Excerpted from Grant Proposal
“Medical Advocacy Program for Rape/Crime Victims in Community Hospitals”
Researched and Written by Margie Thomas
Summer 2004
Community hospitals need specialized medical advocacy programs for victims of rape, trauma, and crime. While some human services organizations make available unpaid crisis volunteers at hospital emergency rooms, communities would benefit greatly from specially trained counselors in the unique physical and emotional symptoms immediately following a traumatic event. This type of program would help ensure that medical personnel do not unintentionally exacerbate PTSD symptoms, and that the victim feels safe and not further traumatized after an already intolerable experience of rape/crime.
Rape Crisis Centers have historically provided important assistance to individuals who are having forensic evidence collected. It is vitally important that sex offenders be prosecuted before they perpetrate again. Statistically the average rapist will rape 8 to 12 times before he is caught. If victims of sexual assault were to feel emotionally safe to visit hospital ER’s for time-sensitive forensic evidence collection and blood testing of possible ingestion of date rape drugs, law enforcement teams would be more effective at prosecuting and incarcerating offenders so that they would not be able to offend again.
Many communities do not have access to the Department of Public Health’s specialty program of Sexual Assault Nurse Examiner (SANE), currently present in large city hospitals, whereby professional nurses, physicians, and ancillary medical personnel have been trained in specific unique needs of rape survivors and crime victims. The same needs exist for victims in suburban and rural communities.
Medical Advocacy Programs would utilize immediate short-term cost-effective strategies to prevent long-term PTSD by providing specially trained counselors to act as liaisons in healthcare facilities between victims and medical personnel. Unless specially trained advocates are made available at ER’s to establish empathic support, victims are not likely to utilize medical services, the community-at-large is at risk of transmission of sexually transmitted diseases, at risk for assault by an un-apprehended perpetrator, and responsible for the prohibitive costs of later health-care interventions.
According to the latest trauma research an experience of sexual assault can adversely impact an individual for the rest of his/her live if he/she is not properly supported in the immediate aftermath of the traumatic event. (Van der Kolk, MD, Peter Levine, PhD) The complex debilitating psychiatric and physical symptoms in victims are directly linked to the neurobiological stress of overwhelming trauma, and it is increasingly evident that the quality of care provided in the time period immediately following assault is critical to whether or not an individual has the propensity to develop post traumatic stress disorder (PTSD) necessitating later long term expensive treatment. Prolonged stress disorders may result from factors that follow the initial rape/attack if providers are not sensitive to the unique needs of victims. Medical exams are not particularly pleasant to the average person but can be utterly devastating to a trauma victim. Even “normal” medical care may prolong the shock response, thereby impeding biological resolution. While medical staff members are expert in performing the technical aspects of evidentiary examinations and prophylactic treatments, many victims encounter personnel who are insufficiently trained on sexual assault issues, overworked, and hurried, and consequently insensitive. A perceived threat to the body integrity of the recently traumatized victim can increase the risk for PTSD. The busyness, lengthy delays, unnecessary procedures, noises, lights can prolong the anxiety in an already taxed nervous system of a rape/crime victim. Small everyday stresses combined with the traumatic event can sufficiently overwhelm the victim’s biological system to induce long-term effects on the neuro-chemical response to stress.
Since it is recently becoming known that prolonged stress is a precursor of chronic physical illness then it would be best that adequate time, space, and compassion be allowed for the emotional/physiological discharge phase so that the nervous system could naturally re-regulate. There is great variability in the expression of distress and one is better served by knowing the principles than by identifying sets of symptoms. Understanding individual experience as opposed to imposing one’s own template is the key for creating therapeutic rapport. Both psychologically and biologically the severity of traumatic events is related to their being intense, inescapable, uncontrollable and unexpected. The degree of control over events is an important bio-psychological modulator of the effect of stress on the brain. Since current theories point to the causal role of early distress in PTSD, the focus should be on reducing distress by all possible means even in a busy medical facility. Aside from life-saving treatment, the victim needs to know that she is in control and has choices about medical procedures.
The field of medical advocacy is in the fledgling stage but many organizations are implementing structures to help patients manage their health care. As recently as a generation ago, people would visit the same medical practice for many years. The doctors and nurses knew their patient’s comprehensive medical history. Making a house call, sitting at the bedside of a sick patient, comforting loved ones–these interactions were fundamental to a doctor’s job. Nowadays physicians have become specialized and over-scheduled. Hospital-appointed advocates coordinate patient services and often serve as mediators or educators for patients. These advocates, although helpful, must balance the needs of the patient with the needs and resources of the institution paying their salaries. Some institutions have created positions variously known as case managers or continuing care managers, who try to improve the outcomes for both the patient and the institution. Condition-based advocates fill another big void to certain patient populations. These advocates usually work through nonprofit organizations. For people with certain illnesses or diseases advocates help patients understand their diagnosis and treatment options and locate knowledgeable physicians. Patients are finding that their fears are being alleviated and are having positive experiences. Medical advocates are bridging the gaps in the system.
