STUDENT MATERIAL TO VICTIM EMPOWERMENT: BRIDGING THE SYSTEMS MENTAL HEALTH AND VICTIM SERVICE PROVIDERS TABLE OF CONTENTS INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . 3 UNDERSTANDING AND RESPONDING TO THE TRAUMA OF VICTIMIZATION. . 12 Identifying and Assessing Signs of Crisis . . . . . . . . 14 Secondary Victimization . . . . . . . . . . . . . . . . . 29 Cross Cultural Issues in Crisis . . . . . . . . . . . . . 34 POST TRAUMATIC STRESS DISORDER, RAPE TRAUMA SYNDROME AND BATTERING. . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Trauma and Post Traumatic Stress Disorder . . . . . . . . 44 Diagnostic Criteria for Post Traumatic Stress Disorder. . 46 Rape Related Post Traumatic Stress. . . . . . . . . . . . 49 Ten Warning Signs of Mental Illness . . . . . . . . . . . 55 Depression. . . . . . . . . . . . . . . . . . . . . . . . 56 Hostage in the Home . . . . . . . . . . . . . . . . . . . 58 CLINICAL PERSPECTIVE: THINKING BEYOND THE OFFICE . . . . . . . 74 Thinking Beyond the Office. . . . . . . . . . . . . . . . 75 Integrating Awareness of Victimization into Treatment . . 77 Therapy in the Context of the Survivor's Life . . . . . . 88 The Therapy Relationship. . . . . . . . . . . . . . . . . 95 Caring for Ourselves and Each Other . . . . . . . . . . .109 RESOURCES. . . . . . . . . . . . . . . . . . . . . . . . . . .113 Outline for Interagency Agreement . . . . . . . . . . . .114 Interagency Agreement Example . . . . . . . . . . . . . .116 BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . .118 RESOURCES. . . . . . . . . . . . . . . . . . . . . . . . . . .127 INTRODUCTION Although the world is full of suffering, it is also full of the overcoming of it. Helen Keller This project was supported by Grant No. 95-MU-GX-K003 awarded by the Office for Victims of Crime, Office of Justice Programs, U.S. Department of Justice. The Assistant Attorney General, Office of Justice Programs, coordinates the activities of the following program offices and bureaus: Bureau of Justice Statistics, National Institute of Justice, Office of Juvenile Justice and Delinquency Prevention, and the Office for Victims of Crime. Points of view in this document are those of the author and do not necessarily represent the official position or policies of the U.S. Department of Justice. Introduction "There is nothing more isolating than the pain of violation. It forces victims to question themselves and their world because it destroys two essential beliefs: (1) their sense of trust and (2) their sense of control over their lives. After the crime is over, victims begin to struggle with their reactions...they are often overcome with fear, anger, guilt and shame. They may feel contaminated and unworthy of help. Their relationships with family and friends can be seriously disrupted, and if they become involved with the police and the courts, they may come to believe that no one understands or cares about what has happened to them." (The Crime Victim's Book, Bard and Sangrey, 1986) A victim of a serious personal crime as well as significant others, family members and friends, go through a difficult adjustment period, often experiencing the impact of the crime in varying degrees for the remainder of their lives. Purpose This curriculum and participant's resource manual were produced with a grant from the Office for Victims of Crime. The resource manual contains a collection of articles and information written from either a mental health or a victim services perspective. Because these perspectives are not always in agreement, there may be conflicting points of view which participants can use as discussion starters. Individuals with diverse backgrounds, expertise and experience in victim services and mental health served as an advisory panel and assisted the Pennsylvania Coalition Against Rape with the development of this curriculum. The panel members of Victim Empowerment: Bridging the Systems - Mental Health and Victim Services Providers saw the project as essential and vital to the provision of quality support services and treatment for victims of crime and their significant others. They also saw this project as an opportunity to develop a collaborative systems approach to victim services between mental health and victim services providers. The Pennsylvania Coalition Against Rape wishes to thank the advisory panel members for their time and expertise in the development of the curriculum outline. Advisory Panel Members Panel Chair: Dr. Ida Marie Gentzler, Assistant Professor of Sociology and Community Psychology, Penn State Harrisburg, Middletown, PA Training Development Coordinator: Donna Johnson, Consultant, Norristown, PA Author, Thinking Beyond the Office: Mary Margaret Hart, Licensed Psychologist, Bellefonte, PA Project Manager and Editor: B. J. Horn, Training Coordinator, Pennsylvania Coalition Against Rape, Harrisburg, PA Additional Panel Members: Beverly Andrews, Counseling Supervisor, The Sexual Assault Resource & Counseling Center of Lebanon County, Lebanon, PA Rosalie Danchanko, PA State Director, Neighbors Who Care, and President, Coalition of Pennsylvania Crime Victims Organizations, Johnstown, PA Susan Jensen, Child Therapist, Bethel Park, PA Bernadine P. Lasher, Director, Council on Domestic Violence and Sexual Assault, Midland, MI Grace S. Mattern, Director, New Hampshire Coalition Against Domestic & Sexual Violence, Concord, NH Dawn McKee, Project Coordinator, Pennsylvania Commission on Crime and Delinquency, Pleasant Gap, PA Beth Resko, Women's Program Therapist, The Meadows Psychiatric Center, Centre Hall, PA Judith Rex, Coordinator, Vermont Network Against Domestic Violence and Sexual Assault, Montpelier, VT Jamie Snyder, Director, Center for Sexual Assault & Domestic Violence Survivors, Columbus, NE Advisory Panel Recommendations For this curriculum to be utilized to its maximum potential, the panel made the following recommendations: The training curriculum will be provided to individuals only as part of a training program. A 'train the trainers' program will be conducted to ensure that the manual and its information are used consistently. Trained teams, representative of victim services and mental health professionals, will be sought. Trainees or participants will be selected with the advice and input of local community leaders. Trainees are to be representative of the victim services and mental health fields. Trainees are to be motivated individuals who are committed to change and willing to promote change in their respective communities. Funding and resources should be available to address the recommendations as stated. Core Beliefs and Concepts The material in this manual has been selected based on these core beliefs: We need a violence-free culture Victims should be the focus of the system(s) The victim empowerment as the model includes: Victims Having the right to be believed and owning their stories Being in control of the healing process Service Providers Acknowledging the rights and responsibilities of victims Respecting the choices of victims Providing victims with options for choices Avoiding inappropriate labeling of victims Working collaboratively with other systems to support victims Victims are not to blame for their victimization People are responsible for the effects of their behavior The trauma of victimization is not mental illness but victimization is trauma and needs to be addressed Confidentiality is important Why Build a Bridge? A mental health professional who has not received any training on the unique emotional and psychological issues of trauma may not be able to appropriately respond to a crime victim or even make a suitable referral. For example, to someone not trained in victimization issues, a burglary might be seen as a minor loss of possessions, something to be dealt with quickly by the police and insurance company, with perhaps the added security of new locks. However, to burglary victims, there has been a violation of an extension of themselves. For many, the loss or damage to money and/or possessions are not nearly as harmful as the intrusion into the privacy of the home, the place where people are supposed to feel safe. Historically, mental health counselors, psychologists, and psychiatrists have not received extensive training in victimization issues. In a recent survey by the Mental Health Association of more that 175 mental health professionals in Berks County, Pennsylvania: Less than one-third of the 130 respondents were willing to and/or had experience in working with victims of violent crime Only a handful indicated they had more than limited experience There were very few mental health professionals who indicated knowledge of sexual assault issues At the Erie County Rape Crisis Center in Pennsylvania: Approximately 25% of its clients, who were victims of sexual assault/abuse or victims of other crimes, were also receiving services at one or more mental health service providers It is important to note that not all crime victims require treatment by a mental health professional. If a victim is regarded as having functioned adequately or "normally" prior to the victimization, then the crime is seen as a crisis or a disruption to the life of the victim. While a victim's response may not "look" normal to those who do not have an understanding of trauma issues, it could be a normal response to an abnormal event. Victim service providers use crisis intervention techniques, including empowerment counseling, to restore the victims to their previous level of functioning. They address issues unique to the victimization such as: - Safety - Body boundaries - Self-esteem - Regaining power and control - Re-establishing trusting relationships Studies such as Rape in America (NVC, 1992) show that many victims do not successfully regain control over their lives after their victimization. Although many crime victim programs provide victims with long term counseling, including support groups, numerous individuals are concurrently and appropriately seen by mental health professionals. For those programs that are limited to crisis services and for those clients who should be referred for further treatment for mental health issues, victim services providers must learn when and where to refer clients: Victim services counselors must learn the warning signals to make referrals, such as those offered by the American Psychiatric Association, which include: - Prolonged depression or apathy - Suicidal ideations - Substance abuse - Inability to cope with daily activities after an appropriate period of time Victim programs must develop referral lists of mental health providers who understand trauma and victimization issues, are willing to accept clients who do not have insurance coverage or funds and are available without prolonged waiting periods. Through coordinated appropriate releases with mental health practitioners, victim services staff can continue to address the victimization needs such as court accompaniment, and specific victimization counseling. Ten years ago, the American Psychological Association Task Force on the Victims of Crime and Violence, chaired by Morton Bard, Ph.D., made the following recommendations: Psychologists involved in service delivery should acquire specific, identifiable skills in direct intervention with victims. More psychologists should acquire specialized consultative skills to increase the capacity of indigenous workers to help victims. More psychologists should become involved in initiating and evaluating changes in the criminal justice system to ameliorate the problems victims experience in that system. More psychologists who are prepared to do so should actually provide service directly to victims, to indigenous helping systems, and in the criminal justice system. Psychologists should be more involved in gaining knowledge about the victim experience and about helpful intervention for victims. There should be greater public awareness about the mental health needs of victims and the roles psychologists can serve in helping victims. The APA should endorse laws and legal arrangements that facilitate the realization of victims' interests and encourage the formal evaluation of these arrangements. Dr. Bard made recommendations for the mental health community in The Crime Victim's Book, which include: Establishing training programs that enable practitioners to treat crime victims and their families Establishing and maintaining direct liaisons with victim services agencies These