First steps to treating rape-and a therapy story

I wrote this one to show you how badly I can blow a case, and to make suggestions to increase the odds it won't happen to you.


You people know me as therapydoc, but I do research and have a faculty appointment, too. One day I took a call, expecting it to be a client, but it was the dean asking me if I would please take on a funded project. There is this small problem, she tells me, of acquaintance rape.

Ultimately a new agency to treat college rape survivors off campus gets off the ground because of the project, and I get a paper out of it, present it to the annual meeting for the Council on Social Work Education.  It's about how social workers should be treating rape.

But the following story happened years before, when all I had to go on was my fairly extensive knowledge of cognitive behavioral and exposure therapies for anxiety and post traumatic stress.  I had used these tools for all kinds of abuse and assault, even for rapes that had happened in the past.

So I'm thinking I'm good talking to a rape victim, someone freshly violated .  Dispassionately, quietly, she tells me, "I was raped over the weekend."

Tell me everything.

"It was right outside your office, across the street at the park on Saturday night. I had parked my car on the street and left a party around mid-night. I saw a man in the car parked behind mine. Before I got into my car and knew what was going on, he grabbed me and pulled me into the park and . . ."

How awful. Did you report it?

"No. I was very embarrassed and I guess, shocked. I was a virgin. I just wanted my mother. I went home. We wanted to keep this private so we came to you for help. The insurance company said you could help me. You know this."

Uh, huh. I know a little. Do you mind telling me the story again? Try to remember everything.

She tells the story again. I am treating this like other trauma or crisis, going over the story, not because I care about the grisly details, but for the healing and warmth, the retelling in a safe place.  I think she'll suffer, this will haunt her, she will have nightmares, and want to warn her of this, begin the exposure therapy immediately, rather than get to know her as a person.  So I objectify her, too, treat her from the book.  I haven't even heard of Rape Trauma Syndrome, something unique, needing something different.  It's not in the DSM.

Assuming that there is meaning in the madness, the mandatory telling and retelling of the narrative, there is theory behind exposure therapy.  Flood the brain with details and it will tire of them.  People who haven't been raped retell silly stories to their friends about things that upset them, then tell them again to others, then retell them to friends-- and the stories are infinitely less traumatic. Somehow there's mastery in the retelling. We feel more control over the situation

I not only tell people to retell stories, but if they are traumatic, we'll do the retelling under very controlled circumstances, bit by bit, over many sessions, for cognitive exposure.  The cognitive in this type of intervention is a way of saying imagined, or visualized, in the brain. That's how therapy is, sometimes, very purposeful, behavioral.  And this helps quite a bit, structured technique.  Add a little EMDR, and you're golden.

Like I said, I'd done all kinds of cognitive behavioral therapy for trauma victims, and there's more than retelling.  We might do a rewrite of a trauma, for example, then repeat the rewrite over and over again in sessions. Sometimes the victim of an assault will bring in a friend or trusted relative and we'll talk about revisiting the scene of the crime, repeatedly, to allow the brain to integrate the idea that in fact, the perpetrator is no longer hanging around.  This type of therapy is useful for any type of assault.  It's useful for kids, too, who have been beat up, bullied.

But rape.  Treating rape.

Wrapping your head around so much stuff, you can't rush it, and sometimes all of that work does nothing to counter the idea that the perpetrator will come around again, eventually.


Rape can be devastating. It can affect a person's emotional and physical health (and will). Reproductive problems or pregnancy, sexually transmitted disease, broken arms, bruises, tears, concussions, even death happen. Emotional symptoms include depression, anxiety, sleeplessness, intense fear, flashbacks, nightmares, suspicion, hyper-vigilance, isolation, irritability, lack of concentration. Socially things can go crazy—victims hide from everyone, stop going to school, lose jobs. 

All of the above and more are consequences of rape.

This is not a short-term therapy.

I have to admit, when this young woman came to see me, I didn't know enough because I knew nothing about Rape Victim Advocacy.

If I had referred this young woman to a victim advocate program or had worked closely with one at the time, she might have continued her treatment, perhaps joined a support group, worked to become a survivor, to help other victims become survivors. 

Who knew?

Rape victim advocate agencies are state funded (in Illinois, relatively well funded at this first writing in 2006) and employ individuals who have often experienced rape themselves, who may have had therapy, surely had support and advocacy, and are now able to work with victims to empower and transform them into survivors.

Advocates call their clients frequently after the first contact, worry about them when they don't show up for appointments, ensure legal advocacy and medical intervention. In other words, they go the extra, extra mile.

Sure rape victims can use therapy and will need to recover from the physical-emotional onslaught they experienced. But I have to say, seriously, based upon my own knowledge and my experience treating that young woman four years ago, that this trauma calls for more than therapy. My client didn't return after the second visit.

Rape victim advocates are the best first step. All kinds of docs need to know this, not only therapists and psychiatrists, but primary care physicians, Ob-gynes, everyone. Get the word out.

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