As authority figures, doctors, even with the best of intentions, are likely to elicit powerful feelings and behaviors of mistrust and fear and noncompliance in patients who have been violated. The medical advocate would help create better therapeutic alliances between providers and trauma victims by encouraging physicians and nurses to continuously inform the trauma victim about choices regarding exams and treatments, steps to be taken during tests and procedures, and medications given. Acting as an interpreter, mediator, and negotiator the medical advocate would effectively sort out the information between doctor and patient, offering options and valuing the patient as an expert in his or her own experience which would increase the sense of safety and encourage the patient to take an active role in recovery.
The medical advocate would help to create an atmosphere at the hospital emergency room that is conducive to completing the physiological trauma cycle to lessen risk of PTSD such as chronic depression, anxiety, and somatic symptoms. To prevent further traumatization to the victim’s sensitized biological system the medical advocate would help medical personnel to be tuned and responsive to the victim’s attempts to gain a degree of comfort and dignity during the exam. Due to the psychobiological stress in the victim’s nervous system, he/she may appear to overreact extremely to any noise or approaching stranger as if the assault is happening all over again, go into fight, flight or freeze reactions at the slightest provocation and may have intolerable anxiety to any reminder of the traumatic event. The job of the medical advocate would be to inform the victim and medical staff to be aware of these possible realities to hopefully lessen the number of triggers, and to normalize the perceived overreactions, such as hysterical laughter, excessive crying, and or shivering. Explanation by the advocate of possible oscillation of symptoms as appropriate responses to trauma would help victims to begin the process of healing. This information in turn would help busy personnel to do their jobs effectively, because when the victim feels validated he/she is more likely to comply with unpleasant, though necessary procedures to ensure his/her well-being.
Another facet of the medical advocacy program would be to refer rape victims exhibiting stress symptoms to counselors for psychological counseling, and to medical physicians and nurse practitioners expert in the physiological, neuro-chemical, biological symptoms as indicators of possible prolonged stress symptoms and able to prescribe pharmacological interventions. The early aftermath of traumatization offers a window of opportunity during which individuals at risk for developing chronic stress disorders can be identified and treated.
Many victims of rape are of low-income means, likely without medical insurance, and would need to be informed about resources. Social or cultural mismatch between helpers and victims may reduce the usefulness of treatment, so this is an issue to be addressed in many communities.
Summary
The period immediately following rape/crime is two-fold. There is the reality that for physical, legal, societal reasons a medical exam should be performed. There is also the need for victims to bring to resolution the trauma cycle in order to avoid PTS symptoms. Well-planned, compassionate care in the short term would prevent many years of emotional suffering by victims, and save money often spent by social service agencies, tax payers, and insurance companies, for long term treatment interventions.
Specially trained medical advocates would be versed in this two-fold plan, acting as liaisons between medical staff and the trauma survivors. Supportive and informative on the complexities of diagnosis/treatment of physical injuries and sexually transmitted diseases, forensic evidence collection, assessment of pregnancy, and use of testing procedures, the medical advocate would help the victim make informed choices from a myriad of options.
Secondary to the necessary physical procedures is that the medical advocate, who is trained in emotional well-being and psychological interventions, would create an atmosphere at the hospital that is conducive to completing the trauma cycle to avoid PTS symptoms. Even “normal” medical care may prolong the numbing freeze response, thereby delaying resolution. The process of lying still while being examined by a male physician needs to be as quick and painless as possible. Adequate time, space, and compassion need to be allowed for the emotional/physiological release phase of crying, shaking, shivering, moaning, nervous laughter, appropriate angry outbursts in order for the nervous system to re-regulate. Also, the busyness in hospital emergency rooms can prolong the hyper-arousal already in the nervous system caused by the trauma, thereby requiring an advocate to explain the importance of no lengthy delays, and the toll of unnecessary procedures.
While it is 100% possible to heal the effects of the initial trauma, the critical moments in the trauma aftermath, often taking place in hospital emergency rooms, determine whether the victim’s symptoms are cemented necessitating later expensive long-term treatment, or hopefully brought to resolution eliminating the nervous symptom’s physiological PTS imprint. With crucial “sensitive” medical intervention, victims would partake of medical services earlier, hence lessening and eliminating anxious/depressive symptoms, and saving money in the long run.
References: The Body Remembers by Babette Rothschild, Waking the Tiger by Peter Levine, The Body Keeps the Score by Bessel van der Kolk (See book and resource list).