comments were echoed by Shelly Neiderbaum, one of the founders of the International Association of Trauma Counselors, Inc., at the National Organization for Victim Assistance 1995 Conference. UNDERSTANDING AND RESPONDING TO THE TRAUMA OF VICTIMIZATION To experience anguish and anxiety in the face of the perils that threaten us is a healthy reaction. Far from being crazy, the pain is testimony to the unity of life. The deep interconnections that relate us to other beings. Joanna Macy Trauma of Victimization Victims of personal crimes are dealt a severe blow to their view of reality: They have been deliberately violated by another human being The crimes may range from having a pocket picked to murder The issues involved with each type of crime are unique The personal abilities of victims to deal with the specific type of crime are also unique Extent of Victimization Every 2 seconds a property crime is committed Every 15 seconds a woman is battered Every 46 seconds someone is robbed Every minute 1.5 adult women are raped Every minute approximately 6 American children are reported as abused and neglected Every 21 minutes someone is murdered Every day 55 Americans are killed in alcohol-related traffic crashes (from National Victim Center 1994 Crime Clock) Stages of Crisis Most victims experience a common series of emotional reactions. This parallels the grief process outlined by Elisabeth Kubler-Ross in On Death and Dying, or rape trauma syndrome described by Ann Burgess in Rape and its Victims. It consists of three basic stages: STAGE ONE: Crisis/Acute Stage Denial - "This cant' be happening to me, it must be a dream." "I feel like an observer, watching and reliving someone else's experience." STAGE TWO: Intermediate Stage (24 hours to 6 weeks): A series of different emotions intrude and fade with varying intensity: fear, anger, guilt, frustration, embarrassment. They are often accompanied by disruptions in eating/sleeping patterns and a change in lifestyle. Victims can fluctuate between feeling able to cope to feeling out of control. One minute they will blame themselves and the next rage against the individual(s) who harmed them. STAGE THREE: Reintegration (one week to one year): Victims resume normal life. The intrusive memories lessen and the victims integrate the crime into their total life experiences. As one victim commented, "I have it in perspective now and don't think of it very often anymore." While these are the primary stages of crisis, victims react differently. Many victims are amazingly resilient and can cope easily in the aftermath of a crime. In some cases, it takes longer for the bruises to heal than the emotional scars. Much depends on how the crime is perceived by the victim, family and friends, and the community. Victims' reactions do not take place in an isolated environment, but are influenced by other circumstances. Identifying and Assessing Signs of Crisis* Crisis Invervention With the gift of listening comes the gift of healing, because listening to your brothers or sisters until they have said the last words in their hearts is consoling. Someone has said that it is possible "to listen a person's soul into existence." I like that. -Catherine de Hueck Doherty Overview Natural caregivers have known for centuries the value of listening with great care and little judgment to a person's sorrow and pain. Though some people have a natural gift for providing that kind of help, most people need some assistance in learning the basics of crisis intervention -- it is, to a degree, "contra-instinctual" -- and everyone can, with study, improve their crisis intervention skills. In the aftermath of a catastrophe, most victims must deal with the physical and emotional shockwaves of the event but also, in short order, with the sense of helplessness, powerlessness, and a loss of control. For many victims, the physical and emotional reactions which describe crisis are not severe, and recede after a few hours or days. For others, the crisis is put on hold while they mobilize their survival skills, and only days, even years, later, are they slapped with a sense of the enormity of the event, now vividly remembered. Even victims who do not develop the symptoms of long-term stress reactions face the risk that certain "triggers" will reproduce the old feelings of panic, helplessness, anger, and the like. "Crisis Intervention" is obviously a humane effort to reduce the severity of a victim's crisis, to help the victim win as much mastery over the crisis experience as possible. To understand the potential benefits of crisis intervention, it is worth emphasizing that these are a battery of skills that victim advocates should possess -- but so should others whose professional work brings them into contact with victims in crisis. A common response in the shock of the moment is for the victim to retreat into a childlike state, and when the immediate danger is passed, to turn to someone nearby who is perceived as an authority figure for help-- a law enforcement officer, teacher, nurse, a friend, anyone who offers a sense of "parental" comfort. Anyone whose job constantly puts them in that role discovers how "accessible" the victim is at the moment. The helper is now invested with extraordinary influence in the life of the victim in crisis. In these circumstances, the helper is a crisis intervenor -- perhaps a gifted one, perhaps one whose talents have been forged by experience, or far more likely, a conscientious professional with no training or skills in how to interact with people in crisis, to the detriment of both the victim and the professional. "Crisis" encompasses a number of intense, tumultuous emotions; it can be a continuing condition, or alternatively flare and recede; any stressful, post-crime event, such as going to a battered women's shelter, or to a lineup, or to a trial, may put the victim back into crisis. While there are no predictors about who will experience crisis, or when the onset will be, or how severe it will be in the intensity or duration, a working presumption for most crisis intervenors is that the sooner the service is offered, the better. Indeed, there is a conviction among many practitioners that on-scene intervention, when the victim is in the early stages of distress, may prove to prevent or greatly reduce the crisis symptoms that might otherwise afflict the victim. Techniques A. Safety and Security 1. The first concern of any crisis intervenor should be for the physical safety of the victim. Until it is clear that the victim is not physically in danger or in need of emergency medical aid, other issues should be put aside. This is not always immediately obvious. Victims who are in physical shock may be unaware of the injuries they have already sustained or the dangers they still face. For the crisis intervenor who is responding to a telephone crisis call, the question should be posed immediately, "Are you safe now?" Intervenors who are doing on-scene or face-to-face intervention should ask victims if they are physically harmed. That question alone may cause the victim to become aware of a previously undiscovered injury. 2. A parallel concern should be whether the victim feels safe. The victim may not feel safe in the following circumstances: The victim can see and hear the assailant being interviewed by law enforcement officers. The victim is being interviewed in the same area where the attack took place. The victim is not given time to replace torn clothes. The victim is cold and uncomfortable. The assailant has not been apprehended and he has threatened to return. Any of these may make the victim feel unsafe even if there are law enforcement officers present. In the aftermath of Edmond, Oklahoma, post office mass murders in 1986, one of the survivors of the attack said that he would not feel safe until the assailant, Patrick Sherrill, whose final killing was of himself, was physically in his grave. 3. A priority for some victims and survivors is the safety of others as well. If a couple has been robbed in a street crime, each may be more worried for the other person than himself or herself. Parents are often more concerned about the safety of their children than their own. 4. Survivors of victims of homicide may not focus on safety but rather seek a sense of security through the provision of privacy and nurturing. Their anguish and grief can be made more painful if there are unfamiliar and unwanted witnesses to their sorrow. They, too, will suffer feelings of helplessness and powerlessness. The shock of the arbitrary death of a loved one is usually not assimilated immediately and survivors may not understand questions or directives given to them. One mother did not realize that she had said yes when she was asked if she wanted to identify the body of her son. When she was taken to the morgue, she became hysterical and distraught because she was not properly prepared. 5. All victims and survivors need to know that their reactions, their comments, and their pain will be kept confidential. If confidentiality is limited by law or policy, those limits should be clearly explained. 6. Security is also promoted when victims and survivors are given opportunities to regain control of events. They cannot undo the crime or the death of loved ones, but there may be opportunities for them to take charge of things that happen in the immediate aftermath. 7. Hints for Helping. a. Make sure the victims/survivors feel safe or secure at this point in time. Sit down to talk. Ask the victims/survivors where they would feel safest when you talk to them, and move to that location. If it is true, reassure them with the words "You are safe now." Identify yourself and your agency clearly, and explain your standards of confidentiality. You might say, "Our program's standards require me to keep all information that you tell me confidential unless you give your permission to me to release it..." If possible, keep media away from victims/survivors or help them in responding to media questions. If the case involves a sensational crime and there are media representatives approaching the survivors, try to ensure that the victims/survivors understand that they do not have to answer questions unless they want to, and under circumstances of their own choosing. If they have loved ones about whom they are concerned, try to find out as much information as possible about the safety of the loved ones. For instance, a mother who has been a victim on the way home from work might not be as worried about the victimization as the safety of a child who is home alone awaiting her arrival. If victims are to be interviewed by law enforcement officers, try to ensure that they understand questions by asking them to repeat the question back to the interviewer. Provide victims with information that may help to assure them of their safety. For instance, if they have been survivors of a massacre, it may help if they are assured that the gunman is dead, or that he has been apprehended. If they are not safe, keep them informed about the extent of additional threat. For instance, if the gunman is still at large, try to get information about his whereabouts. If possible, find them an alternative location at which to stay for a few hours or a few days. In the aftermath of the serial killings of five co-eds in Gainsville, Florida, the victim/witness program and the community arranged for students to sleep together in dormitory-like conditions in a large auditorium surrounded by guards, all to restore a sense of safety. Give victim permission to express any reactions and respond non- judgmentally. Say: "You have a right to be upset over this tragedy, so don't be afraid to tell me what you are thinking." b. Respond to the need for nurturing -- but be wary of becoming a "rescuer" on whom the victim becomes dependent. The "rescuer" who ends up months later making decisions for the victim has subverted the primary goal of crisis intervention; that is, to help the victim restore control over his or her life. An apt analogy for the role of the crisis intervenor at this stage is as follows: when a person breaks his leg, a doctor sets it and puts it in a cast. While it heals, the patient uses crutches to get around, and when the cast is removed, the leg still needs exercise and care to become strong again. When someone survives a violent crime or the death of a loved one, they survive with a fractured heart. The crisis intervenor becomes like the doctor. The initial intervention