Victims of Rape: Repeated Assessment of Depressive Symptoms

Transcription

1 Journal of Consulting and Clinical Psychology 1982, Vol. 50, No. 1, Copyright 1982 by the American Psychological Association, Inc X/82/ $00.75 Victims of Rape: Repeated Assessment of Depressive Symptoms Patricia A. Resick Medical University of South Carolina Beverly M. Atkeson, Karen S. Calhoun University of Georgia Elizabeth M. Ellis University of Georgia This study investigated depressive symptoms in rape victims for 1 year following their assaults. One hundred fifteen victims were seen approximately 2 weeks after the assault and at 1, 2, 4, 8, and 12 months postrape. A matched control group of nonvictims was seen at the same intervals. To control for the effects of repeated testing, three additional groups of victims were assessed only once at 2, 4, or 8 months postrape. All participants completed the Beck Depression Inventory and were administered the Hamilton Psychiatric Rating Scale for Depression. Both the self-report measure and the interviewer-rated measure of depression showed similar results. Depressive symptoms were significantly higher in victims of rape than in nonvictim controls following the assault. By 4 months postrape, depressive symptoms in the victim group had diminished, and the victims were no longer significantly different from the nonvictim control group. Results from the single-testing victim groups indicated that repeated assessment affected the self-report measure somewhat but not the interviewer-rated measure. Variables reflecting prerape functioning were more predictive of continued problems with depressive symptoms than were demographic variables or variables associated with the rape and its aftermath. Most of the initial studies on the psychological sequelae of rape reported fear and anxiety as the predominant symptoms (Burgess & Holmstrom, 1974a, 1974b; Notman & Nadelson, 1976; Queen's Bench Foundation, 1976; Sutherland & Scherl, 1970). However, in describing victim reactions, depressive symptoms (e.g., sleep and eating disturbances, guilt, shame, feelings of worthlessness, irritability, fatigue, decreased libido, and suicidal ideation) have also been reported frequently (Katz & Mazur, 1979). Recently, Frank, Turner, and Duffy (1979) used an objective self-report assessment in- This research was supported by National Institute of Mental Health Grant MH29750 from the National Center for the Prevention and Control of Rape. The authors would like to thank Virginia Looney, Karen Johnson, and Diane Whitaker for their help with data collection and Patrick W. Edwards and Jorge Mendoza for help with data analysis. Thanks are also due to the Grady Hospital Rape Crisis Center staff for their cooperation in conducting this study. Requests for reprints should be sent to Karen S. Calhoun, Department of Psychology, University of Georgia, Athens, Georgia strument to examine depressive symptoms in victims of rape 1 to 4 weeks postassault. Of the 34 victims assessed, 24% exhibited mild levels of depressive symptoms, 24% moderate levels, and 20% severe levels. Because the victims were tested only once within 1 month of the assault, it is not known whether they continued to exhibit depressive symptoms in the months following the assault or if their symptoms increased or decreased. Conclusions concerning depressive symptoms in rape victims were also limited because the study did not include a nonvictim comparison group. The primary purpose of our study was to determine the incidence, severity, and duration of depressive symptoms in victims of rape. Both a self-report measure and an interviewer-rated measure of depression were used to compare symptoms of rape victims with symptoms of a nonvictim control group. Depressive symptoms were assessed immediately after the assault and at five additional time periods in the year following the assault. To control for the effects of repeated 96

