SANCTUARY:
A Content Analysis of Literature
on Trauma-informed Psychiatric Inpatient Treatment
for Female Survivors of Rape and Sexual Assault
Under Involuntary Hold
Kristen Muché
California State University, Long Beach
School Of Social Work
May 2013
INTRODUCTION
Problem:
Majority of inpatients in acute psychiatric settings have histories of trauma, especially sexual violence
Often times, the external coping mechanisms for these individuals appear in the form of self-injurious
behaviors, which are then responded to by professionals with the mindset of impending suicide
Lack of education and training regarding the connections between sexual assault and coping
mechanisms continues to be reflected in the modern interventions utilized within psychiatric settings,
as systems stemming from the medical model versus an empowerment model are still in place
For this reason, a paradigm shift is warranted, so as to reduce the risk of re-traumatization for rape
and sexual assault survivors under involuntary hold, within these institutions
Purpose:
To gain a better understanding of the issues faced by involuntarily held female survivors of rape and
sexual assault within acute inpatient psychiatric settings and explore what existing inpatient traumainformed training was in place
Question:
How have acute inpatient psychiatric units demonstrated trauma-informed practices in their treatment
of Danger to Self (DTS), or suicidal, female patients who are also rape and sexual assault survivors?
SOCIAL WORK RELEVANCE
Quality of Life
The extent to which the culture of rape and sexual assault among
survivors, as presented in the reviewed literature, was explored, and
recommendations for new areas of research were made, so that
quality of life can be increased
Sensitivity Training
The ultimate goal of this study was for all acute inpatient psychiatric
facilities to adopt trauma-informed training requirements within
their departments, so that the rate of re-victimization among rape
and sexual assault survivors will decrease
CROSS-CULTURAL RELEVANCE
Viewing mental health facilities and hospitals as microcosms
Rape and sexual assault survivors represent every race and ethnicity across
the board (Rozée, 1993; Holmes, 2002)
Culture shock of psychiatric wards (Rozée, 1993; Holmes, 2002)
Part of the desired experience, in trauma-informed care, is for survivors’
cultural, religious, racial, ethnic, gender, and sexual orientation identifications
to be inquired after and carefully considered, especially in understanding their
own perspectives, or interpretations, of what has happened to them
(Underwood et al., 2007; Holzman, 1994).
Studies from multiple countries were utilized for the purpose of assessing
similarities and differences among trauma-informed care and its impact on
rape and sexual assault survivors, in addition to evaluating attitudes and
understanding regarding involuntary hold, restraint use, seclusion, and
significant clinical variables among this population
METHODS
Research Design:
Systematic review of literature based on a content analysis method
Study Selection and Sampling:
Analyzed 30 empirical studies, published between 2009 and 2012, that reported
findings on the independent areas of the following:
• Female rape and sexual assault survivors; acute inpatient psychiatric environments
wherein involuntary hold, restraint use, and seclusion were practiced; and traumainformed services
Data Collection Method:
Multiple research databases, including EBSCO Host and PsycINFO; professional journals
of social work, psychology, mental and psychiatric health care, and related disciplines
Data Analysis:
Content was analyzed based upon the most common influencing factors. In analyzing
the findings of these empirically based studies, the researcher identified three
significant findings, two recommendations for future research, and two limitations within
each study, chosen on the basis of relevance to this study
RESULTS
Majority of acute inpatient psychiatric units consist of individuals with mood, anxiety,
and substance-related disorders
 Majority of individuals with mood, anxiety, and substance-related disorders are rape
and/or sexual assault survivors
 Majority of acute psychiatric inpatients are rape and/or sexual assault survivors
 Parallel with self-injurious/parasuicide behaviors (e.g. cutting or selfmutilation without the intent to kill), as self-blame and isolation were often
paired with post-rape or sexual assault incidences, leaving survivors in a
state of hopelessness and dead ends, in terms of emotionally supportive
resources
Need for trauma-informed care, education, and implementation among staff is dire, as
the coercive measures in place appear to produce extremely negative effects on rape
and sexual assault survivors, hurting and disabling them rather than caring and
empowering them
 Lack of awareness to this connection between psychiatric patients and survivors, in
that the majority of them are one in the same
RESULTS CONT’D.
