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March/April 2017 Issue

Sexual Assault on Campus: Trauma-Informed Treatment
By Jennifer Rollin, MSW, LCSW-C
Social Work Today
Vol. 17 No. 2 P. 18

Every year, swarms of high school seniors wait in anxious anticipation to receive notice of whether they have been accepted or rejected by the colleges that they have applied to. Transitioning to college is an exciting time and for many brings up visions of Greek life, challenging academics, a buzzing social scene, and a transition to newfound independence. However, what many prospective college students don't think about is the high rates of sexual assaults that are occurring on campuses nationwide.

Experts agree that sexual assault on college campuses is highly prevalent. However, some also maintain that the taboo around discussing it is becoming less severe. Kelley Kitley, LCSW, owner of Serendipitous Psychotherapy, LLC, says, "Sexual assault is on the rise on college campuses. Survivors are also reporting it more, so our communities are becoming more aware."

Additionally, Lara Kassoff, PhD, a licensed clinical psychologist in private practice, who previously served as the trauma services coordinator at George Washington University, says, "Sexual assault has always occurred, but students are more aware of what it is and more willing to talk about it than previously. I have had students come to me and say that they did not realize what happened to them was sexual assault until much—sometimes years—later, when learning about it in a class, through campus outreach, or from a friend."

Even with the increase in conversation, recent research indicates that one in five women and one in 16 men are sexually assaulted while in college. That number may be even higher, as many survivors do not report the trauma that they endured. There are a variety of reasons why student survivors might choose to not report their assault. Many survivors feel shame and guilt surrounding what happened. Furthermore, some might worry that they will not be believed or that others may blame them. Additionally, Kassoff says, "It is often difficult to prove what happened, and the process of seeking justice through a trial may be retraumatizing for a survivor."

Further, it is critical that clinicians empower their clients to make their own decision regarding whether or not to report their assault. Additionally, if a clinician is not knowledgeable or interested in receiving further training in working with survivors of campus sexual assault, it is important that they refer to a specialist. When it comes to treating survivors of campus assault, it is critical that clinicians are knowledgeable about the prevalence, impact on survivors, and trauma-informed treatments.

Impact on Survivors
There are a variety of ways that student survivors may be impacted following the trauma that they experienced. It's important to note that everyone's experience of sexual trauma and subsequent reactions are different; however, there are some commonalities.

For instance, research suggests that college sexual assault survivors are more likely to experience mental health problems such as depression and PTSD. They are also at an increased risk for abusing drugs and alcohol. Kitley explains that in her clinical experience she has seen that "Survivors can be impacted by living in fear, isolation, decrease in academics, poor self-hygiene and over- or undereating, over- or undersleeping, depressive symptoms, anxiety and/or panic, PTSD, and replaying the incident, which can cause nightmares, flashbacks, [and] triggers."

Additionally, there are other unique factors to take into consideration when it comes to working with survivors of sexual assault on college campuses. Kassoff says, "Survivors on college campuses are in a unique situation in that they live in a very small community. A large majority of survivors have been assaulted by someone they know. This could be someone in their dorm [or] a common class, or [could] even [be] a friend. It is likely that they may run into their perpetrator just going about their day, in the cafeteria, walking across campus, or at a party. This contributes to a sense of fear and lack of safety for survivors."

Kitley explains that other impacts on a sexual assault survivor on a college campus could include "Having to visibly see where she was attacked and the association of negative feelings every time she passes the location of where the incident took place."

Furthermore, survivors may be afraid of comments and judgment they might receive from the college community. Anchal Khanna, MS, LCMFT, a psychotherapist at Sequence Counseling and Consulting Services, says, "Depending on the powerful position/influence of the 'alleged perpetrator,' it could impact friendships, support, and alliances, especially if the alleged perpetrator and survivor share mutual friends. In some cases, if a report hasn't been made, survivors may be in the same classes as the alleged perpetrator. If they choose to drop those classes, it will once again give the alleged perpetrator power." Kitley says that these circumstances often result in "changes in relationships as well as an overall lack of trust."

Trauma-Informed Treatment
When working with student survivors, it is critical to utilize trauma-informed models of treatment. It's important to note that regardless of the treatment that is used, one of the initial steps in working with student survivors is to establish a sense of safety and to build trust within the therapeutic relationship.