2 testing, three additional groups of rape victims were assessed only once at 2, 4, or 8 months postrape. In addition, a number of variables, including demographic variables, assault variables, and prerape functioning variables, were examined to determine their predictive value with respect to depressive symptoms in rape victims. Method Research Participants Victim group. The participants in the victim group were female rape victims initially seen at the Grady Memorial Hospital' Rape Crisis Center in Atlanta, Georgia. Victims, aged 15 years and older, learned of the study from a packet of materials they received in the emergency room and by a letter they received several days following the assault. Of the approximately 1,000 victims informed of the study "during the 14 months of data collection, 115 agreed to participate. The victim participants ranged in age from 15 to 71 years, (M = 25.6). Fifty-three percent of the victims were between 20 and 30 years old. Sixty-three percent were. black and 37% white. Socioeconomic level was measured by the Myers and Bean (1968) classification system: 1% were upper class, 2% were upper-middle class, 14% were middle class, 46% were lower-middle class, and 38% were lower class (M = 4.1 on a scale of 1 to 5). Thus, most victim participants were young, poor, and uneducated. Demographically, the victim participants were similar to the general victim population seen at the Rape Crisis Center and to previously reported samples of urban rape victims (Katz & Mazur, 1979). Descriptive aspects of the victim participants' assaults have been published elsewhere (Resick, Calhoun, Atkeson, & Ellis, 1981). Control group. The participants in the control group were 87 women recruited from social service agencies, the Young Women's Christian Association, and public housing projects. They were asked to participate in an investigation of life stresses. Controls were comparable with the victim participants in terms of age (M = 28.6 years), race (68% black, 31% white), and socioeconomic level (M = 3.8). Single-testing victim groups. The participants in the three single-testing victim groups were female rape victims initially seen at the Grady Memorial Hospital Rape Crisis Center. All eligible victims who had been assaulted 2, 4, or 8 months previously and who could be located were contacted by letter and asked to participate in one assessment session. The 2, 4, and 8 month singletesting victim groups included 22, 26, and 24 victims, respectively. Multivariate analysis of variance (MAN- OVA) comparing the age, race, and socioeconomic level of the victims in the single-testing victim groups to those of the larger victim group was not significant. Characteristics of the rapes (e.g., amount of violence, number of assailants, sex acts performed, assault duration) were also similar across groups. DEPRESSIVE SYMPTOMS IN RAPE VICTIMS 97 Assessment Measures I Beck Depression Inventory (BDI). The BDI (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) is a selfadministered pencil-and-paper questionnaire. It consists of 21 items related to common symptoms of depression. Each item has four symptom statements ordered in increasing severity and scored from 0 to 3. For each item the respondent selects which of the four statements best describes the way she feels at the present time. Scores on each item are added, with higher scores indicating more severe depression. Adequate reliability and validity data for this inventory were reported by Beck (1967). Hamilton Psychiatric Rating Scale for Depression (HPRS). The HPRS (Hamilton, 1960; Mowbray, 1972) is a rating scale developed for use by an interviewer in a semistructured interview. It consists of 17 items related to common symptoms of depression. Each item is defined in terms of increasing severity and scored from 0 to 2 or 0 to 4. Scores on each item are added, with higher scores indicating more severe depression. Interrater reliabilities for the total score have been reported to be.80 to.90 (Hamilton, 1960). Interview data. A structured interview was used to assess the assault and its 2-week aftermath. Three areas were assessed. One, labeled assault trauma, consists of 20 items pertaining to the amount of violence involved, the amount and kind of sexual assault to the victim, and other fear-engendering elements. The second, labeled assault support, consists of 7 items relating to the number of people in whom the victim confided and the responses of those in her support network. The third, called assault reaction, consists of 20 items regarding immediate problems experienced by the victim and shifts in her life-style brought about by the rape, such as nightmares, breaking up with a boyfriend, and moving. Response choices for each question were ordered in increasing severity. Scores for each area were obtained by summing the response choices and dividing by the number of items in that