helps the survivor by protecting that heart as much as possible against further harm. Later, the crisis intervenor provides support, understanding, and a few crutches while the survivor begins the long process of healing a broken heart. c. Help survivors to re-establish a sense of control over the small things, then the larger ones, in their lives. While it is important to assist survivors with practical activities, it is also important to allow them to make decisions for themselves and to take an active role in planning their future. The crisis intervenor initially can offer survivors a sense of control by asking them simple questions involving choices that are easily made. For instance, "What name would you like me to use in talking with you?" "Where would you like to sit while we talk?" "Would you like a glass of water?" Often the recovery of a physical object that is important to the survivor helps to re-establish a sense of control. For instance, after an arson burned down much of one family's home, the entire family was strengthened when a law enforcement officer found their cat in the bushes nearby. The family had thought the cat had died in the fire. B. Ventilation and Validation 1. Ventilation refers to the process of allowing the survivors to "tell their story." While the idea of "telling your story" seems a simple concept, the process is not easy. Victims need to tell their story over and over again. The repetitive process is a way of putting the pieces together and cognitively organizing the event so that it can be integrated into the survivor's life. The first memory of the event is likely to be narrowly focused on, say, a particular sensory perception or a particular activity that occurred during the event. Victims usually see the criminal attack with tunnel vision. They know intuitively that other things are happening around them, but they may focus on an assailant's knife, their struggle to get away, their first impression of a burglarized room. As time goes by, memory will reveal other parts of the event. These bits of memory will come back in dreams, intrusive thoughts, and simply during the story-telling process. The victimization story will probably change over time as they learn new things and use the new information to reorganize their memories. For example, a victim who reported a burglary first told the crisis intervenor that he heard a noise and he went downstairs to see what was wrong, finding a burglar in his front room. The burglar grabbed something and struck him in the stomach before running out the front door. There was a crash and then everything went silent. When the man repeated the story the second time, he said that he remembered that it was just a noise, but it sounded like some whispering and rustling. On a later telling, he remembered that when he came downstairs, he saw a brief flash of light toward the back of the house. Upon investigation, it was discovered that there had probably been two burglars and one had exited through the kitchen window in the rear of the house. This process of reconstructing a story results in inconsistent or contradictory stories, which undermine an investigation or a prosecution. However, from a crisis intervention perspective, it is perfectly normal for the process of ventilation to reveal a more complete story over time. Realistically, a victim will tell his story over and over again, with or without a crisis intervenor, in order to reconstruct the event, so that the story will often change anyway. The difference is that the crisis intervenor will provide a sounding board for the victim's distress as the review process unfolds. For victims, the replaying of the story over again helps them get control of the real story. The "real" story is not only the recitation of the event itself, but usually includes the story of various incidents in the immediate aftermath; the story of ongoing traumatic incidents related to the crime; the story of families' or friends' involvement in the event; and so forth. Each of these stories must be integrated into the victim's final mental recording of the event. 2. A part of the ventilation process is finding words or other ways that will give expression to experiences and reaction. In this aspect, ventilation is often culturally-specific. Some cultures may express their reactions through physical or various artistic forms rather than words. In most of the United States, words are the most comfortable form of expression. The power found in putting words to feelings and facts is tremendous. There is often a depth of emotion in telling another person that a loved one has died, even in finding the name of the loved one. The power is also illustrated in the release that many victims find when an intervenor responds to their ventilation with a word that expresses what victims feel. For instance, victims may feel intense anger towards an assailant and find the word "anger" insignificant to express their intensity. When an intervenor offers a word like "outrage" or "fury" to describe their feelings, victims often feel a sense of liberation -- a sense of permission to feel such intense emotions. The exact words to describe events and experiences are often vital. For example, Mothers Against Drunk Driving (MADD) is adamant about the importance of calling the collision of a car driven by someone drunk a drunk- driving "crash," a term often used to describe a mechanical or human error. 3. Validation is a process through which the crisis intervenor makes it clear that most reactions to horrific events are "normal." a. Validation should be content-specific. Example: rather than saying "I can't imagine how upset you are," it is preferable to say "I can't imagine how upset you are about your son's death in the car crash." b. Care should be taken in the words that are used to validate. For instance, many survivors do not want to hear their reactions are "normal reactions to an abnormal situation" - a common summation of what crisis and trauma produce - because survivors want to have their experience validated as unique. Telling them that their reactions are "not common" seems to be more effective. c. Where possible, repetition of the actual phrases that the survivors use to describe experiences is useful. Example, if someone says, "I can't sleep at night, I am so afraid that someone will break in and kill me and my family," an appropriate response would be, "It's not unusual for you to be afraid after such a terrifying experience. If you can't sleep at night, that only shows how afraid you are." 4. The focus of validation should be that most reactions of anger, fear, frustration, guilt, and grief do not mean that the victim is abnormal, immoral, or a bad person. They reflect a pattern of human distress in reaction to a unique criminal attack. a. While most reactions are normal, there are some people with pre- existing mental health problems who have harmful reactions. There are also some who react to personal disasters in a dangerous way - to themselves or others. In the aftermath of crisis, the intervenor should always be alert to any words or other signs of suicidal thoughts or threatening behavior towards specific individuals. If these arise, seek immediate professional help - a mental health professional, a suicide hotline, even a law enforcement agency if there is an imminent threat to someone else. b. While most reactions are normal, most people have not experienced such intense feelings, so they think they are "going crazy." Survivors should be reassured that while the crisis has thrown their lives into chaos, they are not, as a consequence, crazy. 5. Hints for Helping. The following introductory questions will help the victim focus on the crime in an objective way. It will help the victim impose an order on the event and begin to take control of the story. It may help to ask the victim to recall that day from the beginning, so that the "normal" parts become part of the crisis story. a. Ask the victim to describe the event. b. Ask the victim to describe where he or she was at the time of the crime, who he or she was with, and what he or she saw, heard, touched, said, or did. c. Ask the victim to describe his or her reactions and responses. As the victim begins the description, remember to validate the reactions and responses. If she says: "I remember turning stone cold when I felt the hand on my back and a tug at my purse," say, "Some people have called that a `frozen fright' reaction." d. Ask the victim to describe what has happened since the crime, including contact with family members, friends, the criminal justice system, and so on. Responses to this question will help reveal whether the victim has suffered additional indignities as a result of the crime or whether the victim has been treated with dignity and compassion. e. Ask the victim to describe other reactions he or she has experienced up to now. Again, validate reactions. f. Let the victim talk for as long as you can. If you are running out of time, give the victim at least a fifteen-minute warning, such as, "Mrs. Jones, I really want to hear more about your experience and reactions, but I have to leave in about fifteen minutes. If we don't finish up this part by then, I want to do that tomorrow, at a time that is good for you. If I don't hear from you, I'll give you a call, if that's okay." g. Don't assume anything - even the apparent pattern of the crisis reaction is suspect. So, for example, the victim's controlled calm of the moment may yield to tears in a few minutes, or a few weeks. Indeed, if the victim is experiencing crisis, it is safe to bet that his or her reactions will take new form over time. h. Don't say things like: I understand. It sounds like... I'm glad you can share those feelings. You're lucky that... It'll take some time but you'll get over it. I can imagine how you feel. Don't worry, it's going to be all right. Try to be strong for your children. Calm down and try to relax. Do say things like: You are safe now (if true). I'm glad you're here with me now. I'm glad you're talking with me now. I am sorry it happened. It wasn't your fault (if there was no attributable blame to the victim). Your reaction is not an uncommon response to such a terrible thing. It must have been really upsetting to see [hear, feel, smell, touch] that. I can't imagine how terrible you are feeling. You are not going crazy. Things may never be the same, but they can get better. To improve communication with the victim, avoid words like: Feelings - although this chapter is concerned with victims' feelings, in practice it is better to stick with the word "reactions" to describe "feelings." Many people are uncomfortable with being asked to talk about their feelings or emotions. Share or sharing - ask people to tell you about their experiences. Don't ask them to "share" those experiences or thank them for "sharing." No one can literally share another person's experience, even if they have suffered through the same event. Many people resent the presumption implicit in this term, or the "social work" connotation it carries. Client or Victim or Survivor - when talking to or about a person for whom you are providing crisis intervention, use the victim's preferred name. Incident or Event - when referring to the crime or the criminal attack. While such words may be used in other settings, they are inappropriate in talking with the person who has survived such an "event." Alleged - when referring to a victim. Let the lawyers speak of alleged victims and offenders if they need to. Victim advocates should assume that people who describe themselves that way are what they say - victims of crime. C. Prediction and Preparation 1. One of the potent needs that most victims have is for information about the crime and what will happen next in their lives. Remember, their lives have typically been thrown into chaos and they feel out of control. A way to regain control is to know what has happened and what will happen - when, where, how. 2. The information that is most important to victims is practical information. The following are examples. Note that some topics may raise scary possibilities that the victim has not even considered; the intervenor may tactfully touch on such issues or defer them. However, never duck any unpleasant surprise if there is reason to believe that the victim will find out about it soon. a. Will the victim have to relocate? Many burglary victims need to move temporarily