Additionally, there is no one-size-fits-all approach to treatment; a variety of therapeutic modalities have been shown to be helpful in treating survivors of trauma. The following are some of the top therapeutic modalities that experts in the field recommend for use with student survivors:

• Cognitive Behavioral Therapy (CBT). The primary aim of CBT is to examine how an individual's thoughts impact their subsequent feelings and behaviors. Thus, CBT focuses on challenging any maladaptive thinking patterns and working to replace them with more helpful thoughts in order to impact one's feelings and behaviors.
Numerous studies have examined the use of CBT in treating trauma survivors and many have found significant improvement from pre- to posttreatment.
Kitley explains that she uses CBT in her work with student survivors, stating, "Often survivors blame themselves, and we work through restructuring the thoughts with a nonblaming/nonshaming approach."

She notes "automatic negative thoughts might include: 'If I wasn't intoxicated this never would have happened,' or 'If I would have just said no more aggressively, this would have never happened.' We replace the automatic negative thoughts with more empowering/reparative thoughts such as, 'This was not my fault,' and 'I didn't do anything wrong.'

Khanna explains that she utilizes CBT in a variety of ways when working with student survivors, such as providing psychoeducation about symptoms of posttraumatic stress and aiding student survivors in challenging any thoughts that provoke anxiety and decrease their sense of personal agency. She also uses relaxation and anxiety management strategies with survivors, which helps them to learn how to manage symptoms before delving into the narrative of the assault.

• Narrative Therapy. Narrative therapy is another treatment that many practitioners who work with student survivors find to be helpful. Narrative therapists help clients to objectify problems, place them within a larger sociocultural context, and create room for other stories.

In this modality, the therapist and client work together to create and build upon alternative storylines. Additionally, narrative therapy is an approach that focuses on empowerment and helping individuals to have a greater sense of agency in their lives.

Khanna explains that through her use of narrative therapy with student survivors she aims to "assist the client in recognizing the relationship between socialized messages, misconceptions of sexual assault, its impact on the survivor, and how that can make it hard to report." She explains that she uses narrative therapy to help clients to "contextualize their responses to the assault (e.g., freezing and not fighting back, not reporting, not telling anyone)" as well as to "validate their responses, which places increased accountability on the alleged perpetrator."

Kitley also uses narrative therapy when working with student survivors. She states, "In treatment, when the client engages in narrative therapy, they have the opportunity to share their experience from beginning to end as freely as they feel comfortable in a safe environment. "Additionally, it is important to ensure that as a therapist you are empowering the client rather than pushing your own agenda or time frame for disclosure. Kitley explains, "As a clinician, it's important to be aware of when the client is ready and not to push to avoid over- or retraumatization."

• Eye Movement Desensitization and Reprocessing (EMDR). EMDR therapy is an evidence-based approach to treating survivors of trauma. The primary aim of EMDR is to help people heal by transforming the negative thoughts, feelings, and physical sensations associated with trauma.

Sheryl Aaron, LICSW, EMDR-C, a psychotherapist in private practice, utilizes EMDR in her work with student survivors. After a "period of stabilization and resourcing," Aaron explains, "clients identify a picture that represents the worst part of what they remember from the assault. They also identify the negative thoughts and messages about themselves that are linked with that memory. For some clients, it may be 'I'm not safe.' For others, it may be something like 'It's my fault.'"

Aaron continues, "They're then asked to bring up the picture, the negative thought, the emotions, and the physical feeling they're experiencing, and watch a light moving left and right for a short period of time. This left-to-right, or bilateral, eye movement is thought to mimic rapid eye movement sleep, during which experiences are processed and memories are consolidated in the brain. We then repeat this process until the client's distress about the memory has dissipated, and they are able to remember the assault without feeling as if they're reexperiencing it."

Aaron says, "Since the goal of EMDR is not just symptom reduction but [also] helping clients develop a new narrative about the trauma, clients also choose a new, positive thought about themselves that they want to link with the memory. When clients are done in EMDR, instead of 'It's my fault,' they are able to think and feel that statements like 'It's not my fault,' or 'I did the best I could,' are true." She notes that while it's different from more traditional treatments, she has found EMDR to be highly effective in her work with student survivors.

• Trauma Incident Reduction (TIR). TIR is a rapid form of evidence-based treatment that has been demonstrated to be effective in helping survivors to resolve symptoms of posttraumatic stress.

TIR involves an imaginal desensitization procedure, which uses guided imagery to help those struggling with symptoms of posttraumatic stress. TIR is a structured and client-centered approach to trauma treatment.

