their presentation of Janet’s work on trauma and psychological adaptation by noting that after more than a 100 years, nothing much remains to be learned about how memories operate, are stored, and interact with emotions and behavior in order to diminish their hold over current experience.

Clinical Implications

These current neurobiological findings have direct implications for clinical practice. First, the long-term symptom sequelae of rape and sexual abuse victims has to be understood not only from a psychosocial-political perspective, but from a biological basis. Trauma learning is realized in alterations in primary and secondary memory processes. The search for appropriate biological interventions that can reestablish dysregulation is an optimum outcome. However, the associative damage done via the prolongation of symptoms and the interpersonal violations require a variety of approaches from self-help support groups to focused psychotherapeutic approaches.