because their homes are no longer secure. If relocation is necessary or recommended, what are the victim's options? b. Does the victim have adequate financial resources to pay for any immediate needs caused by the crime? The robbery victim may not have money to pay for food or rent, even if a compensation program may reimburse a victim at a later date, the need for immediate money is sometimes overwhelming. c. What legal issues confront the victim? Will the case be processed in the criminal justice system? Will there be an investigation? What are the chances that there will be an arrest - and then prosecution, trial, conviction, and sentencing? Does the victim have civil litigation options? Might it be feasible for the victim to sue the offender or a third party who might be held responsible for factors leading up to the attack? Note that honest answers and estimates are essential; to the victim of a "cold" burglary with no immediate suspects, the bad news is that fewer than one such case in fifty results in an arrest in most jurisdictions - and giving a rosier picture will undermine your future credibility. By the same token, there may be many questions that arise which are beyond the intervenor's expertise; note them, and help the victim to get expert answers. d. What immediate medical concerns face the victim? An injured victim needs information about the extent of those injuries. A sexual assault victim may need information to make informed decisions on testing for pregnancy or sexually-transmitted diseases, including HIV. The survivor of a victim of homicide or catastrophic injury may need detailed information about the cause of death or extent of injuries. e. What will be expected of the survivors of a homicide victim in the immediate future? Will they be asked to identify the body? If so, what is the condition of the body? Is there a need to address immediately funeral considerations? (Some religions call for immediate burial.) Do the survivors know their loved one's body will be given an autopsy? f. What does the victim need to know about the media? As indicated above, if the case is sensational or has a "newsworthy" face to it, it is likely that there will be media coverage. Does the victim know his or her rights? Is the victim prepared for a full media intrusion? Has the victim been warned that what appears in the media may not have any relation to the truth as he or she has experienced it? 3. The second priority is the information on possible or likely emotional reactions that the victims might face over the next day or two, and over the next six months or so - emphasizing that there is no particular timetable when victims can expect to experience crisis reactions, or which of the intense emotions may surface. In many ways, this review will become as important as anything else they learn. In the initial stages of dealing with the crime, practical issues are their priority. Some of the emotional concerns that should be outlined, however, are the following: a. Immediate physical and mental reactions to crisis. These reactions may include inability to sleep, lack of appetite, anxiety, numbness, estrangement from the world, a sense of isolation, anger, fear, frustration, grief, and an inability to concentrate. b. Long-term physical and mental reactions. These reactions may include intrusive thoughts, nightmares, terror attacks, continued sense of isolation, inability to communicate with others, sleep disturbances, depression, inability to feel emotion, disturbance of sexual activity, startle reactions, irritability, lack of concentration, and so forth. c. Reactions of significant others. While some friends or family members serve as the most important source of emotional support for victims, many cause as much harm as good. Three common reactions that may cause victims distress are: over-protectiveness; excessive anger and blame directed toward the victim; and an unwillingness to talk about or listen to stories of the crime. d. Victims should expect that everyday events may trigger crisis reactions similar to the ones they suffered when the crime occurred. Thus, the birthday of the son who was murdered may trigger overwhelming feelings of grief and anger about the murder. A sunset of a particular shade and color may trigger a panic attack in a victim who was robbed during such a sunset. The smell of alcohol on the breath of a young man may trigger an outburst of rage in a young woman who had been raped by a man who had been drinking. 4. In addition to needing predictable information, victims need assistance in preparing for ways in which they can deal with the practical and emotional future. The following are some hints for helping. a. Take one day at a time. Suggest that the victim plan each day's activities around needed practical tasks. Help the victim list the tasks that need to be done and set a goal for accomplishing a certain number each day. Victims who have been severely traumatized may want to check in with you after each day to report their progress and to receive positive feedback on any successes. b. Problem-solving. Show the victim how to use problem-solving techniques to address the overwhelming problems that he might face. Suggest that the victim list the three most important problems confronting him for the next day. After he makes his list, have him analyze whether all three really need to be done in the next twenty- four hours. If he thinks so, ask him to sort the list in priority order. Take the first problem he has listed and ask him to think about all the possible ways he might deal with the problem. After he has discussed such ideas, ask him to choose the option that he thinks is most feasible. Example: Jim is a robbery victim. The robber stole his wallet and the contents of his pockets, which included all of his cash, his bank card, his driver's license, his car and apartment keys, and a pocket watch. Jim is panicky because it's 9 at night and he doesn't have any money and doesn't know how to get home. Even if he is able to get there, he doesn't have keys to get into his apartment or to drive to work in the morning. You ask Jim to list his three biggest problems. He says: getting home, getting in his apartment, and getting to work in the morning, in that priority order. You ask him to think of all the possible ways he might be able to get home. After some thought, he decides that he can borrow a quarter from you and call a friend to come get him. He then realizes that his friend would probably let him stay at his house overnight, if needed. He also realizes, as he is thinking, that he might be able to call his landlord from his friend's house and arrange to get into his apartment. As he begins to think calmly and carefully about the problem he remembers he has an extra set of keys to both his apartment and his car at home... and so the problem-solving begins and may continue. c. Talk and write about the event. Suggest to victims that they use audiotapes or write a journal to tell their unfolding stories. Even if no one else sees or hears these stories, it is a way of expressing oneself and a way of processing thoughts. d. Plan time for memories and memorials. It can be predicted that certain things will be trigger events for future crisis reactions. Urge victims to try to think through what those trigger events might be and allow themselves time to deal with those reactions. For example, a woman who had been sexually assaulted on October 14 routinely took that day off from work to do something nice for herself and to think about her pain. e. Encourage victims to identify a friend or family member on whom they can rely for support during times when they must confront practical problems. If they are able to name that person, suggest that they call and explain their need for support and help. If this is done in advance, it makes it easier to request certain help when the time comes. f. Good nutrition, adequate sleep, and moderate exercise can significantly help victims survive times of crisis. That underestimated triad is, in fact, the basis for virtually all stress reduction programs. Help victims set up their own regular routine of health. At first it may be difficult, but if they keep trying they will readily realize some benefits. ... Charles Dickens said, "No one is useless in this world who lightens the burdens of others." * Reprinted with permission of National Organization for Victim Assistance Secondary Victimization* After the trauma of a crime, many report being victimized by the very systems that were designed to help them. The media, health services and criminal justice system can respond to victims of crime in ways that make them feel traumatized again. A counselor can help to reduce the chances of secondary victimization by helping victims to understand their rights. Crime Victims' Rights While the American criminal justice system is primarily modeled after the English system, there is an important difference in criminal prosecutions. Historically, criminal prosecutions in England were private actions brought by the victim or a representative of the victim. In the American tradition, a crime is deemed to have been committed against the state or against society as a whole. An unfortunate outcome of this is the victim's assignment as a witness. Since the crime is viewed as being committed against the state, it is the state's job and right to prosecute. In criminal cases, it is not the victim who decides if the case will go to court. The victim has little or no control over the process of bringing the offender to justice. In recent years, America's victims' rights movement has advocated to up-grade the victim's role in the criminal justice process. It has sought to balance the rights of victims and the accused. During the past two decades, all states have passed laws affirming the rights of crime victims. Almost every state has enacted "victims' bills of rights." A quarter of the states have passed constitutional amendments for victims' rights. Today, victims are frequently categorized - sexual assault victims, domestic violence victims, child abuse or neglect victims, elderly victims of abuse, victims with disabilities, victims of hate-motivated crimes, and even Good Samaritans. Many states have included surviving family members of homicide victims in their definition of "victim." These groups often have rights and remedies that are unique and distinct, such as protection from abuse orders for domestic violence victims, videotaped testimony and testimonial aids for child victims, and protective services for elderly victims. All states have rights for crime victims, but the scope varies greatly from state to state. Victims' rights can include: The right to attend and/or participate in criminal justice proceedings The right to notification of the stages/proceedings in the criminal process and of other legal remedies Protection from intimidation and harassment The right to confidentiality of records Speedy trial provisions The right to prompt return of the victim's personal property seized as evidence from offenders The availability of offenders' profits from the sale of the stories of their crimes Victim compensation and restitution Victim Impact Statements* Courts in every state are permitted to consider or even to request a victim impact statement. These statements provide a way for those deciding a case to factor in the human cost of the crime and for victims to participate in the criminal justice process. Almost all states provide for victim input at sentencing. Impact statements can be mandated by law, or left to the judges' discretion. Most victim impact statements normally written, and become part of the pre-sentence report. They may be drafted by the official preparing the pre-sentence report, the victim, or survivors of the victim, depending on the law. In some states, the parent or guardian of a minor or incompetent victim can prepare the statement. The Child Protection Act of 1990 permits child victims of Federal crimes to submit victim impact statements in ways that are "commensurate with their age and cognitive development," which could include drawings, models, etc. A state may allow written or oral statements at sentencing. The oral statements may be made by the victim, survivors of a victim, or in some states, a representative of the victim or victim's estate. Victim impact statements can include the financial, physical, psychological or emotional harm that the victim or