Rachel B. Singer, LCSW-C, MSW, a psychotherapist at The Mindful Heart, LLC, says she often uses TIR in her work with student survivors. Singer explains that "TIR creates a safe space free of distractions, judgment, and interpretations where clients are able to begin repeatedly viewing/processing a past traumatic incident that has previously been repressed."

Singer explains, "Sessions typically run between 90 and 120 minutes. Throughout a TIR session, the therapist is helping to facilitate a client's examination and resolution of a past traumatic incident. Resolution is typically achieved in one or two sessions depending on the specific incident and the symptoms experienced by the client."

Challenges in Treating Student Survivors
Even with effective treatment strategies, treating student survivors is complicated and comes with its own unique challenges. One such challenge is that survivors might be afraid of encountering the perpetrator on campus or at social events. Thus, it is important that clinicians who are working with student survivors take this into account. Kassoff explains, "Student survivors are at risk of either isolating themselves socially or exposing themselves to triggering situations. Social life at colleges often revolves around parties and drinking, which are typically the circumstances where sexual assaults occur. Thus, it is important to help students to reengage socially in ways that feel safe and supportive."

Additionally, Kassoff notes that "Students are often reluctant to take time off from school to engage in treatment, but this is important to consider depending on how the survivor is coping and what their needs are for recovery. This can be particularly difficult if student survivors do not want to disclose their assault to their parents." Students who recognize that they need to take time off from school in order to receive treatment may be reluctant to do so due to a fear of stigma and judgment from others."

Khanna adds that another challenge in terms of engagement in treatment is that, "Due to the overwhelming visceral reactions, survivors may not follow through with treatment for fear of it triggering those emotions." Thus, she says, "It is critical to not engage in discussing the details of the trauma of sexual assault without helping the client develop an internal and external sense of control. This involves teaching them relaxation techniques, grounding, and containment strategies and developing a plan of keeping themselves safe."

Additionally, student survivors may be struggling with a variety of mental health issues, such as PTSD, eating disorders, alcohol and drug use, and self-harm. Therefore, it is critical that they are evaluated and appropriately treated for any mental health issues they may be experiencing.

Treatment Considerations
It is critical that student survivors are met with a nonjudgmental and compassionate approach. Often, survivors struggle with feelings of shame and self-blame. Thus, it is important that clinicians do not perpetuate or reinforce these beliefs.

Khanna explains, "It will be difficult for the survivor to heal if the clinician has trouble believing them or might suggest that the victim was to blame for the sexual assault in some way. This will only serve to revictimize the survivor."

Furthermore, when working with student survivors, establishing a sense of safety and trust is key. Aaron says, "Initially, this includes giving the client permission to sit wherever they need to sit in order to feel safe; to have the door open, if needed; and to bring someone or something to session that gives them a sense of security. Some clients may need to come during daytime hours if the assault happened at night. Or you may need to help them identify ways they can modify the trip to and from your office in order to feel safer."

Additionally, it is helpful for clinicians to inform students about their right to report the assault, as well as reporting options. However, it is also imperative that survivors are empowered to make their own decision regarding whether or not to file a report.

Khanna says, "During the first session, it is important that the clinician informs the clients about the university Title IX requirements, before they refer them to other offices on campus. This gives the client a sense of personal agency and choice and complete informed consent. Counselors are exempt from reporting sexual assaults to the Title IX officers, but other faculty staff are mandated to make that report."

Singer shares some situations that therapists often encounter when working with survivors of campus sexual assault. She explains, "It is key in these situations that the therapist respects the dignity and autonomy of their client.

• Our clients may or may not be at a place where they are ready to cut ties/break off the relationship with the perpetrator. 

• Our clients may not be interested in pursuing any kind of legal action against their perpetrator (whether through the school or with law enforcement).

• Our clients may not be ready to talk about the incident in detail or share any aspect of the assault right away (if at all)."

Additionally, it is critical that clinicians "meet the clients where they are" in regard to their experience and decisions following the trauma. It is also important that clinicians validate their client's feelings and help to normalize any trauma responses that they may be experiencing.

Working with survivors of trauma, including student survivors, can bring unique challenges; however, it also can be highly rewarding. Ultimately, as social workers it is important that we are aware of our areas of specialty as well as our limitations so that we can ensure our clients receive appropriate treatment.

When working with student survivors, it is helpful to emphasize that healing is possible. With access to trauma-informed treatment and support, student survivors can discover a sense of empowerment and go on to live productive and meaningful lives.

— Jennifer Rollin, MSW, LCSW-C, is a psychotherapist in Rockville, MD. She specializes in treating adolescents, survivors of trauma, and individuals with eating disorders.