Clinical and theoretical implications

This research has a number o f implications both for current conceptualisations o f PTSD, and for clinicians working with survivors o f drug-rape. Firstly, it demonstrates, importantly, that drug-rape survivors experience chronic and severe symptoms of anxiety, depression and PTSD, which are comparable in both quality and quantity to other trauma populations. Furthermore, drug-induced loss o f consciousness during the rape, and consequent anterograde amnesia did not lessen the severity o f posttraumatic symptomatology in this study. These results indicate the need to make psychological therapy services available to survivors o f drug-rape, and demonstrate the long-term, detrimental impact o f this type o f assault on survivors’ emotional wellbeing.

A second implication is regarding DSM-IV criteria for PTSD diagnosis. Freedy et al (1994) found successful access to counselling to be positively associated with a DSM-IV diagnosis. A similar association is also found between diagnosis and criminal compensation. However, over a third of participants did not fulfil DSM-IV criterion A1 and/ or A2 for PTSD due to the moderating effects o f the drugs during rape, and therefore could not receive a diagnosis of PTSD. This suggests that achieving legal and clinical remediation might therefore be more difficult for survivors o f drug-rape. This seems unjust, given that these participants reported posttraumatic symptomatology (intrusions, arousal and avoidance) of comparable severity to those who met DSM-IV criterion A, and to ‘non-drug’ PTSD populations. A more accurate measure of the impact of drug- rape, both in clinical and legal contexts, might therefore be the severity o f current symptomatology, rather than the presence or absence o f a diagnosis.

Furthermore, this research supports a growing body o f empirical research in showing that peritraumatic dissociation and emotional numbing during trauma actually result in more, rather than less, severe PTSD (Dunmore et al, 1999; Roemer et al, 1998; Griffiths et al, 1997). It also suggests that severe PTSD can develop in the absence o f intense fear, helplessness or horror during the trauma. Again, these are important findings for therapists and for gaining criminal injuries compensation. In addition, they highlight a theoretical shortcoming of current conceptualisations of PTSD, in their emphasis on intense affect and perceived life threat during trauma as central to diagnosis. Taken together, both the current and previous research suggest that future diagnostic criteria should incorporate peritraumatic emotional numbing and dissociative responses into its conceptualisation of Criterion A1 and A2 for PTSD diagnosis.

The model presented in Figure 12 offers a useful conceptual framework, adapted from Ehlers and Clark (2000) in which to understand the impact o f drug-rape and structure cognitive-behavioural interventions. As their model indicates, the intervention will depend on the extent of memory impairment, content o f negative appraisals, and particular maladaptive coping strategies employed by a survivor. Some potential strategies for interventions with drug-rape survivors are described below.

Current cognitive conceptualisations of PTSD (Brewin et al, 1996; Ehlers and Clark, 2000) highlight both imaginai exposure to trauma memories (SAM’s), and cognitive restructuring (of VAM’s) (Padesky, 1994) as key components o f therapy for PTSD. Participants reported situationally accessible intrusive memories of comparable quality to other trauma populations (van der Kolk and Fisler, 1995), based on fragments or “islands” o f memory for the rape, indicating that imaginai exposure therapy would be an

appropriate intervention following drug-rape. However, higher drug-induced dissociation was shown to result in more fragmented, uncontrollable, vivid ‘reliving’ symptoms, and severely impaired autobiographical memory. Such effects are known to impede successful habituation to the traumatic memory and the development of a coherent trauma narrative though exposure therapy (Foa and Hearst-lkeda, 1996). The drug- induced impairment of autobiographical memory is therefore likely to impede emotional processing and psychological therapy for PTSD.

In addition, previous research has demonstrated subjective perceptions o f trauma, rather than objective memories or severity, to predict PTSD (Sales et al, 1984). Therefore, targeting commonly reported “worst case scenarios” using cognitive therapy approaches would be beneficial, particularly for survivors who have no explicit memory of the rape and cannot undertake imaginai exposure. Given that some participants reported feeling “(ir/ve/î” to “go over and over events to try and remember”, focusing cognitive therapeutic interventions on facilitating acceptance o f memory loss, challenging specific catastrophic interpretations regarding memory loss (e.g. “i t ’ll all come flooding back and I won Y be able to cope ”, and “I need to remember to get over this”) to alleviate chronic processing would beneficial.