victim's family suffered. State law might specify what can be included in the statement, or it may simply permit a "description of the impact of the offense." Victims may be permitted to state what sentence they wish the offender to receive or voice their opinions about the proposed sentences. In more than half of the states, victims can submit impact statements even if the offender was sentenced prior to the passage of an impact statement law. The majority of states also permit victim input at the parole hearing. In 1990, the California legislature passed a law which permits the use of videotaped victim impact statements at parole release hearings. Acknowledging that many victims are unable to travel to parole release hearings, more states are permitting video impact statements. Some states are permitting the use of audiotaped victim impact statements for the same reasons. Victim impact statements that are submitted to the court at the time of sentencing should also be included in an offender's file. This assists the paroling authorities in understanding how the crime affected the victim(s) soon after it occurred, rather than its impact at the time(s) of parole release hearings. In over half of the states, the original victim impact statement is kept on file by corrections authorities, and reviewed as part of the parole process. Many states solicit updated impact statements for parole hearings as well. Crime Victims and the Media* In its rush to be the first with the news, the media can often inflict a "second victimization" upon crime victims or survivors. Common complaints that victims have include: interviewing survivors at inappropriate times; filming and photographing gruesome scenes; searching for the "dirt" about the victim; seeking interviews with friends or neighbors', interviewing or photographing child victims; printing victims' names, addresses or places of employment; and scrutinizing victims' past. After a crime, victims are frequently physically and mentally numb. They are confused and disoriented. A recent study shows that television news directors agree in principle that crime victims have privacy rights and the individual's right to privacy is not outweighed by the public's desire to know. However, directors are less likely to adhere to this principle if they know a competitor is going to break the story. While victims have rights when dealing with the media, many yield to media pressures and answer questions that they would not consider answering under other circumstances. In most cases, there are no legal remedies if his or her rights are violated. The National Victim Center developed this list of rights for victims: To say "no" to an interview To select the spokesperson or advocate of the victim's choice To select the time and location for media interviews To request a specific reporter To refuse an interview with a specific reporter even though he or she has granted interviews to other reporters To say "no" to an interview even though the victim has previously granted interviews To release a written statement through a spokesperson in lieu of an interview To exclude children from interviews To refrain from answering any questions with which the victim is uncomfortable or that the victim feels are inappropriate To avoid a press conference atmosphere and speak to only one reporter at a time To demand a correction when inaccurate information is reported To ask that offensive photographs or visuals be omitted from airing or publication To conduct a television interview using a silhouette or a newspaper interview without having a photograph taken To completely give the victim's side of the story related to the victimization To refrain from answering reporters' questions during a trial To file a formal complaint against a reporter To grieve in private Medical Issues* Twenty-eight percent of rape victims report some degree of physical injury as a result of the rape (Rape in America, 1992). Every year, domestic violence results in almost 100,000 days of hospitalizations, almost 30,000 emergency department visits, and almost 40,000 visits to physicians (American Medical Association, 1991). Every year hospitals spend millions of dollars treating victims -- including victims of physical abuse, homicide, terrorism, aggravated assault, rape and domestic violence. Even though hospital staff see many victims of trauma and in many cases are one of the first to respond to victims, hospitals are frequently understaffed and personnel undertrained to deal effectively with the emotional needs of victims. Individuals whose physical wounds do not appear to be severe may be forced to sit and wait while others are treated. In some cases the victim and the offender may be brought to the same hospital for treatment. The victim may be forced to be in close proximity to the offender while awaiting or receiving medical treatment. Staff who deal with victims of crime on a daily basis may respond to victims in ways that seem to minimize their pain and emotional trauma. Because treating victims of crime is routine, hospital staff may fail to explain procedures with sensitivity and care and thereby cause secondary victimization. Fear of HIV With the HIV/AIDS epidemic, the trauma of a sexual assault has evolved into a potentially life threatening concern. To date, there have been no documented cases of HIV transmission in adult victims as a result of a sexual assault. This does not mean that transmission is impossible. The physical trauma to the body increases the susceptibility to infection. Child or elderly victims are at increased risk of infection. Although there is no prescribed way to introduce the topic, a discussion about the rape exam or general health concerns may provide a natural opening to insert the topic. A counselor can also wait for the victim to raise the issue. A victim's desire to have an offender tested for HIV is understandable, but the results rarely relieve the fear and anxiety. Knowing the results of an offender's present HIV test does not guarantee that the victim is free from exposure to HIV. Current research indicates that a person could be exposed to the virus, yet not test positive for months or years. This individual could transmit it to another even though test results are negative. Additionally, in many cases the offender may never be apprehended. Although a number of states have mandated testing of alleged and/or convicted offenders, not all provide for immediate testing or automatic notification to victims. Due to the high-risk behaviors of numerous sexual offenders, and the frequency with which some children are assaulted by the same offender, the risk of infection for children, when compared with adults, is higher. While the risk is higher, the incidence of HIV infection in children is so low that testing is not recommended unless a strong belief or evidence exists that the offender engages in high-risk behaviors or the child exhibits symptoms of sexually transmitted diseases. If testing is deemed advisable, the parent(s) or legal guardian(s) must give permission. Most people consider sexual assault victims as the victim group at highest risk for HIV infection. However, domestic violence victims should also be considered. Women whose partners use drugs are at risk. Victims may be coerced into using intravenous drugs with shared needles, and consequently exposed to the virus. Most battered women are not powerful enough to convince their partners to use a condom. Sexual assault may be part of the battering cycle. Cross Cultural Issues in Crisis* I. Understanding Cultural Contexts A. CULTURE (cul' tur): "the totality of socially transmitted behavior patterns, arts, beliefs, institutions, and all other products of human work and thought characteristic of a community or population." The American Heritage Dictionary of the English Language 1. Issues that help define culture identity include attitudes towards spirituality, birth, dress and other factors. 2. Sources of cultural identity include not only race, ethnicity, nationality and religion but also such attributes as age, gender, language, sexual orientation. B. Placing yourself in your own cultural context. It is important to know your own values and cultural references before trying to interact with others with different values and references. II. Issues Of Cultural Perspective A. Culture and crisis 1. Most literature on trauma and appropriate intervention strategies is based on theoretical and philosophical paradigms drawn from a white, Anglo-Saxon, Judeo-Christian perspective in the United States. Yet it is clear that people with different cultural backgrounds, including those backgrounds that are drawn outside of race, ethnicity, nationality or religion, may perceive trauma and appropriate treatment differently. "All ethnically focused clinical, sociological, anthropological, and experimental studies converge to one central conclusion regarding ethnic America: Ethnic identification is an irreducible entity, central to how persons organize experience, and to an understanding of the unique 'cultural prism' they use in perception and evaluation of reality. Ethnicity is thus central to how the patient or client seeks assistance (help-seeking behavior), what he or she defines as a 'problem', what he or she understands as the causes of psychological difficulties, and the unique, subjective experience of traumatic stress symptoms. "Ethnicity also shapes how the client views his or her symptoms, and the degree of hopefulness or pessimism towards recovery. Ethnic identification, additionally, determines the patient's attitudes toward his or her pain, expectations of the treatment, and what the client perceives as the best method of addressing the presenting difficulties." E.R. Parsons, "Ethnicity and Traumatic Stress: The Intersecting Point in Psychotherapy," in Trauma and Its Wake, ed. Charles R. Figley, Brunner/Mazel: New York, 1985. 2. Several different conceptual schemes provide some insight into how different cultures may need different types of intervention or strategies for service delivery. a. The Axis of Control describes the degree to which individuals feel in personal control of their lives, and the degree to which they may feel personal responsibility for what happens to them, or their community. b. The Axis of Conflict describes how people tend to react to conflict in their lives and the goals they seek in resolving that conflict. c. The Axis of Life attempts to illustrate different perspectives on life and death issues and whether individuals seek to resolve their concerns about life and death through communing with nature, God or technology. 3. Each perspective described through these suggests differences in attitudes, philosophies and values when providing outreach and service to different cultural groups. B. Cultural assessment 1. That analysis can be based on any dominant and uniting characteristic of a population. For instance, if a crisis response effort was being planned for an intervention at Gallaudet University, the only four-year liberal arts university for deaf people in the United States, it would be important to think of the frame of reference of the hearing impaired or deaf populations. It would be critical to think about the integration into the hearing impaired culture, or lack thereof, of any particular group or individual within the college. 