area. A structured interview was also used to assess the victim's personal and interpersonal functioning prior to the rape (for controls, prior to participation in the study). Areas assessed.included (a) transience', (b) school/job adjustment, (c) social network, (d) sexual adjustment, (e) history of physical/sexual abuse and victimization in violent crime, (f) physical health, (g) alcohol and drug use, (h) phobias/anxiety attacks and obsessive/compulsive behaviors, (i) paranoia and anger/hostility, (j) depression and history of suicidal behavior, and (k) psychiatric treatment history. Except where noted as history, functioning was assessed for the 1-year period prior to the rape (for controls, prior to participation in the study). Each area assessed inpluded 3 to 10 questions, with response choices ordered in increasing severity. Scores for each area were obtained by summing the response choices and dividing by the number of items in that area. ' Procedure Research participants in the victim and control groups were assessed at six intervals postrape: 2 weeks, 1 month, 2 months, 4 months, 8 months, and 12 months. Single-

3 98 ATKESON, CALHOUN, RESICK, AND ELLIS testing victims were assessed only once: at 2 months, 4 months, or 8 months postassault. During each assessment, participants gave written informed consent and filled out a battery of self-report measures. Participants were then administered the HPRS in a semistructured interview. The interviewers were not aware of the participants' BDI scores at the time of the HPRS interview and rating. In 21% of the interviews, a second interviewer was present and independently scored the HPRS as a measure of interrater reliability. At the initial assessment, participants were given the structured interview to assess their prior adjustment, and victim participants were given an additional structured interview concerning the assault and its aftermath. The interviews were conducted by a female clinical psychologist or a female research assistant trained and experienced in interviewing rape victims. Each assessment lasted l'/2 to 2 hours. Participants were reimbursed for the time and expense of participating in the study. Results Longitudinal Analyses A two-way ANOVA (Groups X Assessments) with repeated measures on one factor was computed for the sample of victim («= 43) and nonvictim controls (n = 21) who attended all six assessment sessions. Analysis of the BDI scores showed significant differences between victim and nonvictim groups, F(\, 62) = 8.80, p <.01; across assessment periods, F(5, 310) = 17.87, p <.001; and for the interaction between these two factors, F(5, 310) = 6.55, p<.001. Mean BDI scores for victims and controls at each assessment are shown in Figure 1. Newman-Keuls analyses indicated significant changes in victims' BDI scores between 2 weeks to 1 month, between 1 to 2 months, and between 2 to 4 months postassault (p <.05). Victims' BDI scores were significantly higher than those of controls at 2 weeks, 1 month, and 2 months postassault (p <.05) but not at subsequent assessments. A two-way ANOVA (Groups X Assessments) of the HPRS scores with repeated measures on one factor also showed significant differences between victims and nonvictim controls, F(l, 52) = 9.36, p<.01; across assessments, F(5, 260) = 10.39, p <.001; and for the interaction between these two factors, F(5, 260) = 4.46, p<.001. Mean HPRS scores for victims and controls at each assessment are shown in Figure 2. Newman-Keuls analyses indicated no sig LJ 16 OL 8 l4 " 12 z < 10 \ B a CD o o Victims Victims (total sample) A 1\ Controls A Controls(totalsample) D Single Testing Victims MONTHS Figure 1, Mean scores on the Beck Depression Inventory for victims and controls at each assessment period. nificant improvement in victims' HPRS scores after 4 months postassault (p <.05). Victims' HPRS scores were significantly higher than those of nonvictim controls at 2 weeks, 1 month, and 2 months postassault (p <.05) but not at subsequent assessments. Interrater reliability obtained for 21% of the HPRS interviews (n = 182) by computing the Pearson product-moment correlation coefficient was UJ g" o co LJ S < I O O Victims Victims (total sample) A A Controls A Controls (total sample) D MONTHS Single Testing Victims 9 10 Figure 2. Mean scores on the Hamilton Psychiatric Rating Scale for Depression for victims and controls at each assessment period.