In addition to negative appraisals about their memory loss, participants reported high levels o f negative appraisals on the PTCI regarding control, trust, self-blame and safety and their reactions at the time o f the assault. The relationship of negative posttraumatic appraisals with elevated posttraumatic fear and PTSD symptomatology indicates that cognitive restructuring approaches (e.g. Padesky, 1994) focussing on these appraisals would also benefit survivors. As Weaver et al (1998) have highlighted, cognitive

interventions to challenge negative appraisals in PTSD following drug-rape might be the sole form o f intervention with survivors who have no explicit memory of the trauma. They note that, “Trauma-focused work with [drug-rape] victims with little (or no) memory focuses on their thoughts and fears about the experience. For example, there can he a profound impact on the individual’s sense o f personal control, thoughts about the malevolence o f others, and imagined ‘worst case scenarios’”. Particular negative cognitive appraisals identified through this research as foci for assessment and intervention through cognitive restructuring include:

• Self-blame relating to behaviour or emotional response during the assault.

• Negative appraisals regarding memory loss (fears that something “even worse” happened or that the memories would “come flooding back and be unmanageable”). • Issues o f trust, control and safety, and self-directed negative cognitions.

• Negative appraisals about the long-term effects of the drugs, e.g. “they have damaged my brain permanently”, which could be challenged through psychoeducation about the drugs.

Finally, participants universally reported low levels o f peritraumatic affect and negative cognitions (i.e. no “emotional hotspots” or moments of intense affect during the trauma) due to the moderating effects of the drugs. Rather, negative appraisals and intense emotions associated with rape memories developed post-trauma. This suggests that, for this population, cognitive restructuring could be successfully achieved outside reliving, as appraisals are unlikely to have occurred peritraumatically, and been encoded in SAM (Grey, Holmes and Brewin, in press).

4.13. Summary

This is the first research project to clinically investigate the psychological consequences o f drug-rape. The results were considered in the light o f current cognitive theories o f memory and PTSD, as well as cognitive psychopharmacology. Drug-rape survivors experienced significant depression, anxiety and PTSD, which was comparable with other trauma populations. This was true even for the third of participants who did not meet DSM-IV diagnostic criterion A1 and/ or A2 for PTSD, and for participants with extensive memory loss for the rape. The cognitive effects o f the drugs shared clinical and conceptual similarities with peritraumatic dissociation, and were similarly predictive of PTSD severity, and the ‘reliving’ quality o f intrusive memories. Furthermore, drug- induced numbing of fear responses during the rape was associated with more extensive negative posttraumatic appraisals, fear and PTSD symptomatology. These results add to a growing body o f empirical research indicating that current conceptualisations of PTSD, including DSM-IV criterion A, should incorporate emotional numbing and dissociation, in addition to intense fear, helplessness and horror. This study supports the existence of a reciprocal relationship between negative appraisals and attributions, and the severity of PTSD symptomatology, with a similar profile o f negative appraisals being identified for drug-rape survivors as for other rape populations.

Based on their cognitive model (figure 12), Ehlers and Clark (2000) propose the following interventions for chronic PTSD:

• Elaboration and contextualisation of memory (SAM) for the trauma through imaginai exposure, to place it within the context o f prior experience

• Modification of maladaptive posttraumatic appraisals that elicit increased fear and arousal

• Reduction in dysfunctional cognitive and behavioural coping strategies such as avoidance

The finding that drug-rape survivors reported comparable intrusive memories and negative appraisals to ‘non-drug’ trauma populations, both o f which were associated with more severe PTSD, indicates that this approach would similarly benefit drug-rape survivors. However, the drug-induced impairment of episodic memory is likely to make achieving complete emotional processing much more difficult.