2. For purposes of illustration on how an assessment might be made, the following is a "checklist" for helping counselors determine the level of ethnic identification that a victim may have. a. Determine the extent that the ethnic language is spoken in the home. b. Determine how well English (or the dominant language or dialect in a country) is spoken. c. Determine the stresses of migration on the ethnic group as a whole and how long the individual or community has been in the United States. d. Determine the community of residence and the opportunities the individual has for linking with people of a similar ethnic origin. e. Determine the educational attainment and socio-economic status of the individual and the community. f. Determine the degree of religious faith of the individual or the community and whether that faith reflects the religion of the ethnic group. g. Determine the presence of intermarriage in the community, by the individual, within the individual's family, or within the community as a whole. C. Understanding Cultural Competence 1. A long-held theory of cross-cultural assistance has been that it is best if members of the same cultural, racial or ethnic group assist each other. That is, an Hispanic/Latino victim theoretically would best be served by an Hispanic/Latino counselor. While this is still a useful goal in some cases, it has not been practical in application since there has often been a shortage of helpers from different cultures in the communities where they are needed most. 2. James Green offers the following definitions of ethnic competence that could be utilized as well to explain a more generic definition of cultural competence. (Source: James Green, Cultural Awareness in the Human Services. Prentice Hall, 1982.) a. "Ethnic competence as awareness of one's own cultural limitations. One of the implications of the model of help-seeking behavior is that the more similar the cognitive and affective characteristics of the client and the worker, the greater chances for effective communication...cultures are in fact different." b. "Ethnic competence as openness to cultural differences. The belief that underneath we are all the same and that we all share a basic understanding of what is good and valuable in life might well be added to our list of common American values. These beliefs derive from the melting pot ideology, with its assumption (and hope!) that the cultural differences that separate people are less important than the things that unite them, and that manifestations of differences are best under-emphasized in order to assure tranquillity in social relation... The acceptance of ethnic differences in an open genuine manner, without condescension and without patronizing gestures is critical for the development of an ethnically competent professional style..." (While Mr. Green accurately refers to the traditional belief about a melting pot society -- more and more people currently subscribe to the "tossed salad" description of the mixture of ethnicities.) c. "Ethnic competence as a client-oriented systematic learning style. All cross-cultural encounters are potential learning experiences. They may result in the discovery of new information or an enhanced understanding of something not fully appreciated before. Systematic learning depends on whether the worker-as-health-provider is willing to adopt the role of worker-as-learner." d. "Ethnic competence as utilizing cultural resources. To do so, the worker must know the resources available to the client and how they may best be used. "Resources" here mean not only community agencies but also institutions, individuals and customs indigenous to the client's own community." e. "Ethnic competence as acknowledging cultural integrity. In catch phrases such as "culture of poverty," "cultural deprivation" or "the black problem" the prejudicial view is expressed. Yet all cultural traditions and extant communities are by definition rich, complex and varied." III. Recommendations For Cross-Cultural Service Delivery A. Preparation for providing cross-cultural victim assistance 1. Take advantage of as many cross-cultural educational opportunities as possible. 2. Consider the following possibility. Most people who think of themselves as members of a dominant cultural group spend less time learning about minority groups than do minority groups within the same population. Minorities need to learn about dominant cultural values in order to survive or succeed. 3. Be aware of institutional and latent cultural bigotry. Such bigotry includes racism, sexism, ageism, homophobia, and so forth. While it is easy to identify obvious indicators of bigotry, subtle signs of discrimination, ignorance and prejudice may be more difficult to observe. a. Language often carries inherent messages of prejudice. b. Stereotypes also often are indicators of bigotry. c. Educational programs can carry implicit biases in favor of the dominant culture. d. Symbols, traditions, and behaviors may be implicitly discriminatory. e. It is wise for crisis responders to spend time thinking about the difference between bigoted words, phrases, or humor, and what constitutes non-bigoted or discriminatory speech. f. Racism is one of the most important factors in cultural experiences. Some have suggested that the more people of one race are exposed to people of other races the less likely either race will be racist. However, others suggest that if people lack any exposure to a different race they may also be non- racist. People become racist when exposed to negative experiences or stereotypes about other races. When those experiences or stereotypes are reinforced by media, friends and family, language or formal education, racism becomes entrenched. B. The following action plan for working in a cross-cultural context is based on further work of Erwin Parsons. 1. Prior to doing cross-cultural intervention, find out about a culture's routines, traditions and impact of family relationships. Routines such as regular mealtimes or mode of dress can affect when and how interventions are made. Crisis responders should be prepared to participate in traditions to the extent possible. 2. The orientation: Have an open discussion about difficulties of working with individuals or groups who come from a different cultural context than yours. a. Express a willingness to learn about the ethnic group involved. b. Communicate some appreciation and respect for the individual's culture. c. Acknowledge your differences and your limitations. 3. Address practical problems first. a. Deal with immediate environmental problems such as financial loss, secure shelter, family conflict and the like that the individual is having difficulty handling by himself. b. Build trust. c. Assist the survivors or victims with financial resources or compensation if possible. d. Help the survivors focus on something tangible that they can accomplish over the next few days. 4. Crisis intervention with cultural focus. a. Search for the meaning of suffering and pain relevant to the dominant cultural group involved. b. Search for the meaning of death in the culture. c. Search for the meaning of life. d. Make an effort to acknowledge your limitations with language or other communication concerns, and ask the survivors to tell you if you say something wrong or do something offensive. e. Ask survivors to tell their story and talk to them about the crisis reaction. f. Ask survivors if their families should be present during discussions or if they would like to have clergy members present. g. Ask survivors if they would like to go to a place or worship or if there are any ceremonies or rituals that are particularly directed at crisis in the culture. h. Ask survivors to describe what they would like you to do to be of assistance to them and then tell them truthfully what you can or can't do. I. Useful cross-cultural intervention includes: reduction of isolation, relaxation techniques, meditation, education about crisis and trauma reactions, neuro-lingual programming, reframing the crisis in culturally relevant terms, helping individuals to develop control, increase self-esteem and self- regulation. j. Be aware of culturally specific communication techniques such as the use of eye contact, the integration of food and drink in discussion, the pace of conversation, body language and so forth. IV. Different Ethnic-Cultural Contexts Crime victimization is often more prevalent within minority populations than between the dominant population group and minorities; therefore, crime victimization is included as a context for understanding cultural environments. While ethnic groups suffer victimization, they often also become victims of the system when accused of crimes. Victims Who Are Disabled Individuals with a physical disability are more likely to be unemployed, under-employed and less well educated. Women who are disabled are less likely to be married than men who are disabled. People of color who are disabled are more likely to be negatively impacted both economically and socially. Persons with disabilities are not only misunderstood by society as a whole but often by their families as well. They are frequently discouraged from expressing themselves sexually. When working with an individual who has a disability: Ask how to best handle any situation of which you are unsure. Remember that the victim is a person who happens to be disabled, rather than a disabled person who happens to be a victim. An attendant or family member may not be able to communicate with the victim any better then you. It is not appropriate to talk to family members without the permission of the victim or instead of the victim. The victim should decide if another individual should be present for the interview. A care-taker may be the one abusing the victim. A victim who at some point lived in an institution or residential facility may have rigid ways of thinking, been encouraged to be friendly to everyone or experienced abuse by staff or other residents. An inability to speak does not equal an inability to hear. If an interpreter is needed, always speak to the victim, not the interpreter. Learn the shorthand, such as "GA" for go ahead, and the protocol for telephone relay services. When working with a victim who is blind or sight impaired: Allow the victim to take your arm when walking rather than taking his/her arm. If there is a guide dog, do not comment about the dog's inability to protect the victim. Asking about a dog's behavior is a form of victim blaming. Introduce yourself every time you enter the room; announce when you are leaving. POST-TRAUMATIC STRESS DISORDER, RAPE TRAUMA SYNDROME AND BATTERING Powerlessness is a political condition, while passivity is a strategy adopted by the powerless to survive...The process of victimization consists of (1) first putting the victim in a position of powerlessness relative to the victimizer, and then (2) repeatedly impressing the victim with his or her powerlessness, including the powerlessness to escape, until the victim adopts passive and compliant behavior to stay alive. Anne Jones Trauma and Post Traumatic Stress Disorder In her book, Trauma and Recovery, Judith Herman (1992) reminds us that the ordinary response to the horrors that occur in our lives is to expel them from our consciousness. There are certain violations that are unspeakable. While they are unspeakable, they refuse to be buried because there is an equal but opposite conviction that denial does not work. Herman tells us "remembering and telling the truth about terrible events are prerequisites both for the restoration of the social order and for the healing of individual victims." However, since atrocities are frequently shrouded in secrecy, evidence of a traumatic event initially appears as a symptom, not a story. The distress symptoms of traumatized people concurrently call attention to the existence of an unspeakable secret while deflecting attention from it. We see this clearly in the way people who experienced a trauma alternate between feeling numb and reliving the event. Mental health professionals call this dissociation. "People who have endured horrible events suffer predictable psychological harm. There is a spectrum of traumatic disorders, ranging from the effects of a single overwhelming event to the more complicated effects of prolonged and repeated abuse. Established diagnostic concepts, especially the severe personality disorders commonly diagnosed in women, have generally failed to recognize the impact of victimization" (Herman, 1992, p. 3). Traumatic syndromes as well as the recovery processes have basic features. The primary stages of recovery are: establishing safety reconstructing the trauma story restoring the connection between survivors and their communities The challenge is to help survivors reconnect the pieces, rebuild history and make meaning of their current symptoms in the light of prior events. The traditional sphere in which this occurs for women is within the experiences of domestic and sexual life; while for men it is within the experiences of war and political life. Studying psychological trauma means coming face to face with human vulnerability to natural acts or disasters and the evil deeds of humans. We witness horrible events. When the events are natural disasters, witnesses are readily inclined to sympathize with the victim. Conversely, when the traumatic events are of human creation, witnesses are caught in the struggle between victim and perpetrator. Morally, it is impossible to remain impartial. Witnesses take sides. The