4 DEPRESSIVE SYMPTOMS IN RAPE VICTIMS 99 Cross-Sectional Analyses Because of problems with missing data commonly associated with longitudinal studies, the above analyses did not include the victim and control participants who failed to attend all six assessment sessions. To include these participants, one-way ANOVAS comparing the victims and nonvictim controls at each assessment period were computed. Multiple ANOVAS were necessary because of the different composition of participants at each assessment period. These comparisons yielded results similar to those with the repeated-measures ANOVAS. Analyses of the BDI indicated that victims scored significantly higher than nonvictim controls at 2 weeks, 1 month, and 2 months postassault, F(l, 178) = 24.26, p<.001; F(l, 176) = 14.10, p<. 001; F(l, 166) = 11.56, p <.001, respectively, but not at subsequent assessments. With the HPRS, victims' scores were significantly higher at 2 weeks, 1 month, 2 months, and 4 months postassault, F(l, 175) = 61.00, /x.ool; F(l, 174) = 23.22,p<.001;F(1, 163)= 10.54,p<.001; and F(l, 152) = 6.64, p <.01, respectively, but not at 8 months and 12 months postassault. To determine whether the victims who failed to complete the study differentially affected the results, analyses were computed comparing the scores of victims who dropped out with those who attended all six assessment sessions. No significant differences were found on the BDI or HPRS scores for these two groups at the first assessment. Demographic variables (i.e., age, race, socioeconomic level) and rape characteristics for these two groups were also not significantly different. Effects of Repeated Assessment To assess the effects of repeated testing, one-way ANOVAS comparing each singletesting victim group to the larger victim group at their respective assessment periods were computed for both the BDI and the HPRS scores. With the BDI, a significant difference was found for the 4-month group only, F(l, 117) = 13.41,p<.001. However, the 2-month and 8-month comparisons approached traditional levels of significance, F(l, 112) = 2.99, p<.09, and F(l, 102) = 3.57, p <.06, respectively. On the HPRS, no significant differences were found between the single-testing victim groups and the larger victim groups. Incidence and Severity of Depressive Symptoms To determine the incidence and severity of depressive symptoms in victims, BDI and HPRS scores were divided into four groups (i.e., normal, mild, moderate, and severe levels) based on cutoff scores suggested by Beck (1967) and Mowbray (1972), and the percentages of participants in each group were computed. 1 On the BDI initially, approximately 75% of the victims reported mild to severe levels of depressive symptoms. At 1- year postassault, 26% were still reporting mild to severe levels compared to 17% of the controls. Although the HPRS norms are more stringent, the percentages of victims exhibiting depressive symptoms show similar changes over time. Initially, 57% showed mild to severe symptoms, whereas at 1 -year postassault, only 14% did so. Correlations between BDI and HPRS scores at each assessment ranged from.70 to.77 with a mean of.73. Multiple Regression Analyses Although victims and controls did not differ significantly by 4 months postassault, a sufficient number of victims continued to exhibit depressive symptoms at 4, 8, and 12 months postassault to warrant examination of possible contributing factors. Therefore, a series of stepwise multiple regression analyses were computed to determine which variables were predictive of depressive symptoms in victims after 2 months postassault. For the initial analyses, six variables were selected because they were representative of information typically available to rape-crisis counselors. These six predictor variables 1 The percentages of victims and controls at each severity level for the six assessments can be obtained from the authors.