Psychiatric programs with trauma-informed care and training in place significantly increased
survivors’ levels of functioning, perceptions of being understood and not judged, and both rate
and quality of recovery
 Unlike the programs that did not have trauma-informed care in place, which, as a result,
had catastrophic effects on survivors, including, but not limited to, re-traumatization and
re-victimization, stereotyping, ignorant and objectifying interventions, and victim-blaming
tactics
Need for partnerships between community sexual assault centers and psychiatric inpatient
hospitals and units
Areas of suicidality, sexual assault, and involuntary commitment shared common concerns
and risk factors, whereas the studies on trauma-informed care not only presented findings
complementary to these concerns and risk factors, but also confirmed the response to the
recommendations and future research statements made by these study areas
 Studies on trauma-informed care responded to this by providing multiple frameworks for
these interactions to take place, in newly devised policies and training systems that
identified precious knowledge and empathy as the basis for this paradigm shift to begin
IMPLICATIONS FOR SOCIAL WORK
Self-injurious behaviors are misunderstood and should be re-evaluated as maladaptive
coping mechanisms, rather than exclusively as suicide attempts
A step between being identified as a threat to one’s self or others and involuntarily held
should be taken, encouraging dialogue in both an emotionally and physically safe space
Partnerships with sexual assault agencies should be established, so that PET members
would, first, be trained in identifying symptoms specific to sexual trauma and, second,
assess whether or not the identified person would be more appropriate (i.e. receive
better customized treatment) for a sexual assault crisis facility or a locked down acute
psychiatric inpatient facility
Reporting parties should be trained in trauma-informed care, so that once an external
symptom of trauma or self-injurious behaviors manifest in a client, these parties can
engage in dialogue and trauma assessment, so that the decision to involuntarily hold a
client is not prematurely made
IMPLICATIONS FOR SOCIAL WORK CONT’D.
Dissociative and rage-like features were also attributed to the high volume of rape and
sexual assault survivors within acute inpatient psychiatric facilities (Klanecky et al.,
2008; Painter & Howell, 1999)
• These characteristics keep with the intensely elevated and unstably impulsive
features experienced in individuals with Bipolar I Disorder: Manic Episode,
dissociative disorders, and Borderline Personality Disorder, which are largely
prevalent among survivors of rape and sexual assault, primarily those with histories
of childhood sexual abuse (Gallop et al., 1999; Sansone et al., 2011)
• Further research for how these features could be misinterpreted as exclusively
psychotic or attributed to Schizophrenia, possibly leading to survivors internalizing
the notion that they are “going crazy”, and not a history of rape and/or sexual
assault, could provide a deeper insight into an area that seems to be quite relevant
to this study’s findings, as well as provide even more incentive for mandatory
trauma-informed care training
REFERENCES
Gallope, R., McCay, E., Guha, M. & Khan, P. (1999). The experience of hospitalization and restraint of women who have a
history of childhood sexual abuse. Health Care for Women International, 20, pp. 401-416.
Holmes, J. (2002). Acute wards: Problems and solutions: Creating a psychotherapeutic culture in acute psychiatric
wards. Psychiatric Bulletin, 26(10), 383-385.
Holzman, C. G. (1994). Multicultural perspectives on counseling survivors of rape. Journal of Social Distress & the
Homeless, 3(1), 81-97.
Klanecky, A. K., Harrington, J. & McChargue, D. E. (2008). Child sexual abuse, dissociation, and alcohol: Implications of
chemical dissociation via blackouts among college women. The American Journal of Drug and Alcohol
Abuse, 34, pp. 277-284.
Painter, S. G. & Howell, C. C. (1999). Rage and women’s sexuality after childhood sexual abuse: A phenomenological
study. Perspectives in Psychiatric Care, 35(1), pp. 5-17.
Underwood, L., Stewart, S. E. & Castellanos, A. M. (2007). Effective practices for sexually traumatized girls: Implications
for counseling and education. International Journal of Behavioral Consultation and Therapy, 3(3),
403-419.
Rozée, P. D. (1993). Forbidden or forgiven? Rape in cross-cultural perspective. Psychology of Women Quarterly, 17,
499-514.
Sansone, R. A., Chu, J. W. & Wiederman, M. W. (2011). Sexual behaviour and borderline personality disorder among
female psychiatric patients. International Journal of Psychiatry in Clinical Practice, 15, 69-73.