side that many choose is the side of the perpetrator because all that the perpetrator asks is for witnesses or society to do nothing. To side with a victim, requires the witnesses to share the burden of the victim's pain. Ask Vietnam veterans if people want to know what really happened during the war, and they will say "no." Society, without individuals or groups willing to hear and report the pain, prefers to look the other way. It happens even more frequently when the victim is already devalued by society (a woman, a child). Devalued individuals find that the most traumatic events of their lives take place outside the range of socially validated reality. Their experiences are unspeakable. In the field of psychological trauma, there has been debate about whether individuals with post-traumatic conditions should be treated with care or contempt. Are they genuinely suffering or are their stories products of their imagination? Despite the literature documenting the occurrence of psychological trauma, debate still centers on the basic question of whether these incidents are credible and real. Those who spend too much time treating victims of traumatic events are viewed with suspicion by many of their colleagues. There have been three periods during the past century when a particular form of psychological trauma has become a public concern. Each time, the study of trauma has flourished in association with a political movement. The first of these was hysteria, the archetypal psychological disorder of women. Its study grew out of a political movement of the late nineteenth century in France. The second was shell shock. Its study began in England and the United States after World War I and reached its peak after the Vietnam War. The political setting was the disillusionment with the Vietnam war and the growth of an antiwar movement. The last and most recent traumas to come to public awareness are sexual and domestic violence. The feminist movement brought them to public view. Today's understanding of psychological trauma is built upon a synthesis of these three areas of inquiry. Not until the women's liberation movement of the 1970's was it recognized that women in civilian life had post-traumatic disorders. The real but private conditions of women's lives were hidden. The privacy created powerful obstacles to consciousness and made women's reality practically invisible. Those who spoke about sexual or domestic abuses were subject to public humiliation, ridicule and disbelief. Women remained silent out of fear and shame, and silence permitted sexual and domestic exploitation. This confirmed what Freud had dismissed as fantasies. Sexual assaults against women and children were pervasive. A survey conducted in the early 1980's by Dianna E. H. Russell, a sociologist and human rights activist, concluded one woman in four had been raped and one woman in three had been sexually abused in childhood. For the first time, women designated rape as an atrocity. Feminists redefined rape as a crime of violence - of power and control - rather than a sexual act. Feminists also redefined rape as a method of political control, forcing the subordination of women through terror. In 1980, psychological trauma became a "real" diagnosis for the first time. In that year the American Psychiatric Association included in its official manual of mental disorders a new category called Post Traumatic Stress Disorder (PTSD). PTSD occurs in war and peace, as the result of natural disasters or planned attacks, in single or repeated episodes and at the hands of strangers and loved ones. Diagnostic Criteria for Post Traumatic Stress Disorder* A. The person has been exposed to a traumatic event in which both of the following were present: 1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. 2. The person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior. B. The traumatic event is persistently re-experienced in one (or more) of the following ways: 1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed. 2. Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content. 3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur. 4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. 5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: 1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma 2. Efforts to avoid activities, places, or people that arouse recollections of the trauma 3. Inability to recall an important aspect of the trauma 4. Markedly diminished interest or participation in significant activities 5. Feeling of detachment or estrangement from others 6. Restricted range of affect (e.g., unable to have loving feelings) 7. Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span) D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: 1. Difficulty falling or staying asleep 2. Irritability or outbursts of anger 3. Difficulty concentrating 4. Hyper-vigilance 5. Exaggerated startle response E. Duration of the disturbance (symptoms in Criteria B, C and D) is more than one month. F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Acute: if duration of symptoms is less than 3 months Chronic: if duration of symptoms is 3 months or more With Delayed Onset: if onset of symptoms is at least 6 months after the stressor * from Desk Reference to the Diagnostic Criteria from DSM-IV, American Psychiatric Association At the moment, the study of psychological trauma seems to be firmly established as a legitimate field of inquiry. Twenty years ago, the literature consisted of a few out-of-print volumes. Now there are new books, new research findings and new discussions every month. Traumatic events are extraordinary, not because they are rare, but rather because they overpower normal human adaptations to life. Unlike ordinary misfortunes, traumatic events generally involve threats or perceived threats to life. Victims encounter feelings of helplessness and terror. Long after danger is over, victims experience the event as though it were continually recurring in the present. They are unable to return to "normal," for the trauma repeatedly intrudes. It is as if time stops at the moment of trauma. The traumatic moment breaks into consciousness in the form of flashbacks and nightmares. Small, seemingly insignificant reminders can trigger these memories, which return with the vividness and emotional force of the original event. As a result even normally safe encounters may feel dangerous. Traumatized people who cannot spontaneously dissociate may attempt to produce similar numbing effects by using alcohol or narcotics. It has become clear that traumatized people run a high risk of compounding their difficulties by developing dependence on alcohol or other drugs. Although dissociation, or even intoxication, may be adaptive defense mechanisms at the moment of total helplessness, they cease to be once the danger is past. They prevent the integration necessary for healing. Unfortunately, dissociation, like other symptoms of the post-traumatic stress syndrome, is persistent. Traumatic events place enormous stress on basic human relationships. They can sever ties of family, friendship, love and community. They can shatter the self image that is formed and sustained in relation to others. They can undermine belief systems. They can violate the victim's faith in a natural or divine order and cast the victim into a state of crisis. Traumatic events destroy victims' fundamental assumptions about the safety of the world, the positive value of the self and the meaningful order of creation. The damage to relational life is not a secondary effect of trauma. Traumatic events destroy victims fundamental assumptions about the safety of the world, the positive value of the self, and the meaningful order of creation. Support from other people may temper the impact of the event, while blame or a hostile response may compound the damage and intensify the traumatic syndrome. After traumatic life events, survivors are highly vulnerable. Their sense of self is shattered. That sense can be rebuilt only as it was built initially, in connection with others. Sharing the traumatic experience with others is an element of recovery. In this process, the survivors seek assistance not only from those closest to them but also from their communities. The response of these communities has a powerful influence on the ultimate resolution of the trauma. Re-establishing the bonds between the traumatized person and their communities depends upon public acknowledgment of the traumatic event and some form of community action. Once communities acknowledge that a person has been harmed, they must assign responsibility for the harm and repair the injury. These two responses - recognition and restitution - are necessary to rebuild the survivor's sense of order and justice. Rape-Related Post-Traumatic Stress Nearly one-third of all rape victims develop Rape-related Post-traumatic Stress Disorder (RR-PTSD) sometime in their lifetimes, and more than 11 percent suffer from RR-PTSD at the present time. Thirteen percent of American women surveyed had been raped and 31 percent of these rape victims developed Rape-Related-PTSD. Of the 683,000 women raped each year in this country, approximately 211,000 will develop RR-PTSD each year. Rape victims are three times more likely than non-victims of crime to have a major depressive episode. Rape victims are 4.1 times more likely than non-crime victims to contemplate suicide. Thirteen percent of all rape victims actually attempt suicide. Compared to non-victims of crime, rape victims are: 13.4 times more likely to have two or more major alcohol problems; and 26 times more likely to have two or more major serious drug abuse problems. from Rape in America: A Report to the Nation, National Victims Center, 1992. Rape Trauma An acute and long-term emotional reorganization process that occurs as a result of completed or attempted rape, and lasts for months or years after the actual rape has occurred. Stages A. Acute/Impact Reaction 1. Immediately and several days after the rape 2. Ways of showing anger a. Expressed style - fear, crying, smiling, restlessness, tenseness b. Controlled style - feelings hidden by calm, composed attitude 3. Somatic Reactions a. Physical: soreness and bruising from the physical attack, irritation and throat infections for women forced into oral sex b. Skeletal muscle tension: inability to sleep or restlessness while asleep, edgy and jumpy over minor incidents c. Gastrointestinal Irritability: stomach pains, appetite affected, nausea d. Genital Disturbances: vaginal discharge, an itchy, burning sensation on urination, chronic vaginal infections, rectal bleeding/pain 4. Emotional Reactions a. Fear of: how friends will react, not being believed, rapist retaliation b. Shock/disbelief c. Agitation/anger d. Shame/self-blame e. Confusion/bewilderment f. Extreme sense of guilt 5. Her needs a. Someone to believe her b. Emotional support/acceptance c. Reassurance about how she handled the attack 6. Additional needs a. Examination by physician even if it is several days after the attack b. Aid in reporting the crime B. Outward Adjustment Phase 1. Lasts from weeks to months 2. Emotional reactions a. Intense fear: pregnancy, V.D., physical violence or death, crowds, being approached from behind, intercourse, fear of the unexpected (because the rape may have been unexpected) b. Anxiety: anticipating medical exams, court hearing in which she'll face the rapist, prospect of losing partner c. Denial - refusing to believe the rape happened d. Lost sense of security 1. Nightmares in which a. Victim is in danger and wants to do something but wakes before acting b. Victim succeeds in fighting off assailant c. Humiliation, embarrassment d. Self-blame e. Feelings of wanting revenge f. Fear of sexual things g. All problems become intensified 3. Physical signs a. Antipregnancy medicine - causes nausea. Consist of 25-50 mg. of diethylstilbestrol (DES) administered per day for five days b. Anti-venereal disease medicine - causes nausea. Consists of 4.8 million units of aqueous procaine penicillin administered intramuscularly c. Burning sensation when urinating and itching or burning discharge from vagina d. Tension headaches 4. Her needs a. Counselor to be patient as she retells her story; time and time again, if necessary b. Aid in approaching family and friends c. Counseling with partner about her fear of sexual intercourse d. Meet with other rape victims so she won't feel as isolated and helpless C. Depression Phase 1. Lasts days to months 2. Her emotions a. Loss of self-esteem as her defenses break down b. Obsessive memories c. Uncertain about being able to control her life and environment 3. Her needs a. Support through the sentencing of her rapist and any possible end to intimate relationship b. Overcome her guilt feelings c. Help in re-establishing intimate relationships D. Integration and Resolution Phase 1. Lasts months to years 2. Her emotions a. Lack of trust in men b. Anxious and depressed when something reminds her of the rape 3. Her needs a. Support and someone to listen b. Guidance in steps to make her feel more safe 1. Obtain unlisted phone number 2. Move to another location 3. Extended vacation to get away for a awhile Reactions Above and Beyond Rape-Related PTSD That May Require Different Kinds of Intervention Depressed for an extended period of time (several weeks) Demonstrated psychotic behaviors Talk of or attempts at suicide Use of alcohol or drugs to self medicate Abrupt/dramatic changes in sexual behavior; confusion about sexuality Expresses a hatred of sex Ten Warning Signs of Mental Illness* 1. Marked personality change. 