5 100 ATKESON, CALHOUN, RESICK, AND ELLIS (three demographic variables age, race, and socioeconomic status and three rape variables assault trauma, assault support, and assault reaction) were entered into the multiple regression analyses for the victims' BDI scores (criterion variable) at 4, 8, and 12 months postassault. At 4 months postassault, victim BDI scores were significantly predicted by assault support and assault reaction, F(2, 90) = 7.26, p <.001, combined R 2 =.14. At 8 months postassault, victim BDI scores were significantly predicted by assault support, F(l, 78) = 5.89, p <.05, R 2 =.07. At 12 months postassault, victim BDI scores were significantly predicted by assault reaction, age, and socioeconomic status, F(3, 62) = 4.45, p <.01, combined R 2 =.18. In the second set of stepwise multiple regression analyses 11 predictor variables from the structured interview assessing prerape functioning were used with victim BDI scores again as the criterion variable. At 4 months postassault, physical health problems, depression and suicidal history, and sexual adjustment prior to the rape significantly predicted victim BDI scores, F(3, 79) = 12.19, p <.001, combined R 2 =.32. At 8 months postassault, anxiety attacks and obsessive-compulsive behaviors prior to the rape significantly predicted victim BDI scores, F(l, 67) = 8.42, p <.001, R 2 =.20. At 12 months postassault, anxiety attacks/ obsessive-compulsive behaviors, psychiatric treatment history, and physical health problems prior to the rape significantly predicted victim BDI scores, F(3, 55)= 12.94, p<.001, combined,/? 2 =.41. Discussion The results of the present study indicate that victims of rape do exhibit depressive symptoms following the traumatic event of the assault and that these symptoms, as measured both by self-report and interviewer ratings, are significantly greater than those exhibited in a sample of nonvictims. Furthermore, the average duration of victims' depressive symptoms is similar to that of outpatient reactive depressions; that is, the symptoms diminish to normal levels within 2 to 4 months (Weissman & Paykel, 1974). Counselors and therapists working with victims in the first months following rape should be sensitive to the probable presence of depressive symptoms. It may be possible to overlook these symptoms when the most notable symptoms exhibited by victims are fear and anxiety (Burgess & Holmstrom, 1974a, 1974b). The effects of repeated assessment on victims' depressive symptoms are not clear. Victims' scores on both the BDI and HPRS improve with the passage of time. However, with the BDI, periodic participation in research appears to facilitate the reduction of depressive symptoms; the BDI scores of the single-testing victims decrease over time but not at a rate comparable to those repeatedly assessed. As measured by the HPRS, the same periodic participation has no effect on the course of the victims' adjustment; repeatedly assessed victims and single-testing victims obtain similar scores at comparable time periods. Several hypotheses concerning these differences are plausible. Some of the reduction in the BDI scores of the repeatedly assessed victims could reflect regression toward the mean, demand characteristics of participation in the study, or a therapeutic effect of the assessment procedures. Although this was clearly not a treatment study, several victims voluntarily expressed the belief that participation had been helpful to them. Possible explanations concerning the elevated BDI scores (relative to the HPRS scores) of the single-testing victims are not as numerous. The single-testing victims more often reported that they had not discussed the rape with anyone. Participation in the assessment for many was the first time or one of the few times they had shared their thoughts and feelings concerning themselves and their rapes. Although the BDI instructions clearly asked the respondent to select the statements that best described the way she was feeling at the present time, the self-reported symptoms of single-testing victims may have been magnified and more representative of the cumulative distress experienced by the victims since the rapes. Perhaps the interviewers, through careful questioning with the HPRS, were able to assess more accurately the severity of the single-testing victims' current depressive symptoms.

6 Although the depressive symptoms of most victims return to normal levels by 4 months postrape, a number of victims con-. tinue to exhibit depressive symptoms at 4, 8, and 12 months postrape. Predicting who these victims will be is of importance to counselors and therapists working with rape victims. The level of trauma present in a rape situation is not predictive of continued problems with depressive symptoms. Instead, the extent of the victim's immediate problems following the assault and the response of friends and family to the victim are important. Crisis counseling that focuses on reducing the amount of disruption experienced by the victim and on increasing the quality of the victim's social support may directly affect the duration and severity of a victim's depressive symptoms. Twelve months postrape, the demographic variables of age and socioeconomic status are also predictive of depressive symptoms, with older and poorer women experiencing more problems. Because of their economic situation, poorer victims live in high-crime areas with the continued risk of victimization. This stress combined with other stresses associated with poverty may retard recovery or may separately contribute to the occurrence of depressive symptoms. Explanations concerning the relationship between age and depressive symptoms are not immediately obvious, Although some of the victims in the study were middle-aged or older, 75% were below the age of 30; thus, the age range was restricted. It may be that older victims are more likely to hold traditional beliefs concerning rape and victim blame, are more likely to restrict their activities following rape, have less social support, or are less resilient. Although demographic variables and variables associated with the rape and its aftermath are somewhat predictive of continued problems with depressive symptoms, variables associated with prerape functioning yield much stronger relationships. Women with psychological problems prior to the rape, and in particular problems with anxiety, obsessive-compulsive behaviors, and depression, are more likely to experience a slower recovery with respect to depressive DEPRESSIVE SYMPTOMS IN RAPE VICTIMS 101 symptoms. In addition, problems with sexual relationships and poor physical health prior to the rape may adversely affect the duration and severity of depressive symptoms. Burgess and Holmstrom (1974b, 1978) suggested from tljeir interview data that physical and/or psychiatric conditions prior to the rape compounded the victim's initial reaction and inhibited her general recovery during the 4 to 6 years following the rape. Research on crisis intervention in general also indicates a relationship between pre and postcrisis functioning (e.g., Gottschalk, Fox, & Bates, 1973; Gottschalk, Mayerson, & Gottlieb, 1967). Counselors and therapists who work with victims should be aware of these prerape variables and perhaps address them directly in their therapeutic interventions with victims. To date, the major emphasis of victim research has been on the assessment of the victim's response to rape, Few studies have attempted to predict victim reaction based on events surrounding the rape, demographic information, or information concerning prerape functioning. The results of the present stu.dy suggest that the victim's level of prerape functioning is of much greater importance than has been reported previously. At present the results of the multiple regression analyses should be considered exploratory. Although the victims who chose not to participate were similar demographically to those who did participate, the sample may have been biased in ways not immediately obvious. In addition, the variables selected by the multiple regression analyses need to be cross-validated to ensure that they do not represent spurious relations. Further examination of variables reflecting prerape functioning should increase our understanding of individual differences in psychological reactions to rape, identify victims at risk for severe and/or prolonged reactions, and possibly suggest intervention strategies to help these victims. References Beck, A. T. Depression; Clinical, experimental, and theoretical aspects. New York: Harper & Row, Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. An inventory for measuring depres-

7 102 ATKESON, CALHOUN, RESICK, AND ELLIS sion. Archives of General Psychiatry, 1961, 4, Burgess, A. W., & Holmstrotn, L. Recovery from rape and prior life stress. Research in Nursing and Health, 1978, 7, Burgess, A. W., & Holmstrom, L. L. Rape trauma syndrome. American Journal of Psychiatry, 1974, 131, (a) Burgess, A. W., & Holmstrom, L. Rape: Victims of crisis. Bowie, Md.: Robert J. Brady, (b) Frank, E., Turner, S. M., & Duffy, B. Depressive symptoms in rape victims. Journal of Affective Disorders, 1979, /, Gottschalk, L. A., Fox, R. A., & Bates, D. E. A study of prediction and outcome in a mental health crisis clinic. American Journal of Psychiatry, 1973, 130, Gottschalk, L. A., Mayerson, P., & Gottlieb, A. Prediction and evaluation of outcome in an emergency brief psychotherapy clinic, Journal of Nervous and Mental Disease, 1967, 144, Hamilton, M. A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry, 1960, 23, Katz, S., & Mazur, M. A. Understanding the rape victim: A synthesis of research findings. New York: Wiley, Mowbray, R. M. The Hamilton Rating Scale for Depression. Psychological Medicine, 1972, 2, Myers, J. K., & Bean, L. L. A decade later: A followup of social class and mental illness. New York: Wiley, Notman, M. T., & Nadelson, C. C. The rape victim: Psychodynamic considerations. American Journal of Psychology, 1976, 133, Queen's Bench Foundation. Rape victimization study. San Francisco: Author, Resick, P. A., Calhoun, K. S., Atkeson, B. M., & Ellis, E. M. Social adjustment in victims of rape. Journal of Consulting and Clinical Psychology, 1981, 49, Sutherland, S., & Scherl, D. J, Patterns of response among victims of rape. American Journal of Orthopsychiatry, 1970, 80, Weissman, M. M., & Paykel, E. S. The depressed woman: A study of social relationships. Chicago: University of Chicago Press, Received June 29, 1981