2. Inability to cope with problems and daily activities. 3. Strange or grandiose ideas. 4. Excessive anxieties. 5. Prolonged depression and apathy. 6. Marked changes in eating or sleeping patterns. 7. Thinking or talking about suicide. 8. Extreme highs and lows. 9. Abuse of alcohol or drugs. 10. Excessive anger, hostility or violent behavior. * from the American Psychiatric Association A person displaying one or more of these warning signs may have a mental illness and should be evaluated by a mental health professional as soon as possible. If the individual has experienced trauma due to crime or abuse, the behavior may be a normal response to an abnormal event. Depression The most common complaints that patients tell their physicians are the common symptoms of depression. In 1990, the American Psychological Association reported that depression annually afflicts about 7 million American women and is responsible for 30,000 suicides. This is twice the rate of depression found in American men. The rate of depression and victimization in women may be linked. Symptoms unusual weight gain or loss of weight either sleeping too much or insomnia inability to enjoy pursuits which formerly gave pleasure brooding over the past pessimism about the future loss of interest in sex extreme irritability overreaction to trivial events trouble with concentration or memory neglect of appearance frequent thoughts of death or dying social isolation low self esteem feelings of helplessness A common feature of depression includes the tendency to over generalize the meaning of events. Instead of dealing with adversities as isolated incidents, people with depression see incidents as part of a larger pattern. They are inclined to see things as black or white. For example, a mother trying to solve family problems, realizes that some solutions will work well while others will not. But the mother who is depressed tends to feel there are no solutions. Recovery Depression can often be successfully treated. Depression can be caused by sudden changes in brain chemistry (endogenous) or by personal tragedy or trauma (exogenous) which trigger chemical changes. Serotonin and norepinephrine are chemicals that affect mood. When confronted with trauma or tragedy, a person may become depressed. The amounts of serotonin and norepinephrine in the brain plummet. After about three weeks, the levels of the chemicals usually rise and the person begins to feel better. For some people, the levels of serotonin and norepinephrine do not return to normal. With low levels of the chemicals, the person may feel continually "blue." But if the quantity drops further, it could lead to clinical depression. There are drugs which can restore the levels of serotonin and norepinephrine. In the last few years several drugs have been approved by the FDA for the treatment of depression that have fewer side effects and begin to work more rapidly. For people who suffer from depression as a result of a traumatic event, medication may help them to focus and process what has happened. It can help them sleep, increase their energy levels, and reduce feelings of hopelessness. In addition to medications, talk therapy and support groups are used to treat depression. Frequently they are used in combination. Hostage in the Home* Domestic Violence Seen Through Its Parallel, The Stockholm Syndrome When most people hear the term domestic violence, they think of punches, bloody noses, black eyes, broken ribs. So people invariably react by saying, "I wouldn't take that! The very first time he hit me, I'd be out the door!" Thinking that one becomes an abuse victim at the moment of the first assault, they imagine how they would react to an assault by a stranger and blame the abuse victim for not reacting to her1 partner's assault as they think they would. People who work with abuse victims are often frustrated and angered by decisions victims make which they consider bizarre and inexplicable. For example, abuse victims often: minimize their injuries refuse to participate in the prosecution of their assailants put up bail to get their abusers out of jail stay with or return to the men who abuse them Because physical abuse is concrete and is all that outsiders can see, and because people do not think that just physical assaults would make someone do the "crazy" things abuse victims do, they conclude that the victim is mentally unbalanced. In fact, the victim's mental state is altered as a result of her relationship with the abuser. Her perceptions of herself, her abuser and life in general have been altered. Not solely due to the physical abuse she may have suffered, but due to years of psychological assaults, the unremitting use of tactics defined by Amnesty International (1973) as "psychological torture." The abuse victim's very different view of her situation is the result of a lengthy process. 1 Although it is clear that there are men abused by female and male partners, and there are women abused by female partners, because "[a]nalyses of police and court records in North America and Europe have persistently indicated that women constitute 90-95% of the victims of those assaults in the home reported to the criminal justice system," (Dobash, et al., 1992), herein the victim will be referred to as female and the perpetrator as male. The bottom line is that pain has no gender, and, as this analysis shows, human beings exposed to psychological torture will react similarly, regardless of sex. Therefore, the author asks readers to mentally translate the term "battered women" into "battered women or men." The abuse victim being subjected to her first assault is a very different person from those who judge her. Prior to that first assault, the abuser has spent months or years using escalating tactics of mental abuse and intimidation, using "minor" physical aggression to control her before moving to actual physical assault. He undermines her psychologically before he ever lays a hand on her. By the first time the abuser strikes her, the victim is no longer like unvictimized people, and simply cannot react like them. Living in fear while undergoing constant psychological degradation each and every day changes her far beyond what outsiders can imagine. One way to make the complex process of victimization that abusers use to gain and maintain control over victims understandable to the average person, is to look at domestic violence through its parallel: the Stockholm Syndrome. The Stockholm or Hostage Syndrome is a "conversion" that occurs when an individual is terrorized while being held in captivity. Given certain specific circumstances, a hostage's view of his/her captor and his/her relationship to him changes 180 degrees from hatred to adulation. The best way to illustrate this psychological turn-around is through the 1985 terrorist takeover of Flight 847 in Europe. (Walker, 1989) After capturing the plane, the terrorist released the women and children - presumably to show what good guys they were. Left on the plane were two sailors and a group of wealthy American businessmen. The terrorists took the plane to the Beirut airport and held the men captive on the tarmac for ten days. During the ten days of captivity, the hostages had guns held to their heads and put in their mouths, and had their lives threatened. They watched their captors beat one of the sailors to death and dump his body out of the tail section of the plane. Most people remember this hijacking from that detail because the image was so vivid in the newspapers and on TV. During their captivity, one of the hostages was forced to read a political statement to the media from the cockpit of the plane. After their rescue, the hostages were flown to the U.S. When they got off the plane, waiting reporters rushed over to interview the man who had read the statement earlier in the week. They asked him only three questions: "Is it good to be home?" "Yes, it's wonderful." "What was it like?" "It was hell." "What were the kidnappers like?" "It's funny you asked that. They weren't bad people. They let me eat, they let me sleep, they gave me my life." Then he said something advocates and police officers have heard from hundreds of victims of abuse: "They have such potential to be good people." He went on to talk about how the terrorists had to do what they did to get publicity for their cause and how America mistreats third world countries. Within minutes, a government spokesperson appeared on camera to say that the kidnappers were not really "good people" - that the man who had been interviewed was a victim of the Stockholm Syndrome. (Walker, 1989) The Stockholm Syndrome was named for the terrorist take-over of a bank in Stockholm, Sweden, in August 1973 when three women and one man were held hostage for six days by two men. (Cooper, 1978) During that incident, when the police stormed the bank to rescue the hostages, the captives fought police at the side of the captors. Afterwards they blamed the police for endangering them, and one of the freed hostages became engaged to a jailed terrorist. This last occurrence led to the investigation and definition of the Stockholm Syndrome. Since then, following numerous hostage-takings, the world has seen former hostages: minimize their injuries refuse to participate in prosecuting terrorists visit their captors in jail recommend and pay for defense counsel ... ALL THE SAME THINGS BATTERED WOMEN DO. While hostages sometimes refuse to prosecute terrorists, hostages receive compassion and understanding. But all too often, when a battered woman is afraid to prosecute her batterer -- who, unlike terrorists, is out on the street knowing where the victim and her loved ones live -- her "refusal" to prosecute is used as an excuse by some members of the criminal justice system to refuse to protect her and prosecute him. The bond of interdependence between captive and captor called the Stockholm Syndrome develops "when someone threatens your life, deliberates, and doesn't kill you." (Symonds, 1980) The relief arising from the removal of the threat of death generates intense feelings of gratitude as well as fear, which combine to make captives reluctant to display negative feelings toward the terrorist. This is pathological transference, a kind of "conversion." Recognition that the terrorist/abuser has the power of life and death over them, combined with gratitude that he has let them live, causes a unique change in perspective -- the hostage/abuse victim and children come to see the captor/abuser as a "good guy," even a savior. "The victim's need to survive is stronger than his impulse to hate the person who has created his dilemma." (Strentz, 1980) Overwhelmingly grateful to terrorists for giving them life, hostages focus on their perceptions of their captors' kindness, not their brutality. Similarly, battered women convince themselves that the abuser is a good man whose violence stems from problems they can help him solve. Stockholm Syndrome develops when an individual is subjected to four conditions (Graham, et al., 1988) Condition One A person is held captive and cannot escape, so her or his life depends on the captor. The reality of captivity is easy to understand in the context of hostages or prisoners because the walls which confine them are made of brick or stone or wo